Term
| Stress: What is it a response to, what two general responses does it involve |
|
Definition
response to any demand, physical or
mental, made upon body
demand requires the individual
respond or take action
involves physiological and/or
psychological responses |
|
|
Term
| Stressor: Definition, where can stress come from? What is Adaptation? |
|
Definition
Any factor that disturbs equilibrium
Stimuli that cause stress can be internal or
external
Internal – comes from within the body
External – from outside the body
Adaptation
process by which physiological or psychological
dimensions change in response to stress
attempt to maintain optimal functioning |
|
|
Term
| Physiological Response to Stress: Local Adaptation Syndrome vs General Adaptation Syndrome |
|
Definition
Local Adaptation Syndrome
Localized
Adaptive
Short term
Restorative
General Adaptation Syndrome
Alarm reaction
Stage of resistance
Stage of exhaustion |
|
|
Term
| Stress and fight or flight |
|
Definition
| During stress sympathetic dominant... lots of focus on constipation in class, peptic ulcer disease (think about cortisol effect on prostaglandins) |
|
|
Term
| Personal response to stress: what does it depend on, actual vs perceived. |
|
Definition
Highly individualized
Depends upon:
Cognitive appraisal
Personality
Past experiences
Patient’s perception that is important
focus on subjective data |
|
|
Term
| Coping mechanism: Definition, Ego-Defense, Task-oriented behaviours |
|
Definition
Psychological adaptive
behaviors
Can be:
Ego-Defense Mechanisms
Offer psychological
protection from a stressful
event
Task-Orientated Behaviors
Use cognitive abilities to
decrease stress, solve
problems, resolve conflicts
& gratify needs |
|
|
Term
| Common defense mechanisms |
|
Definition
Rationalization
Displacement
Compensation
Denial
Repression
Suppression
Fantasy
Somatization
Somatic means related to the body |
|
|
Term
|
Definition
Mild Stress
Situations or stressors that everyone
encounters
Moderate Stress
Lasts longer – several hours or days
Severe stress
Chronic situation lasting several weeks to
years |
|
|
Term
| Unhealthy Coping Strategies |
|
Definition
Physical
Mental
Emotional
Social
Spiritual |
|
|
Term
| Healthy coping strategies |
|
Definition
Cognitive coping skills
Problem-solving skills
Delayed gratification
Self-efficacy
Physical health
Social support |
|
|
Term
|
Definition
Personality characteristics that help
people stay healthy despite facing
stressful life events (commitment,
purpose in life)
ability to view change as a challenge
Sense of personal control over life |
|
|
Term
| Gordon's Assessment for Stress |
|
Definition
I. History
A. Any big change (s) in your life in the last
year or two?
B. Who is the most helpful in talking things
over? Available to you now?
C. Tense or relaxed most of the time? When
tense, what helps?
D. Use any medicines, drugs, alcohol to
relax?
E. When (if) there are big problems (any
problems) in your life, how do you
handle them?
F. Most of the time, is this (are these)
way(s) successful?
Physical Examination:
None, unless somatic concerns |
|
|
Term
| Nursing Diagnoses related to stress and coping |
|
Definition
Coping, ineffective
Defensive coping
Ineffective denial
Coping, readiness for enhanced
Coping, readiness for enhanced family
Family coping – compromised, disabled
Disturbed energy field
Post-trauma syndrome
Rape trauma syndrome |
|
|
Term
| Nursing Interventions to Assist Client with Managing Stress |
|
Definition
Being with/being
there
Teaching/coaching
Avoid stressful
individuals
Regular exercise
Humor
Proper diet/weight
Spiritual Activities
Support system
Rest/relaxation |
|
|
Term
|
Definition
Small & large intestine
Small intestine consists of
duodenum, jejunum & ileum
6.4 meters in length
Large intestine consists of
cecum, ascending,
transverse, descending &
sigmoid colon
1.5 meters in length |
|
|
Term
| Bowl elimination facts: What does stool usually look like, average amount of stools, how many mLs of flatus produced daily? |
|
Definition
Stool is normally soft &
solid, brown & cylindrical
Average 1-2 stools per
day to 1 every 2-3 days
400-700 ml of flatus is
produced daily |
|
|
Term
| How does the GI tract change in older adults? |
|
Definition
Appetite decreases
chewing/salivation may be impaired
Degeneration of cells/mucosa & decreased
gastric emptying
Peristaltic activity slows, absorptive quality of
mucosa changes
Weakening of muscle tone
Slowing of rectal reflex nerve impulses
Constipation more common
May have difficulty controlling bowel elimination |
|
|
Term
| Huge list of things that affect bowel function: |
|
Definition
Dietary pattern & fluid intake
Flatus
Personal habits
Activity & exercise
Medications
Anesthesia & surgery
Pain
Emotions
Other illnesses |
|
|
Term
| Medications to look out for when looking at bowel related issues |
|
Definition
Laxatives - chronic use may cause loss of
normal defecation reflex & muscle tone; can
cause diarrhea; can alter efficacy of other meds
Narcotics - constipation
Antibiotics - diarrhea
NSAIDS - GI irritation; can lead to bleeding
Anticholinergics - decrease GI motility, gastric
acid
others |
|
|
Term
|
Definition
Constipation: infrequent, hard, dry stools
Fecal Impaction: hard mass of stool that
cannot be expelled
Diarrhea: frequent discharge of unformed,
watery stools
Incontinence: inability to control passage of
feces & gas
Hemorrhoids: swollen veins of anus or rectum
(internal or external)
Flatulence: bowel wall stretches with gas |
|
|
Term
| Constipation causes and symptoms |
|
Definition
Causes: insufficient dietary fibre, lack of daily exercise,
immobility, medications, strong emotions, changes of
aging, obstruction from tumors, neurological injury, etc
Symptoms: bloated feeling, distention, may experience
headache, anorexia, nausea, discomfort (usually disappear
following defecation)
Avoid straining (Valsalva’s manuever) especially with
some health conditions (i.e. heart disease/surgery,
glaucoma, ICP, IAP, can cause wound dehiscence)
Fecal Impaction: hard mass of stool that cannot be
expelled, watch for signs of abdominal distention with
flatus, seepage of small amounts liquid stool from anus,
cramping, and inability to defecate despite urge, anorexia,
(clients who are debilitated, confused, etc) |
|
|
Term
| Diarrhea causes and symptoms |
|
Definition
Causes: emotional tension, medications, alcohol or
caffeine, certain foods, inflammatory bowel
disease, infection, suegery that removes large
portion of bowel reducing absorption surface, etc)
Affects digestion, absorption, secretion in GI tract
Symptoms: abdominal pain/cramping, slools cause
itching and redness around anus
* In danger of fluid and electrolyte imbalance > if
prolonged weakness, fatigue, malaise, etc |
|
|
Term
| 5 types of Bowel Diversions |
|
Definition
Ileostomy
Colostomy
End Colostomy
Loop Colostomy
Double-barreled Colostomy (one for stool one for mucus... otherwise you can still have mucus coming from the anus) |
|
|
Term
| Assessment for patients with ostomy |
|
Definition
History:
Bowel elimination pattern. Describe. (Normal and recent
changes) Frequency? Character? (color, consistency)
Discomfort? Problem with control? Laxatives, other aids?
