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Unit4/2
| Question | Answer |
|---|---|
| Testing sensory perception | evaluating the patient's response to pain, light touch, and vibration. (inability to perceive pain or light touch, inability to identify the location of touch, and absence of vibratory sensation.) |
| patients who have impaired sensory functioning | risk for injury, disturbed growth and development, and decreased well-being. |
| Sensory reception | is the process of receiving data about the internal or external environment through the senses. Pt maintain contact with the external environment are vision (visual), hearing (auditory) smell (olfactory), taste (gustatory), and touch (tactile). |
| Stereognosis | sense that perceives the solidity of objects and their size, shape, and texture. In addition, individuals orient themselves internally by the kinesthetic and visceral senses. |
| Kinesthesia | refers to awareness of positioning of body parts and body movement; visceral pertains to inner organs.kinesthetic and visceral senses arise internally from muscles and hollow organs, respectively, and are the body's basic orienting systems. |
| Sensory perception | conscious process of selecting, organizing, and interpreting data from the senses into meaningful information. Perception is influenced by the intensity, size, change, or representation of stimuli, as well as by past experiences, knowledge, and attitudes. |
| stimulus | an agent, act, or other influence capable of initiating a response by the nervous system—must be present. |
| receptor or sense organ | must receive the stimulus and convert it to a nerve impulse. |
| The nerve impulse | must be conducted along a nervous pathway from the receptor or sense organ to the brain. A particular area in the brain must receive and translate the impulse into a sensation. |
| reticular activating system (RAS) | poorly defined network that extends from the hypothalamus to the medulla, mediates arousal. The optimal arousal state of the RAS is a general drive state called sensoristasis. (serves to monitor and to regulate incoming sensory stimuli) |
| disturbed sensory perceptions | sensory overload, sensory deprivation, sleep deprivation, and cultural care deprivation. |
| Sensory deprivation | results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. |
| Sensory overload | so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli. Excessive stimuli over which an individual feels little control; brain is unable meaningfully to respond to or ignore stimuli |
| sensory deficit | impaired sight and hearing, altered taste, numbness and paralysis that result in altered tactile perception, and impaired kinesthetic sense. |
| Factors Affecting Sensory Stimulation | The amount of stimuli different individuals consider optimal appears to vary considerably. stimuli needed to maintain cortical arousal P.1025 include developmental considerations, culture, personality and lifestyle, stress, and illness and medication. |
| rest | connotes a condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed. Awareness of the environment is still maintained. |
| Sleep | is a state of rest accompanied by altered consciousness and relative inactivity. It is a complex rhythmic state involving a progression of repeated cycles, each representing different phases of body and brain activity. |
| NDx Disturbed Sleep Pattern: Difficulty Falling Asleep r/t | Worries about family and lack of destressing rituals |
| NDx Disturbed Sleep Pattern: Difficulty Remaining Asleep r/t | Noise of hospital environment and need for periodic treatments |
| NDx Disturbed Sleep Pattern: Premature Awakening r/t | Barbiturate dependency and lack of knowledge of nonpharmacologic aids for insomnia |
| NDx Disturbed Sleep Pattern: Excessive Daytime Sleeping r/t | Effects of biologic aging (moderate increase in stage I and II sleep; slow-wave sleep, stages III and IV, decreases by 50% or more) |
| NDx Disturbed Sleep Pattern: Altered Sleep–Wake Patterns r/t | Frequent rotations of shift and overtime |
| Implementing | In most cases, sleep problems are not the primary reason for a patient's interaction with the healthcare system. |
| NIC (Nursing Intervention Classification Sleep Enhancement) | Approximate patient's regular sleep–wake cycle in planning care. Determine the effects of the patient's medications on sleep pattern. # Adjust environment (eg, light, noise, temperature, mattress, and bed) to promote sleep. |
| NIC (Sleep Enhancement) continue | Encourage patient to establish a bedtime routine to facilitate transition from wakefulness to sleep. |
| NIC (Sleep Enhancement) continue | Facilitate maintenance of patient's usual bedtime routines, presleep cues/props, and familiar objects (eg, for children, a favorite blanket/toy, rocking, pacifier, or story; for adults, a book to read, etc.) as appropriate. |
| NIC (Sleep Enhancement) continue | # Instruct patient to avoid bedtime foods and beverages that interfere with sleep. # Instruct patient how to perform autogenic muscle relaxation or other nonpharmacologic forms of sleep inducement. |
| NIC (Sleep Enhancement) continue | Initiate/implement comfort measures of massage, positioning, and affective touch. Discuss with patient and family sleep-enhancing techniques. |
| Pain | complex phenomenon,body's defense mechanisms that indicates the person is experiencing a problem, |
| Margo McCaffery definition of pain | Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does.” |
| Acutepain | rapid in onset, varies in intensity from mild to severe (warns the individual of tissue damage or organic disease) |
| Chronicpain | may be limited, intermittent, or persistent but that lasts beyond the normal healing period (remission/exacerbation ) |
