Units 1-4 Flashcards
Define Nursing Process
decision making approach that enhances critical thinking.
focus of nursing care
addresses the response of the client to the illness
Primary purpose of nursing care plan is communication so the health care team can see process and address ways to meet goals
Data Collection Sources
Client is the most reliable source usually, but not always
family and significant others
medical records
Process of data analysis
as a student, do analysis at home, as a staff nurse you do it at the hospital.
Planning Phase
develop interventions and outcomes- test interventions and outcomes/ goals.
don’t evaluate interventions- evaluate the goals
Discharge planning begins on admission!
Implementation phase
carry out planned interventions with ongoing assessment
where we do most of our legal charting- what we did with the patient.
Documentation is a legal requirement and is the final stage of the implementation phase.
Evaluation phase
Valuate effectiveness, was the plan effective based on pt and nrsng goals?
Define Critical Thinking
Purposeful- outcome directed thinking that aims to make judgment based on scientific evidence. rather than tradition or guessing
self directed thinking
evidence based practice- based on research and critical thinking.
attitudes and mental habits that effect critical thinking
be able to think independently intellectual courage intellectual empathy intellectual sense of justice intellectually humble be disciplined so you don't stop at easy answers be creative and self confident
divergent thinking
the ability to weigh important info sort out what’s relevant and what isn’t
reasoning
the ability to discriminate between facts and guesses
clarifying
defining terms and noting similarities and differences
reflection
take time to think it all out
learning readiness
define learning readiness- patient has to be ready to learn
requires assessment of client- are they in pain? are they scared? are they elderly? what is their education level?
people who are not ready to listen can not be taught
client must be accepting of diagnosis and need for teaching in order to learn
motivational principles
pt desire to regain control of the situation
assess what patient wants to know and be able to do himself the most.
always start with the MOST important issue to patient
patient goal characteristics
patient goals must be mutually established by client and nurse and client centered, time specific, and measurable.
measurable learning goals are things you can “test on”
teaching techniques and strategies
establish trust and rapport proceed slowly set goals and boundaries set priorities assess when client learns best use demo/ hands on activities involve significant other limit distractions put safety first proceed simple to complex give praise review material give practice time
benefits of standard teaching plans
make sure nothing is missed or forgotten
others can pick up where you left off
Accountability
to be accountable you need to be able to explain your actions
define pain
pain is whatever the patient says it is
pain can be a good thing because it is a protective role and warns us of potentially health threatening conditions
JCAHO
pt has the right to appropriate assessment and management of pain. 0-10 pain scale
Pain
is a subjective response to both physical and psychological stressors
serves as a basis for nursing assessments
nociceptors
nerve receptors for pain located throughout the body but not in the brain.
acute pain
sudden onset, usually temporary
has identifiable cause
lasts less than 6 months
somatic pain
skin, superficial tissue, muscles, bones, joints
sharp, cutting, burning or dull and diffuse. even throbbing, may be accompanied by nausea or vomiting.
visceral pain
associated with organs, cramps, deep dull and poorly localized.
almost always associated with nausea and vomiting
hypotension and restlessness
referred pain
pain perceived in an area distant from the site of the stimuli.
common with visceral pain
body response to acute pain
a stressor- initiates fight or flight response
increased HR, rapid shallow respirations, increased BP, dilated pupils, sweating
anxiety, fear
characteristics of chronic pain
lasts longer than six months, lowers pain threshold, depression of serotonin and endorphin levels, leads to depression and irritability, complex, and poorly understood
body response to chronic pain
physiologic reaction results in normal vital signs
hormonal responses to pain as it persists, increased BG
pt develops depression, irritability, withdraw, immobility, may be demanding
neuropathic pain
it is caused by the CNS or PNS, causes burning, tingling, or cold sensations
phantom pain
follows amputation, caused by stretching and tearing of nerves
peripheral neuropathy
most commonly associated with diabetics, burning pain from nerve injury
breakthrough pain
pain that exceeds baseline of treated pain
psychogenic pain
pain experienced in the absence of any diagnosed physiological cause or event.
pain threshold
every person has the same pain threshold and receives pain stimuli at the same intensity
pain tolerance
amount of pain a person can endure before outwardly responding to it
TENS unit
electric current that causes tingling so brain receives tingling sensation instead of pain.
avoids drug side effects, patient controlled and works well with other therapies
disadvantages: cost, batteries, can be turned up too high
acupuncture
stimulation of certain points on body to enhance flow of vital energy
biofeedback
electronic method of measuring physiologic responses and giving it back to client.
hypnotism
state in which mind becomes extremely suggestible- possible to achieve complete anesthesia
relaxation
learned activities that completely relax the mind and body, increased pain tolerance.
distraction
redirect attention away from pain
cutaneous stimulation
massage, vibration, heat/cold therapeutic touch
most common approach to pain management
pharmacologic medications
analgesics
means pain reducer and reliever, two major types
non-opioids
acetaminophen-reduces pain and fever but NO ANTI INFLAMATORY EFFECT. most commonly used pain med in the world. can produce toxic effects on the liver.
and
NSAIDs-reduce pain by interfering with prostaglandin synthesis. can cause increased bleeding and gastric ulcers. include two types salicylates (asprin) and ibuprofen (non asprin) inhibits platelet aggregation.
opioids
narcotics, derived from the opium plant, works on CNS
given for moderate to severe pain
can cause respiratory depression and constipation
NARCAN given for OD
Adjuvant drugs
drugs with other specific uses that can provide analgesia in clients with certain types of pain and specific diagnosis
steroids, anticonvulsants, antidepressants, muscle relaxants, local anesthetics
acetaminophen dose per day
never exceed 4000mg a day
difference between asprin NSAID and non- asprin NSAID
ibuprofen does not provide MI or CVA protection, actually can increase clot risk
Tolerance (narcotics)
state in which a larger dose is required to produce the same response that could formerly be elicited by a smaller dose
physical dependence
state in which a withdraw will occur only if abruptly stopped, the body requires the opioid to function normally.
IV opioids for sever/acute pain
Morphine or dilaudid
oral opioids for severe chronic pain
MScontin or Oxycontin
topical analgesic for severe chronic pain
fentanyl patches (duragesic)
oral opioids for moderate to severe acute pain
Hydrocodone, oxycodone, codine, propoxyphene
Carbs kcal
Protein kcal
fats kcal
4
4
9
vitamins
organic compounds
fat soluble ADEK
water BC
minerals
inorganic compounds
positive nitrogen balance
protein synthesis and breakdown are equal.
pre albumin levels
15-36
tells us about recent history
albumin levels
3.5-5
tells us more long terms protein intake
protein
6.5-8.5
Glucocorticoids effects on
CHO
Protein
Fat
CHO- increase BG
Protein- decrease muscle mass, thin skin
Fat-redistributed , potbelly, moonface.