Examination (empty bladder, supine, warm hands
and stethescope)
Auscultate bowel sounds
Palpate to identify distension, masses or
tenderness
Possibly a rectal exam
Examine secretions (if present) for color &
consistency
Also look at mouth, teeth, tongue, gums |
|
|
Term
| Inspection of bowel quadrants - what are you looking for, what's normal, what to do if abdomen is distended |
|
Definition
All 4 quadrants: note contour, symmetry, skin color
and appearance, abdominal girth and abdominal
movements
Normally slightly rounded or flat and
symmetrical, skin should look smooth and intact
and feel soft and supple, free of abnormal color,
rashes, lesions
If abdomen distended: measure the abdomi9nal
girth, place tape across the umbilicus the widest
point and measure daily to determine progression
Should not be able to see peristaltic
movements (i.e. intestinal obstruction) |
|
|
Term
| Auscultation of bowel - how often should you hear sounds, what is infrequent, what is hyperactive? |
|
Definition
Start RLQ and proceed clockwise, listen in
each quadrant for one full minute
Bowel sounds are the movement of liquid and
air > sound like bubbling or gurgling and should
occur every 5-15 seconds
Infrequent (fewer 5/min) or absent bowel
sounds occur normally after surgery
Hyperactive (> 35/min) with diarrhea, etc
If early small bowel obstruction, sounds may be
hyperactive and high pitched |
|
|
Term
| Light Palpation - What is it used for, what is the process, what is the purpose of rectal exam |
|
Definition
Used to identify abdominal distention, masses,
and areas of tenderness
Abdomen normally soft and nontender
Begin at RLQ and move clockwise
Dominant hand with fingers close together,
depress 1-2 cm in dipping motion
*rectal exam may be permitted in an institution to
determine fecal impaction (also inspect anus for
hemmorhoids, inflammation, rectal prolapse or
discharge) |
|
|
Term
| Diagnostic tests for bowel elimination |
|
Definition
Anoscopy (anal canal)
Proctoscopy (the rectum)
Sigmoidscopy (the sigmoid colon)
X-Ray exams
UGI and small bowel follow-through (to examine
small bowel, barium contrast medium swallowed)
Barium enema (to examine lower bowel, barium
inserted through rectal tube)
Stool collection (cultures, ova and parasites,
C-difficile, etc)
Test for OB (occult blood-microscopic blood) |
|
|
Term
| Nursing diagnoses for bowel elimination with example expected outcomes |
|
Definition
Constipation r/t
Diarrhea r/t
Bowel incontinence r/t
High risk for impaired skin integrity r/t
Body image disturbance r/t colostomy or
incontinence
Ineffective individual coping r/t difficulty
adapting to ileostomy
Self-esteem disturbance r/t need for digital
removal of stool
Ineffective health maintenance
Examples:
The client will have soft formed brown
bowel movements (BMs) q 2-3 days
The client will have no more than 2
bowel movements per day |
|
|
Term
| Nursing interventions for bowel elimination |
|
Definition
1. Assess for bowel sounds q shift – no food if absent
2. Regularity – teach to defecate with urge/be prompt when
client has urge
3. Take time for elimination, ensure privacy
4. Foods high in fibre, fluids (1500-2000 ml/day)
5. Exercise (ie. ambulate surgical pts early to encourage
return of peristalsis)
6. Position (sit or squat)
7. Take advantage of gastrocolic reflex, ½ hour post meals
8. Hygiene (hand washing, women wipe front to back)
9. Comfort measures (liquid stool acidic, contains digestive
enzymes)
10. Medicate PRN (exercise caution with laxatives – may lead
to dependence, fluid & electrolyte imbalance) |
|
|
Term
| Care of patient with an ostomy: goals related to which to systems, who could you refer to? |
|
Definition
Can be bowel or urinary diversion
Goals:
Maintain integrity of peristomal skin
Maintain a secure seal
May need referral to ostomy nurse/
enterostomal therapist |
|
|
Term
| How to apply pouching system, common parts of appliances |
|
Definition
current trend is to apply pouch directly to
clean dry skin without using skin prep, paste
or added adhesives, unless patient has a
problem keeping pouch intact
many types of pouching systems
Also called appliances
all have 1. a protective layer that adheres to
skin called ‘skin barrier’ & 2. a ‘pouch’ |
|
|
Term
|
Definition
Observe existing skin barrier & pouch
For leaks, erythema around skin barrier
Note length of time in place
Intact skin barrier with no evidence of leakage can
remain in place for 3-5 days
should cover peristomal skin without
constricting stoma, allowing visibility of
stoma
opening around appliance should be < 2 mm larger
than stoma
pouch should keep pt. clean & dry,
protects skin from drainage, provides a
barrier against odor
Drainage can be very irritating to skin
Observe effluent in pouch
empty if 1/3 to ½ full
Note color, consistency, amt of effluent
Assess type of stoma
can be flush with the skin or a bud-like
protrusion on the abdomen
observe stoma for location, color,
swelling, trauma, & healing or irritation
of peristomal skin
Check abdominal discomfort,
distention, bowel sounds, & any
incisions, sutures
* If the ostomy pouch is leaking,
change it. Taping or patching it leaves
skin exposed to enzymatic irritation * |
|
|
Term
| Stoma appearance: Color/moisture, size, type |
|
Definition
Color/moisture: should be red or pink &
moist (if grey, purple, black, etc report)
Size: decrease for 4-6 weeks after
surgery, measure with each pouch
change
Type: can be flush with skin or a bud-like
protrusion on abdomen (contour-budded
or retracted) |
|
|
Term
| Assessment of peristomal skin, effluent, assess for necrosis of stoma |
|
Definition
Peristomal skin: note if intact, reddened,
excoriated, presence of blisters, rash, scars, folds,
etc
Effluent: from colostomy will be soft or formed;
from ileostomy is liquid; ileoconduit urine will have
mucous in it because of flow through intestinal
segment
Assess for necrosis of stoma: purple or black
discoloration, dryness, failure to bleed, sloughing of
tissue
Immediately post-op, there may be edema and
abdominal distention |
|
|
Term
| Goals of the Nursing Process |
|
Definition
Organize & prioritize
care
Maintain focus on care
needs & priorities
Form clinical reasoning
skills for practice
environment |
|
|
Term
| Nursing Assessment: definition |
|
Definition
Data collection and verification
Subjective
Objective
Organization of data
Gordon’s Functional Health Patterns
Data analysis
Function, dysfunctional, at risk |
|
|
Term
| Nursing Diagnosis: How is it derived, three types |
|
Definition
Derived from assessment data –
dysfunctional or at risk health patterns =
diagnostic areas
Must include critical thinking skills
NANDA diagnostic statements
Types of Diagnoses:
Actual nursing diagnosis (3 part statement)
Risk nursing diagnosis (2 part statement)
Wellness nursing diagnosis |
|
|
Term
| Planning nursing care: General, types of goals, types of nursing interventions, selection criteria for interventions |
|
Definition
• Selecting nursing interventions
– Types:
• Nurse-initiated
• Physician-initiated
• Collaborative
– Selection criteria:
• Characteristics of nsg diagnosis
• Expected outcomes
• Feasibility
• Evidence-based
• Acceptability to patient
• Nurse competencies |
|
|
Term
| Two broad categories of nursing interventions |
|
Definition
– Direct
• ADL’s
• Physical care
• Teaching
• Observing
• Counselling
• Monitoring
– Indirect
• Delegating, supervising & evaluating the work of other staff |
|
|
Term
| Nursing Care Plan: Purpose |
|
Definition
A guide for clinical care
Promotes communication among
caregivers to promote continuity of care
Directs care and documentation
Creates a record that can be used for
evaluation, research and legal purposes
Provides documentation of health care
• Direct care
• Decrease risk of incomplete, incorrect, or
inaccurate care
• Identify & coordinate resources
• Enhance continuity of nursing care
• lists specific nursing actions necessary to
achieve goals & outcomes of care
• Organize information shared among nurses |
|
|
Term
| Concept Care Maps: what are they, what is the foundation, what should it be, how often do you evaluate revive/reuse. |
|
Definition
Diagramatic care plan
foundation is nursing process
requires clinical reasoning skills
purpose is guide patient care
should be practical & realistic
implement, evaluate & revise/reuse q shift |
|
|
Term
| Concept Care Map is used to… |
|
Definition
• Gather/record assessment data
(manifestations)
• Identify client problems (diagnoses) &
treatments (interventions)
– Organize client data
– Analyze relationships in the data
– Establish priorities
– Build on previous knowledge
– Identify what you do not understand
– Enable you to take a holistic view |
|
|
Term
| Clinical Pathway: other names, what is it, when was it introduced, what is the goal |
|
Definition
• also see called Care Map or Critical Pathway
• structured, interdisciplinary standard care
plan
• Predicts day-by-day care required to achieve
outcomes for specific problems within a
certain time frame
• Introduced in 1990’s in UK, US, CAN, AUS
• Goal to improve continuity of care across
disciplines |
|
|
Term
| 4 mechanisms for waste removal |
|
Definition
1. Urine (urinary tract)
2. Feces (GI tract)
3. Skin (diaphoresis)
4. Lungs (expired air) |
|
|
Term
| Three primary functions of urinary elimination |
|
Definition
removal of nitrogenous waste products of
cellular metabolism
regulation of fluid & electrolyte balance
Results in chemical homeostasis of blood |
|
|
Term
| Subjective assessment data for urinary elimination |
|
Definition
Subjective Data
Usual patterns of voiding
Frequency, time of day, normal volume, toileting
ability, urinary control, aids
Recent changes in patterns
Factors that affect elimination
Age, fluid and food intake, any disturbances that
affect I&O – nausea, vomiting… |
|
|
Term
| Physical Assessment for Urine elimination |
|
Definition
A. Urine:
Color, odor, consistency, amount, abnormalities
B. I&O
C. Voiding Pattern
D. Abdominal Assessment
E. Chart Findings |
|
|
Term
| Appearance, smell or normal urine |
|
Definition
Clear, straw colored or light amber in color
Darker urine = increased concentration of urine
Slightly acidic, faint aromatic odor
Transparent at voiding, becomes cloudy as it
stands |
|
|
Term
| A huge list of related factors to assess for in Urine elimination |
|
Definition
Individual differences
Food and fluid
Stress or anxiety
UTI’s
Urinary stasis
Congenital
abnormalities
Injury/trauma
Dehydration
Drug effects
Age
Indwelling catheter |
|
|
Term
| Huge list of Urinary problems |
|
Definition
Incontinence
Stress
incontinence
Dysuria
Frequency
Urgency
Nocturia
Enuresis
Hesitancy
Polyuria
Urinary retention
Residual urine
Cystitis
Oliguria
Anuria
Uremia
Hematuria |
|
|
Term
| General problems caused by issues with urinary elimination |
|
Definition
Impairment of renal function results in
accumulation of wastes in blood
Retention of acidic products of metabolism
causes acid/base disturbances
When urine elimination is compromised,
body uses other means to dispose of
wastes
Creatinine = glomerular filtration rate
BUN = blood urea nitrogen |
|
|
Term
|
Definition
Urostomy
Ileal conduit
Continent urostomy |
|
|
Term
| Huge list of Diagnostic tests for Urine |
|
Definition
Urinalysis – need 5-10 ml
Specific gravity - normal 1.010
> 1.010 means dehydrated
Urine for electrolytes
Dipstick Exam
Culture and Sensitivity (C&S) – first morning void 5-10 ml
24 hr specimens – discard 1
st
am void, sign at bedside/BR
Blood tests – BUN/serum creatinine (normal ratio is 10:1)
increase in ratio indicates kidney damage/failure
Cystoscopy – bladder exam with a lighted scope
local or general anesthetic
X-Ray exams –renal ultrasound, CT scan
Urodynamic studies – to determine dysynergia (neurogenic bladder) |
|
|
Term
| 5 altered patterns of urinary elimination |
|
Definition
Functional incontinence
Reflex incontinence
Total incontinence
Urge incontinence
Urinary retention |
|
|
Term
| Huge (11) list of interventions for Urinary elimination |
|
Definition
1. Remove indewelling catheter
2. Adequate fluid intake (2-3 litres/day)
3. Monitor I/O, regulate fluid intake
4. Void when urge is felt
5. Proper hygiene
6. Perineal muscle tone exercises
7. Limit fluids in pm
8. Ensure privacy/safety
9. Provide assistance, regular toileting schedule
10. Bladder scanning Q4-6 h
11. Intermittent catheterization q 4-6 h if no void |
|
|
Term
| Bladder Management: how are goals set, what should you consider |
|
Definition
Partnership with patient
Set the goal/outcome together
Consistency with fluid intake is critical
Regular toileting schedule
Consider:
Absorbent pads
Waterproof garments
External (condom) catheter
Straight in/out catheterization schedule
Indwelling catheter
Urinary diversion system |
|
|
Term
| What does assessment of Activity and Exercise include |
|
Definition
• describes pattern of exercise activity, leisure &
recreation
• includes activities of daily living (ADL)
– ADL also called ILS (independent living skills)
• also includes assessment of oxygenation
– correct body alignment reduces strain on
musculoskeletal structures, maintains adequate
muscle tone, and contributes to balance |
|
|
Term
| Definitions for Exercise and Activity tolerance |
|
Definition
Exercise
• Physical activity for conditioning the body,
improving health & maintaining fitness
Activity Tolerance
• Type & amount of exercise or work that a
person is able to perform |
|
|
Term
| Thee Factors that Affect Activity Tolerance |
|
Definition
• Physiological Factors
– Cardiopulmonary status
• Emotional Factors
– Mood, motivation
• Developmental Factors
– Age, pregnancy |
|
|
Term
| Definition of mobility and immobility |
|
Definition
• Mobility
– ability of individual to move about freely
– people with complete mobility can achieve needs &
goals independently
– often linked with individual’s perception of health
• Immobility
– may be temporary or permanent
– individual is confined to a position
– unable to change position or ambulate freely
– effects of immobility are systemic & may limit
function/independence
– consequences become more pronounced with time |
|
|
Term
|
Definition
• Physical inactivity eg. Bedrest
• Physical restriction or limitation of movement
eg. Traction
• Restriction of body position & posture eg.
Contractures
• Sensory deprivation eg.neuropathy |
|
|
Term
| 7 Physiological effects of immobility |
|
Definition
• Metabolic changes
– rate, serum protein
• Respiratory
– depth, secretions pooling, risk for pneumonia
• Cardiovascular
– risk for edema, DVT, orthostatic hypotension
• Musculoskeletal
• Integumentary
• Urinary
• Psychosocial |
|
|
Term
| Areas of psychosocial domain that are affected by immobility |
|
Definition
• Emotional
• Intellectual
• Sensory
• Socio-cultural |
|
|
Term
| Two broad categories for physical activity |
|
Definition
• Unstructured
– Usual ADL’s
– Health maintenance
• Structured
– Exercise programs designed to improve physical
fitness
– Includes aerobic exercises, muscular strengthening
exercises & stretching exercises |
|
|
Term
| 6 complications of prolonged inactivity |
|
Definition
• Muscle atrophy
• Stasis of blood – thrombi formation
• Contractures & stiffening of joints
• Pressure ulcers
• Respiratory problems
– Hypostatic pneumonia
– Atelectasis
• UTI |
|
|
Term
| 5 benefits of activity and what other factor is assessed in activity-rest functional health pattern |
|
Definition
• Maintain muscle tone
• Eliminate waste products
• Maintain mobility
• Enhance lung expansion & oxygenation
• Improve blood circulation, tissue perfusion
• Oxygenation is assessed under the activityrest functional health pattern
– The assessment of oxygenation includes
measurement of the vital signs (pulse,
respirations, blood pressure and 02
sat) |
|
|
Term
| 8 things that Oxygenation Depends Upon |
|
Definition
• Patent airways
• Muscles
• Pulmonary compliance (elasticity)
• Transport of oxygen and carbon dioxide
• Medications
• Lifestyle
• Stress
• Environment |
|
|
Term
| Definitions of Atelectasis, Hypoxemia, Hypoxia, hyperventiliation, hypoventiliation, Dyspnea, and Orthopnea |
|
Definition
Atelectasis
• Collapse of alveoli, common in surgical clients
Hypoxemia
• in oxygen content of the blood
Hypoxia
• Insufficient supply of O2 to tissues
Hyperventilation
• Excess ventilation than required to eliminate
CO2
Hypoventilation
• Alveolar ventilation is inadequate to meet O2
demand
Dyspnea
• Difficult or laboured breathing
Orthopnea
• SOB when lying down |
|
|
Term
| Pulse Oximetry - what does it measure, what is the major advantage, normal SaO2, special cases is COPD |
|
Definition
• Measures arterial blood O2 saturation levels
• Non-invasive
• Normal SaO2 – 95-100%
• May see SaO2 low 90% in clients with preexisting COPD
• Results may be altered (incorrect) in some
circumstances |
|
|
Term
| Definition of ventilation, where is the breathing centre located, what is the most important influence on respiration |
|
Definition
• Ventilation = movement of air in and out of the lungs
(breathing)
• The control centre for respiration is located in the
medulla and the pons
• Most important influence on respiration is from
peripheral and central chemoreceptors (nerve cells
that can detect changes in carbon dioxide and
hydrogen ion concentration) |
|
|
Term
| O2 vs CO2 which is the primary regulator of breathing for most people? What is diffusion and what influences it? |
|
Definition
• C02
is primary regulator of ventilation for most
people
• Diffusion
– Gases move across a membrane toward the area
of lower concentration
– Rate of gas exchange influenced by the thickness
of the alveolar-capillary membrane and the gas
exchange surface provided by alveolar walls |
|
|
Term
| 7 factors that affect breathing |
|
Definition
• Position
• Activity and exercise
• Fever
• Age
• Pregnancy
• Weight
• Environment |
|
|
Term
| 11 symptoms of respiratory disease |
|
Definition
• Cough
• Sputum production
• Shortness of breath
• Chest pain
• Wheezing
• Cyanosis
• Clubbing
• Engorged neck veins
• Abnormal breath sounds
• Use of accessory muscles
• Nasal flaring |
|
|
Term
| Information in individual assessment (for general knowledge, not to memorize) |
|
Definition
I. History
A. Sufficent energy for desired/required activities?
B. Exercise pattern? Type? Regularity?
C. Spare time (leisure) activities? Child: play activities
D. Perceived ability (code for level) for:
Feeding __ Grooming __
Bathing __ General Mobility __
Toileting __ Cooking __
Bed Mobility __ Home Maintenance __
Dressing __ Shopping _
Functional level codes:
Level 0: Full self care
Level 1: Requires use of equipment or device
Level 2: Requires assistance or supervision from another
person
Level 3: Requires assistance from another person (and
equipment or device)
Level 4: Is dependent and does not participate
II. Examination
A. Demonstrated ability (from code) for:
Feeding __ Grooming __
Bathing __ General Mobility __
Toileting __ Cooking __
Bed Mobility __ Home Maintenance __
Dressing __ Shopping __
B. Gait __ Posture __ Absent body parts? (specify _____)
C. Range of motion (joints) ___ Muscle firmness __
D. Hand grip __ Can pick up a pencil? __
E. Pulse (rate) __ (Rhythm) __ (strength) __
F. Respirations (rate) __ (Rhythm) __
(Breath sounds) __
Describe your usual breathing pattern
(effortless or difficult) ____
G. Blood pressure __
H. General appearance (grooming, hygiene, energy level)
Include the following:
• Do you have allergies in the different seasons?
• Do you smoke? At home? At work?
• Respiratory irritants? At home? At work?
• Do you use breathing aids?
• Over the counter drugs?
• How many pillows do you sleep with? |
|
|
Term
| 3 techniques of Physical Assessment for ventilation |
|
Definition
• Inspect
– Breathing rate and pattern
• Palpation
– Assess chest for swelling or tenderness, abnormal
chest vibration
• Percussion
– Define air filled and fluid filled portions of lung |
|
|
Term
| Inspection of breathing patterns: Normal, Tachypnea, Bradypnea, Hyperventilation, Hypoventilation, Cheyne-Stokes, Hyperpnea, Kussmaul breathing |
|
Definition
Normal
• Rate (12-20/minute); smooth, quiet,
effortless, regular
Tachypnea
• Over 20/minute; rapid, shallow, regular
Bradypnea
• Less than 12/minute, slow, regular
Hyperventilation
• Increase in rate and depth
Hypoventilation
• shallow, slow pattern; may have hypercarbia
Cheyne-Stokes
• Rate & depth are irregular, with alternating
periods of apnea & hyperventilation
Hyperpnea
• laboured breathing pattern, increased rate &
depth, occurs normally during exercise
Kussmaul Breathing
• rate and depth, regular, air hunger, deep
sighing breaths |
|
|
Term
| Respiration assessment - Palpation: How do you do it, what are you assessing for? |
|
Definition
• Place hands on chest wall, thumbs pointed
inward and almost touching.
• Instruct client to inhale deeply
– Normal findings: expansion should be 2-5cm
– Assess for swelling or tenderness, abnormal chest
vibration |
|
|
Term
| Respiration assessment - Percussion: What is it, what does it allow you to do |
|
Definition
• Technique involving tapping of body with the
fingers to evaluate size, borders & consistency
of some of the internal organs
• Also able to evaluate the amount of fluid in a
body cavity
• Define air filled and fluid filled portions of the
lung |
|
|
Term
| Respiration Assessment - Auscultation: What is it, what are you looking for? |
|
Definition
• Listening for breath sounds with a
stethoscope.
• Breath sounds should be equal on both sides
of chest
– Normal
– Crackles
– Wheezes |
|
|
Term
| Capillary refill - what does it reflect, how do you do it, what is normal? |
|
Definition
• Reflects peripheral tissue perfusion and
cardiac output
• Press on the nail bed until it blanches –
release and note the time for the nail to
return to its normal color
• Normal capillary refill is <3 seconds |
|
|
Term
| Nursing Diagnoses for Respiration |
|
Definition
• Ineffective airway clearance
– Diminished, suppressed or absent cough reflex
• Ineffective breathing pattern
– when breathing pattern fails to provide adequate
ventilation
• Activity Intolerance
– unable to endure physical movement & exercise at
the usual or desired level
– fatigue quickly evident with activity or SOB
• Mobility, impaired physical – “the individual
experiences or is at risk of experiencing limitation
of physical movement but is not immobile:
(Carpenito)
• Self care deficit (specify)
– Bathing
– Dressing
– Feeding
– Toileting
– Instrumental
• Self-care Deficit Syndrome
– ↓ ability to perform each of the 5 self-care
activities
• Anxiety |
|
|
Term
| Nursing Diagnosis - Examples of Goals for Respiration |
|
Definition
• Maintaining
– E.g. Client maintains a patent airway
• Restoring
– E.g. Client achieves improved activity tolerance
• Preventing
– E.g. Client’s tissue oxygenation remains above
90% |
|
|
Term
| Examples of expected outcomes for respiration nursing diagnoses |
|
Definition
• The client will demonstrate an effective breathing
pattern as evidenced by rate, depth and rhythm in
usual range by end of shift today.
• The client will describe the allergens causing asthma
attacks and methods of avoiding contact with them
by the end of education session today.
• The client will demonstrate how to correctly use an
inhaler following education of same this am. |
|
|
Term
| Potential nursing interventions for respiration |
|
Definition
• Positioning
• Teach:
– Deep breathing techniques
– Diaphragmatic or abdominal breathing techniques
– Pursed lip breathing techniques
– Coughing
– Splinting
• Incentive spirometer
• Administer O2
as ordered
• Ensure well-balanced diet with adequate
hydration
• Administer anti-anxiety meds as ordered |
|
|
Term
| Use of oxygen: Purpose, when to use |
|
Definition
Purpose: To prevent or relieve hypoxia
Hypoxia: Decrease in normal levels of oxygen in inspired gases,
arterial blood or tissues.
Sudden change in vitals – tachypnea, tachycardia
SOB
Decrease LOC
Headache
Change in behavior – restless, irritable
Dusky / blue colour to nail beds, lips, skin or mucosa
Decreased lung sounds
Mouth breathing
Low O2 sats or abnormal blood gases |
|
|
Term
| Which professions collaborate in administering oxygen? |
|
Definition
oxygen therapy is administered in collaboration with
physician, respiratory services, physiotherapy and
occupational therapies |
|
|
Term
| Oxygen: Precautions for use, how it it supplied (as in the oxygen itself, not nasal cannula/mask etc..) |
|
Definition
• Oxygen is a highly combustible gas. It ignites
easily in the presence of a spark and fuels fires
eagerly.
• NO SMOKING in areas where oxygen is being
used.
• Ensure electrical equipment in the area is
functioning properly.
• Be aware of procedures in case
of fire, knowing the location
of fire extinguishers and alarms, etc.
• Check O2 levels in portable
tanks before transporting patients.
Supplied:
• Portable tanks with regulators – for transferring
patients and for encouraging mobilization and
independence
• Permanent wall-piped system
Methods:
• Different methods deliver different flow rates and
percentage of O2. Humidifiers may be added to
these. Humidifiers add water- vapour to the
inspired air or oxygen, either of which can be very
drying. The water-vapour that humidifiers supply
provides comfort for the patient as well as helping
to loosen thick secretions in the respiratory tract. |
|
|
Term
| 6 ways to administer oxygen + a bunch of other ways that fit under "other" |
|
Definition
Oxygen Mask: There are a wide variety of masks
available that can deliver varying amounts of
oxygen. Humidity or heated humidity can be
added to these methods. Masks generally fit
snugly over the mouth and nose and are capable
of delivering a higher concentration of O2 than
nasal cannulas. They come in different sizes to
accommodate patients from infants to large
adults.
Simple Face Mask: Delivers from 30% - 60% O2.
Ports at both sides of the mask allow for exhaled air
to escape so the patient does not rebreathe their
exhaled air.
• Partial- rebreather Mask: Simple mask with a
reservoir bag attached. Delivers from 60% to 90%
O2. Patient rebreathes some of their exhaled air
that has some O2 still in it, plus breathing O2
from the source.
• Non-rebreather Mask: A facemask with a
reservoir bag attachment and one-way valves
present in the mask and between the mask and
the reservoir. This method allows for the highest
concentration of oxygen to be delivered. The
valves allow the expired air [CO2] to be expelled
out of the mask and prevent it from mixing with
the O2 in the reservoir bag, thus providing a
higher concentration of O2. Can deliver up to
100% O2.
• Venturi Mask: These masks have wide-bore
tubing and colour-coded jet adaptors that
correspond to a precise percentage of oxygen
concentration and litre-flow. For example, one
colour will deliver 24% at 4L / minute, and
another 35% at 8L / minute. Newer humidity
bottles come complete with O2 – concentration
dials, making it unnecessary to have the colourcoded adaptors and separate oxygen tubing.
• Other: Nasal catheters, transtrachael catheters,
face tents or O2 boxes [bubbles] are other
methods available for O2 delivery but are not
commonly used. |
|
|
Term
| 7 things to do before administering oxygen (assesment and documentation related... think nursing process) |
|
Definition
• Obtain a set of baseline vitals
• Document patients’ behavioral/cognitive status
• Document patients’ current health status
• Document skin integrity [nares, posterior ears]
• Check Drs order for O2 delivery- method & flow
rate
• Document all.
• Check 30 minutes after initiation of O2 Therapy
and document changes to pre-oxygen status, or if
no changes noted. |
|
|
Term
| What to consider when monitoring patient's oxygen... (what are you monitoring, assessing, providing) |
|
Definition
Ensure safety measures are being followed
• Explain treatment to patient [and verify
comprehension] to ensure compliancy.
• Monitor blood work.
• Monitor vital signs /O2 sats.
• Ensure equipment is functioning properly and lines
are not kinked.
• Position patient appropriately.
• Ensure patient gets plenty of rest. [review patient
lifestyle and possible changes that will be needed].
• Provide for nutrition/hydration status as necessary.
• Provide mouth care and care of nares as
appropriate. Remember to view behind the ears
where nasal O2 tubing, or face-mask - elastics lie to
ensure areas are not developing pressure-sores. |
|
|
Term
| Trach Care and Suctioning - Purpose and Requirements |
|
Definition
• PURPOSE: of trach care and suctioning is to
ensure the client has a patent airway and to
prevent growth of bacteria by removing
respiratory tract secretions. Suctioning is used
when the client is unable to clear their own
airway with coughing. Considered a sterile
procedure because the trachea is considered
sterile.
• REQUIREMENTS:
Trach care is performed as required - at a
minimum of q12h unless otherwise ordered.
Stoma care is a sterile procedure in the first
seven days post-operatively. Clean no touch
technique is used for stoma care after seven days
and for all other aspects of trach care |
|
|
Term
| 4 points for Assesment for trach care (all focused on the appliance and immidiate area) |
|
Definition
• check for soiled or loose ties
• non-stable tube
• excessive secretions
• suction trach prior to procedure if needed |
|
|
Term
| Procedure for trach care (likey not important to memorize) |
|
Definition
• Perform hand hygiene, gather equipment.
• Explain procedure.
• Pour sterile saline
– disposable cups or dressing tray if procedure sterile
• Don clean gloves + mask/eye shield (optional)
– sterile gloves if within 7 days
• Unlock (turn counter-clock-wise) or unclip inner cannula &
remove. Be sure to hold flange of outer tube in place with one
hand.
• Place inner cannula in clean disposable cup with sterile saline
in it. Fold pipe cleaner over at one end and use to gently clean
inner cannula, removing any crustations – soak in solution for
a few minutes if required. Rinse with sterile solution over cup.
• If disposable inner cannula – remove & throw away, insert
new inner cannula (q12-24h per facility
policy/manufacturer’s directions)
• If not disposable, gently shake off excess moisture, dry
with sterile 4X4
• Reinsert inner cannula, ensure locked or clipped in place
• Remove trach dressing if present. Assess stoma for
drainage, pressure or irritation to surrounding skin... Using
sterile saline & a cotton tip applicator or 2X2 for each
stroke – cleanse flange and area behind it and around
stoma. Ensure cotton tip or 2X2 wet, not dripping
• Dry outer cannula & stoma site with clean, dry cotton tip
applicators or 2X2’s.
• Change tube holder q24h
– second person required to hold trach securely in place during a
trach tube holder change. Ensure snugly secured (one finger slack
only).
• Apply clean trach dressing prn
• most important to keep skin clean & dry under trach
flange (plate)
– prevents skin irritation/fungal infection
– trach care may need to be done q2-4h if copious secretions or
frequent suctioning.
• Remove gloves, perform hand hygiene.
• Observe & document tolerance to procedure & airway
patency. |
|
|
Term
| Three types of airway suctioning |
|
Definition
Oropharyngeal/nasopharyngeal – used when client can cough but cannot swallow or expectorate secretions. Suction catheter is passed through mouth or nose to level of soft palate
•Orotracheal/nasotracheal – used secretions cannot be cleared by coughing & no artificial airway present. Suction catheter tip is extended to trachea level – preferable route is nose as gag reflex is less.
•Artificial airway (endotracheal tube or trach) – used to keep airway patent & free of secretions bacterial growth |
|
|
Term
| Suctioning: When is it performed, what factors contribute to airway obstruction, what should you encourage patients to do to help clear secretions? |
|
Definition
•Performed when clinically indicated by signs of respiratory distress, vary from patient to patient.
•Factors contributing to airway obstruction include hydration status, lack of humidity, infection & anatomy e.g. swelling, deviated septum).
•Encourage to cough up secretions whenever possible. |
|
|
Term
| Ventilation - Assessing for sings of upper and lower airway obstruction and hypoxia |
|
Definition
•assess for S&S of upper or lower airway obstruction
–e.g. increased RR, adventitious sounds (noisy breath sounds), drooling, nasal secretions, gastric secretions or emesis in mouth.
•assess for hypoxia (decreased oxygen)
–anxiety, confusion, lethargy, apprehension, decreased LOC, inability to concentrate, increased HR, RR & BP, increased fatigue, dizziness, behavioural changes (irritability), cardiac dysrhythmias, pallor, cyanosis or dyspnea. |
|
|
Term
| Supplies and procedure for (Yankauer (oral) suctioning. Not to be memorized. |
|
Definition
Supplies:
•clean gloves
•Yankauer catheter (oral only)
•clean towel
•sterile water or saline
•disposable cups
•portable or wall suction with connecting tubing
•mask or face shield
Procedure:
•Perform hand hygiene and gather equipment.
•Explain procedure to client and what they can expect to feel during the procedure.
•Encourage coughing during procedure.
•Position client – semi-Fowlers or sitting with head hyperextended if able.
•Place pulse oximeter and take reading – leave in place during procedure.
•Place towel across client’s chest.
•Open Yankauer suction catheter but do not remove from packaging – do not allow sterile end to touch non-sterile surface. Connect to suction tubing.
•Pour approximately 100 mls sterile saline into cup.
•Turn on suction to appropriate setting (wall – 80-120 mmHg, portable – 7-15mm Hg for adults.
•Don clean gloves.
•Apply face shield as appropriate.
•Check equipment by suctioning up small amount of sterile solution from cup.
•Place Yankauer suction in mouth along outer gum lines, apply intermittent suction by pressing & releasing thumb from suction vent.
•Slowly move Yankauer around gum lines to suction emesis, mucous or secretions. Allow self-suction as appropriate.
•Encourage client to cough, observe for S&S of respiratory distress.
•Rinse catheter & suction tubing using the sterile solution until clear.
•Assess client status for secretion clearance, repeat suctioning 1-2 more times to clear secretions prn.
•Provide oral care for client.
•Compare client vital signs before and after procedure to assess effectiveness of intervention – seek client feedback for this as well.
Document. |
|
|
Term
| What is the purpose of deep breathing? |
|
Definition
•To promote chest & lung expansion by increasing lung volume & airway diameter
• Prevent stasis of pulmonary secretions
–in immobilized and/or post operative clients)
•To prevent atelectasis and hypostatic pneumonia
a. Atelectasis
secretions block bronchus, bronchiole or alveoli causing collapse.)
b. Hypostatic pneumonia
inflammation of lung from pooling or stasis of secretions |
|
|
Term
| Coughing - how often should it be encouraged if pt has pulmonary/upper or lower resp. tract. infections; How does this change if large amounts of sputum are noted; what conditions could contraindicate coughing |
|
Definition
if pulmonary disease or upper or lower respiratory tract infections, encourage to cough at least q2h while awake if large amounts of sputum noted, encourage to cough q1h while awake & q2-3h during sleeping hours until mucous production has ended
• Coughing may be contraindicated after brain, spinal or eye surgery due to increased intracranial &/or intraocular pressure |
|
|
Term
| Deep breathing and coughing: Which clients is it taught to |
|
Definition
•taught to all clients who are at risk for respiratory impairment
–Immobilized
–Hx of pulmonary problems
–Narcotic use
• Those who have undergone a surgical procedure |
|
|
Term
| Diaphragmatic breathing - what is it used to achieve, what groups is it useful for and what does it promote in those groups |
|
Definition
| diaphragm, instead of accessory respiratory muscles, is used to achieve maximum inhalation concentrates on expanding the diaphragm during controlled inspiration useful for those with pulmonary diseases, post -operative clients & women in labour, to promote relaxation & provide pain control |
|
|
Term
| Pursed lip breathing - what is it, what does it prevent, how do you instruct a client to perform it |
|
Definition
•Involves deep inspiration & prolonged
expiration through pursed lips Prevents alveolar collapse Instruct client to sit forward (perhaps leaning over table) take a deep breath through nose & exhale slowly thru pursed lips (as if blowing out a candle) expiration phase > inspiration phase perfect technique by counting inhalation time & gradually increasing exhalation time Studies, using pulse oximetry as a feedback tool, note arterial O2 sat levels have been increased during pursed lip breathing |
|
|
Term
| Coughing - what do to if there is a possibility for pain, what chracterizes effective coughing, what is the technique discussed in class |
|
Definition
Coughing
If there is a possibility of pain during coughing, offer analgesic prior to performing the exercises Coughing needs to be deep, reaching lungs, not the throat
•Effective coughing best in sitting position (high Fowler’s position)
• Take two slow deep breaths, inhaling through nose, exhaling through mouth
•Inhale deeply a third time, hold the breath to the count of three
•Cough fully for 2 or 3 consecutive coughs without inhaling between coughs (when coughing use abdominal & other accessory muscles) |
|
|
Term
| Splinting the Incision - when is it done, what does it help with, how can the patient do it |
|
Definition
•post operatively, incision must be splinted (abdominal or thoracic surgery)
•gently apply external pressure against incisional area
•limits pain, strengthens force of muscular contractions
To splint, the patient can:
1. Place one hand over incisional area, other hand on top of it. Gently press against area to splint or support it
2. For clients with abdominal surgery a pillow can be placed over the incisional area
3. The nurse may have to assist the patient |
|
|
Term
| Ventilation - Nurse as educator "cheerleader" |
|
Definition
•give clear instructions in techniques of deep breathing and coughing
•rationale as to why needed to ensure compliance
•e.g. post operatively, these exercises will help to clear general anaesthetic from your body
•also helps to prevent stasis “pooling” of secretions & prevent pneumonia (lung infection)
•Q1h while awake, teach on admission
•May use pillow post-op to splint incision
•Document teaching, return demo, frequency performed, any sputum noted – unusual characteristics |
|
|
Term
| Purpose of incentive spirometry |
|
Definition
•encourage voluntary deep breathing by providing patients with visual feedback
•prevent or treat post operative complication of atelectasis |
|
|
Term
| What are the two types of spirometers |
|
Definition
1.Flow Oriented
•one or more plastic balls that can be seen to rise with slow, consistent inhalation
•goal is to maintain the ball(s) elevation for as long as possible
•maximal sustained inhalation & >lung expansion
•used at Capital Health
2. Volume-Oriented
•piston/bellows to be raised to a predetermined volume by inhaling
•achievement light or counter is used to provide feedback to patient
•advantage is that a known inspiratory volume can be achieved |
|
|
Term
| What conditions indicate the use of a spirometer |
|
Definition
•pre & post abdominal, thoracic, cardiac or orhthopedic surgery
•chronic respiratory disease
•history of smoking
•history of pneumonia
•atelectasis |
|
|
Term
| What to document when a patient is using an incentive spirometer |
|
Definition
• Type of Spirometer used
• Volume or flow levels achieved
• Number of times performed per hour
• Patient’s tolerance or adverse effects
• Results of auscultation (lung sounds
before and after use)
• Patient teaching
Report any changes in respiratory status or inability of the client to use the incentive spirometer |
|
|
Term
| Pulse Oximetry: acceptable ranges, when is it live threatening |
|
Definition
• acceptable 90% to 100%
•70% is life threatening
•pulse oximetry detects hypoxia before visible cyanosis of skin occurs
•document on Basic Patient Care Flow Sheet or Vital Signs Sheet |
|
|
Term
| Pulse oximetry: what is accuracy directly related to, what do you need to assess prior to taking O2 sat |
|
Definition
Accuracy directly related to:
•perfusion, systolic BP > 90mmHg, Hgb level
Conditions that decrease arterial blood flow must be assessed prior to taking O2 Sat:
•Peripheral vascular disease
•Hypothermia
•Vasoconstriction
•Hypotension
•Peripheral edema
•Probe applied too tightly |
|
|
Term
| What factors affect O2 saturation as read by pulse oximetry, what sites are used |
|
Definition
•other light sources
–avoid direct sunlight or direct fluorescent lighting
•client motion
•jaundice
•intravascular dyes
•carbon monoxide
–smoke inhalation or poisoning
Sites used:
Earlobe, Finger, Toe, Bridge of Nose, Forehead |
|
|
Term
| Three types of Sputum Tests |
|
Definition
•Culture and Sensitivity (C&S)
–Identifies specific microorganisms
–Identifies drug resistance & sensitivities
•Sputum for Acid- Fast bacillus (AFB)
–Used to screen for detecting tuberculosis
–early am specimen X 3, 3 consecutive days
•Sputum for Cytology
–identifies & differentiates type of cancer cells
–small cell, large cell, oat cell
– early am specimen X 3, 3 consecutive days
–container for specimen has preservative in it |
|
|
Term
| How to collect sputum specimens, what do you need to explain the importance of, do does the pt need to do prior to collecting sample, what should be done prior to coughing |
|
Definition
wear disposable gloves
collect early morning sample
explain importance of coughing & expectorating sputum, not saliva
cleanse mouth or rinse with water prior to collecting
advise not to use mouth wash or toothpaste as these could alter culture results
deep breathing prior to coughing |
|
|
Term
| Sputum Collection - What to document |
|
Definition
•type of specimen
•type of test (e.g. C&S, Cytology, AFB)
•method used (e.g. by suction)
•time & date
•characteristics of sputum
•report unusual sputum characteristics
•monitor lab reports, note & report abnormal findings
•if AFB sputum culture is positive, patient is placed on appropriate precautions; infectious disease practitioner is contacted. |
|
|
Term
| Definitions of comfort and rest |
|
Definition
Comfort:
• A sense of physical, psychological, social, spiritual
& environmental ease; nurse provides comfort by
explaining procedures (decreases anxiety)
Rest:
• Freedom from emotional tension & physical
discomfort; does not equate to immobility or
inactivity |
|
|
Term
|
Definition
Nonrapid eye movement
(NREM)
75-80% of sleep time
Rapid eye movement (REM)
20-25% of sleep time
Once asleep, pass through 4-6,
90 minute cycles; each cycle
consisting of 4 stages of NREM
& a period of REM sleep. |
|
|
Term
|
Definition
A. Pre-sleep period
A. Normally lasts 10-30 minutes
– Progress from stage 1 through 2 of NREM sleep
– followed by a reversal from stage 4-3-2, ending with a
period of REM sleep
– Normally after 90 minutes, a person enters a REM period
– With each successive cycle, stages 3 and 4 shorten and
REM lengthens
B. NREM Stage 3 & 4 sleep
C. REM sleep |
|
|
Term
|
Definition
• Lightest & shortest sleep phase, transition
from drowsiness to sleep.
• Muscles relax, respirations become even, and
pulse decreases.
• Lasts only a few minutes – if person awaken
will say was not asleep |
|
|
Term
|
Definition
• More relaxed
• May still be easily roused
• Still a light sleep |
|
|
Term
|
Definition
• Difficult to rouse
• BP, pulse, body temperature, formation of
urine and oxygen consumption by the muscles
decrease
• Stages 3 and 4 constitute deep sleep or slow
wave sleep = physical restorative sleep. |
|
|
Term
|
Definition
• Completely relaxed
• May not move
• Increase in hormones such
as the growth hormones
and prolactin to stimulate
growth and healing |
|
|
Term
| Sleep stages during which snoring, sleepwalking, and bed wetting are most likely to occur |
|
Definition
|
|
Term
| Difference in dreams between REM and NREM |
|
Definition
NREM 3 and 4 dreams = realistic
REM dreams = vivid and implausible |
|
|
Term
| Growth and development in sleep |
|
Definition
• Newborns
– Sleep 16 hours per day
• Infants
– Sleep through night 3-4 months of age
– Sleep 8-10 hours at night with naps
• Toddlers
– 10-14 hours
– May nap
– Bedtime rituals important
• Preschooler
– Sleep 13+ hours at night
• School-age
– 6 year old – 11-12 hours
– Age 11/12 – 9-11 hours at night
• Adolescents
– 9-10 hours per night
– Often experience EDS (excessive daytime
sleepiness, due to lack of sleep)
• Young Adults
– 6-8.5 hours
• Middle Adults
– Less time sleeping
– Decline stage 4 sleep
• Older Adults
– ↓ sleep quality
• Pregnancy
– Extra sleep during 1
st
and 3
rd
trimesters |
|
|
Term
| Short sleepers vs Long sleepers |
|
Definition
• Short sleepers
– Less than 6 hours
– Thought to be efficient and hard working
• Long sleepers
– More than 9 hours
– Have higher percentage of REM sleep
– Thought to be more creative |
|
|
Term
| Factors that affect sleep |
|
Definition
• Age - need fluctuates with developmental stage
• Personal Habits - routine
• Illness - may interfere with sleep, yet individual may
need more sleep
• Medications - may depress REM sleep
• Emotional Stress – e.g. financial worries
• Nutrition - food or hunger close to hs
• Activity – too much or too little at hs
• Environment – noise, lights, snoring |
|
|
Term
| Dyssomnias and Parasomnias |
|
Definition
Dyssomnias
Insomnia –difficulty falling or staying asleep; often due to
stress/anxiety; feel sleepy, depressed during day
Hypersomnia - exceesive daytime sleeping, often to escape anxieties
or frustrations
Narcolepsy – sudden, irresistible sleep attack; last 30 seconds-20
min; often insomniac at night
• Parasomnias- disruption in sleep cycle, occur during Stage
4
Nocturnal Enuresis - bed-wetting, mostly in children
Somnambulism – sleep walking, mostly children; just guide to bed
Bruxism – grinding of teeth
Night Terrors - awake, disoriented, cry/sit upright in bed, diaphoretic |
|
|
Term
|
Definition
Sleep Apnea
Signs and Symptoms
• Hypersomnia, insomnia, loud snoring
• Morning headaches
• Impotence
• Depression
• Confusion
• Daytime lethargy
• Poor performance
• High BP, Irregular Heartbeat |
|
|
Term
| Signs and Symptoms of sleep deprivation |
|
Definition
– Verbal comments
– Tired, ↓ alertness
– Irritable
– Restless
– Lethargic
– Depressed
– Anxious
– Apathetic, listless
– ↓ concentration
– Forgetfulness
– Minor troubles may seem major
– sensitivity to pain
– Delusions or hallucinations
– Prone to accidents or falls |
|
|
Term
| Types of sleep pattern disturbances |
|
Definition
Types of Sleep Pattern Disturbances
• Delayed sleep onset – may occur with fear, anxiety,
conflict, nonconductive pre-sleep activities
• Interrupted sleep pattern – hospitalized patients, new
mothers
• Sleep pattern reversal – awake at night and sleep
during day, such as in shift workers |
|
|
Term
| Nursing interventions for sleep disturbances |
|
Definition
• Warm milk before bedtime (hs - hour of sleep)
• Allow opportunity to continue with warm bath or
shower before bed
• Follow bedtime ritual (bath, brush teeth, read book,
etc.), same routine is important
• Have own pillow
• Keep noise to minimum
• Discourage daytime naps
• Back massage |
|
|
Term
|
Definition
• “P” permission
– Provide opportunity for expressing concerns
– Every healthcare provider should practice at this level
• “LI” limited information
– Give answers to questions if you know, seek
experienced team members if you don’t know
• “SS” specific suggestions
– Experienced & knowledgeable, give advice
• “IT” intensive therapy
– Specialist in sexuality counseling |
|
|
Term
| Sexual alterations in women with chronic illness/neurological disabilities |
|
Definition
Fatigue
Decrease in sexual desire (libido)
Decrease in genital sensation
Vaginal lubrication
Diminished or absence of orgasm |
|
|
Term
| Sexual alterations in men with chronic illness/neurological disabilities |
|
Definition
Premature ejaculation
Erectile dysfunction
Changed sensation in
the penis
Reduced sexual desire
Orgasmic dysfunction |
|
|
Term
| Sleep Rest Dysfunction: Nursing Diagnosis with possible expected outcomes |
|
Definition
Used to describe temporary changes in usual sleep patterns and/or those that a nurse can prevent or reduce
•Defining Characteristics
•Difficulty falling or remaining asleep
•Fatigue on awakening or during day
•Mood alterations
•Dark circles under eyes
•Sleep pattern disturbance can become etiology of other problems such as ineffective individual coping related to prolonged lack of sleep
•Types of Sleep Pattern Disturbances
•Delayed sleep onset – may occur with fear, anxiety, conflict, nonconductive pre-sleep activities
•Interrupted sleep pattern – hospitalized patients, new mothers
•Sleep pattern reversal – awake at night and sleep during day, such as in shift workers
•The person will demonstrate 6-8 hours uninterrupted sleep (measured by nurse observation q2h during 2300-0700) X 48 hours
•The patient will verbalize having slept better and feeling more rested in two days. |
|
|
Term
| Sexuality-Reproductive Health Pattern |
|
Definition
Our human sexuality is a continuous development between birth & death
We all experience it, in many different ways |
|
|
Term
| Sexuality Issues - what can happen to the importance of sexuality/intimacy in patients with illness/disability, what is the affect of intimacy on self esteem, how can you compensate for it being a sensitive area of discussion |
|
Definition
•Critical to quality of life
•Sexuality & intimacy may become even more important in patients with illness/disability
•Intimacy provides reassurance to self-esteem and to emotional well-being/relationship
•Sensitive area for most
–Terminology/frame of reference needs to be the same for you and patient to be able to converse
–Nurses need to be able to provide opportunity for patient to be comfortable to express concerns |
|
|
Term
| Areas of assessment for Sexuality-reproductive health pattern |
|
Definition
•Individual assessment
•History
•If appropriate to age and situation: Sexual relationships satisfying? Changes? Problems?
•If appropriate: Use of contraceptives? Problems?
•Female: When did menstruation start? Last menstrual period? Menstrual problems? Para? Gravida?
•
•Examination
•None unless a problem is identified or a pelvic examination is part of full physical assessment.
**Gravida is the number of times a women has been pregnant while para is the number of live infants produced frm those pregnancies. |
|
|
Term
| problems is sexuality/intimacy: fatigue |
|
Definition
May be helpful to set aside time in the
morning when fatigue is at its lowest
Naps or rest period prior to sexual activity |
|
|
Term
| problems is sexuality/intimacy: decrease in libido |
|
Definition
Most common
complaint (usually due
to fatigue)
May begin to avoid
situations that were
formally associated
with sex
Worries that partner
may feel rejected
Person with chronic
illness/disability may
experience:
Guilt
Anxiety
Reduced
self-esteem |
|
|
Term
| Cognition/Perception: what is it, what does it incorporate, what are 3 major means of sensory input |
|
Definition
• mental process characterized by knowing,
thinking, learning, judging
• incorporates reasoning, intuition, memory
• includes adequacy of sensory modes, such as
vision, hearing, taste, touch or smell & the
compensation or prosthesis used to deal with
disturbances.
• Eyes/ears/skin are major means of sensory input |
|
|
Term
| Cognition/Perception: what do you include in assessment |
|
Definition
• Level of consciousness
• Orientation to person, time, place
• Memory
• Intellectual functioning |
|
|
Term
| Cognition/Perception: Pain |
|
Definition
• Cognition/perception
health pattern includes
assessment for presence
of pain
• If pain present, determine
location, duration, type,
severity
– Contributing factors
– Relieving factors |
|
|
Term
|
Definition
Prolonged reduction in exposure to sensory stimuli:
• Inadequate quantity or quality of stimulation
ie. life becomes monotonous or meaningless
• May result in boredom, impaired LOC, lack of
coherent thinking, anxiety, fear, depression,
hallucinations
• Most significant deprivation reported to be lack of
human touch
Hospital environment can affect order and
meaning of input, especially ICUs |
|
|
Term
|
Definition
When individual receives multiple stimuli –
overload prevents meaningful response
by the brain
• May present with racing thoughts,
scattered attention, restlessness, anxiety
• Common in hospitalized, ICU, etc. |
|
|
Term
| Cognition and Perception: Manifestations of Altered Functions |
|
Definition
1. Disorganized Thinking
– Thinking, learning, reasoning and remembering do
not occur in an orderly manner. Includes delusions
(fixed false belief) and hallucinations (perceptions
arising from own thoughts – may be visual,
auditory, tactile)
2. Impaired Thought Processes
– Attention span deficits, memory impairment or
altered LOC (ie. alert, lethargic, obtunded,
stuporous, comatose). Impaired judgment, insight,
planning, problem-solving |
|
|
Term
|
Definition
Acute organic mental syndrome – global cognitive
impairment, disturbances of attention, decreased
LOC, increased or decreased psychomotor
activity, disorganized sleep cycle (Porth)
Acute onset – hours to days (can fluctuate during
the day)
Can persist for 30 days or longer – may be residual
effects for months
Frequently seen in hospitalized, elderly
May be presenting feature of presenting illness, and
commonly the only sign of illness
UTI, pneumonia, malnutrition, MI, cancer, etc
Contributing Factors:
• Multiple forces that can cause cerebral
dysfunction and changes to neurochemistry
• Decreased CNS reserve in older adults may
precipitate delirium – less able to adapt to stress
of acute illness, meds, change in environment
• Vision /hearing impairment
• Psychological stress
• Diseases of other organ systems |
|
|
Term
| Nursing care for Delirium |
|
Definition
Screen, assess, manage early!
• Prevention of delirium is goal
• Recognition of syndrome and cause
• Key symptoms: agitation, disorientation,
fearfulness
• At high risk for injury
• Treat underlying disease condition, nutrition,
fluid and electrolyte balance, etc
• Symptomatic and supportive measures
• Promote physical, mental activity
• Relieve discomfort and restore sense of control |
|
|
Term
| Nursing Dx: Disturbed thought process |
|
Definition
A state in which an individual experiences a
disruption in such mental activities as
conscious thought, reality orientation,
problem-solving, judgment, and
comprehension related to coping, personality,
and/or mental disorder
– R/t: Fear, depression, anxiety, stress and
isolation |
|
|
Term
| Nursing Dx: Acute confusion |
|
Definition
(an abrupt onset of a cluster of global, fluctuating disturbances in
consciousness, attention, perception, memory, orientation,
thinking, sleep-wake cycle, and psychomotor behavior )
(Carpenito, 2012).
• r/t cerebral hypoxia or disturbance in cerebral metabolisms
• secondary to: traumatic head injury
• as manifested by frequently & abruptly falling asleep while
talking, lack of attention to conversation, easily distracted during
activity, disorientation to place & time, impulsive actions such as
getting up to chair without noting feet are crossed/wrapped in
blanket, inability to remember where room is located |
|
|
Term
| Nursing interventions for acute confusion |
|
Definition
• Orientate patient to environment
• Introduce self & others to patient
• Decrease extraneous noise, light & other distractions
• Provide reality orientation with clocks, calendars, activity
boards, etc.
• Explain procedures, sounds & equipment to client.
• Promote client safety: uncluttered environment, arm band,
activity aids,
• Removal of dangerous substances
• Do not endorse confusion
• Use of LEAST PHYSICAL OR CHEMICAL RESTRAINT Policy |
|
|
Term
| Nursing Dx: Chronic confusion |
|
Definition
• A state in which the individual experiences an irreversible,
long-standing, and/or progressive deterioration of intellect &
personality (Carpenito, 2012).
– r/t:
• progressive degeneration of cerebral cortex secondary
to Alzheimer’s Disease
• disturbance in cerebral metabolism, structure, or
integrity secondary to glioblastoma metastatic brain
tumor |
|
|
Term
| Nursing interventions for chronic confusion |
|
Definition
• Establish a safe, stable environment
• Employ reality orientation & memory cues consistently
• Encourage acceptance of level of functioning (patient & family).
• Use patient’s name frequently.
• Assist with ADL as required
• Ensure adequate fluid intake & nutrition.
• Assist/promote mobility status.
• Provide socialization opportunity
– Music
– Recreation
– Reminiscence
– Church...
AVOID USING PHYSICAL OR CHEMICAL RESTRAINTS |
|
|
Term
| Broad categories that can affect cognitive function and what they depend on |
|
Definition
• Can be affected by
physiologic, emotional or
environmental factors
• Depends on interaction of
Person and Environment |
|
|
Term
| Big list of Individual factors for cognition/perception |
|
Definition
• Blood flow
• Nutrition
• Fluid and electrolyte
balance
• Sleep and rest
• Organization of
environmental stimuli
(amount & kind of stimuli
& demands) |
|
|
Term
| Cognition/Perception: Big list of things to consider |
|
Definition
• Blood flow
• Nutrition
• Fluid and electrolyte
balance
• Sleep and rest
• Organization of
environmental stimuli
(amount & kind of stimuli
& demands) |
|
|
Term
| Cognition and Perception: Sensory Deficit - what is it, what can it cause, what is proprioception |
|
Definition
A defect in function of sensory
reception & perception
• Visual, auditory, tactile, olfactory,
gustatory, proprioceptive
• Sudden loss may cause fear, anger,
helplessness
• Individual may withdraw – avoid
communication & socialization in
attempt to cope
Proprioception – position sense,
vibration or awareness of posture,
movement & equilibrium |
|
|
Term
| When instilling enema and patient gets cramps what should you do |
|
Definition
| lower position of bag or stop flow |
|
|
Term
|
Definition
Primary prevention?
Stage based approach |
|
|
Term
| Public health nurse talking to schools |
|
Definition
Uses material suited to developmental stage
evaluates understanding and adjusts teaching
Primary prevention |
|
|
Term
| Guest speaker: Nurse that works in the hospital |
|
Definition
Secondary prevention
only patient can use PCA |
|
|