| Source of Pain | Cutaneous (or superficial)/ somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves/Visceral pain is poorly localized and originates in body organs in the thorax, cranium, and abdomen. |
| referredpain | originate in one part of the body but be perceived in an area distant from its point of origin. |
| Neuropathicpain | results from an injury to or abnormal functioning of peripheral nerves or the central nervous system (CNS).exact cause of neuropathic pain is unknown |
| Responses to Pain | physiologic, behavioral, and affective |
| Behavioral (Voluntary) Responses to pain | Moving away from painful stimuli Grimacing, moaning, and crying Restlessness Protecting the painful area and refusing to move Protecting the painful area and refusing to move |
| Physiologic (Involuntary) Responses to pain | Increased blood pressure Increased pulse and respiratory rates Pupil dilation Muscle tension and rigidity Pallor (peripheral vasoconstriction) Increased adrenalin output Increased blood glucose |
| Typical Parasympathetic Responses When Pain Is Severe and Deep | Nausea and vomiting Fainting or unconsciousness Decreased blood pressure Decreased pulse rate Prostration Rapid and irregular breathing |
| Affective (Psychological) Responses | Exaggerated weeping and restlessness Withdrawal Stoicism * Anxiety Depression Fear Anger * Anorexia Fatigue Hopelessness Powerlessness |
| Mildpain | experienced briefly may produce little or no behavioral response |
| intensepain | experienced briefly usually results in reflex action to escape the cause |
| The Pain Process | transduction (activation of pain receptors), transmission (Pain sensations conducted along pathways), perception (sensory process that occurs when a stimulus for pain is present), and modulation of pain (pain is inhibited) |
| The role of the nurse in caring for patients with an alteration in sensory/perception includes 3 primary goals which are | prevent injury assist the patient with developing ways to cope with sensory deficits ensure appropriate stimulation of the senses |
| insomnia | difficulty falling asleep, staying asleep, or early morning awakenings |
| nocturnal myoclonus | abnormal movements or sensation during sleep or when awakening during the night-jerking of the legs while asleep-"restless leg syndrome |
| excessive daytime sleepiness | excessive daytime sleepiness |
| parasomnias | sleep walking, night terrors, bedwetting, tooth grinding |
| narcolepsy | neurological disorder in which a person suddenly falls asleep uncontrollably at inappropriate times |
| three components of pain | # reception # perception # reaction |
| physiologic (involuntary responses) | with moderate & superficial pain you will see- increased HR, BP, RR, blood glucose, muscle tension, sweating, pallor. With severe & deep pain you will see- decreased HR, BP, nausea, vomiting, weakness, increased muscle tension. |
| behavioral/affective responses | withdrawal from stimulus, grimacing, moaning, restlessness, protecting injured area, anxiety, fear, depression |
| acute pain-rapid in onset pain | lasts < 6 months, identifiable cause, once resolved the pain disappears, may range from mild to severe (ex. kidney stone, pass stone and pain resolves) |
| chronic pain- prolonged pain | lasting > 6 months, associatd with an identifiable cause, inteferes with normal functioning (ex. arthritis) |
| intractablepain | chronic pain which is resistant to therapy (ex. diabetic neuropathy or phantom limb pain) |
| referredpain | pain perceived in an area distant from the site of the stimuli (ex. uterine pain referred to back, low back pain referred to hip) |
| factors that affect pain | age sociocultural influences emotional status past pain experiences and coping style knowledge attention |
| Pain mneumonic | P-provoking factors, what caused the pain or makes it worse Q-quality of pain: dull, sharp, pressure, crushing # R- region or radiation of pain S- severity or intensity of pain on a scale of 0-10 T-timing; onset, duration, frequency |
| Independent nursing interventions for pain PART1 | preventing or alleviating compounding causes (constipation, bladder distention, skin irritation from dressings) # proper positioning, using appropriate moving techniques, beds, and equipment anticipatory guidance tell patient what to expect) |
| Independent nursing interventions for pain PART2 | cutaneous stimulation (back rubs, massage, remember gate control theory methods) distraction (visual, auditory, tactile, project like playing games) relaxation techniques avoid social isolation |
| Collaborative interventions for pain control PART1 | medications (analgesics, adjuvant drugs, patient controlled analgesia, local anesthetics) # transcutaneous electrical nerve stimulator (TENS) (skin around a wound is stimulated with mild electrical current, gate control theory in use again) |
| Collaborative interventions for pain control PART2 | accupuncture application of heat & cold hypnosis |
| Collaborative interventions for pain control PART3 | biofeedback (patient learns to replace stress-related responses with relaxation responses) # surgical techniques (permanent interruption of pain pathways) |
| The main constituent of the body | Fluid, comprised of water and dissolved substances in the form of electrolytes, gases, and nonelectrolytes |
| Fluid Balance | The desirable amount of fluid intake and loss in adults ranges from 1500 to 3500 mL each 24 hours, with most people averaging 2500 to 2600 mL per day. |
| intake and output | A person's intake should normally be approximately balanced by output or fluid loss. (not always occur in a single 24-hour period but should normally be achieved within 2 to 3 days.) |
| Intake | Fluid Sources (ingested liquids, food, and metabolism.) Ingested Liquids (largest amount of water/thirst) Water in Food (second largest) Water From Metabolic Oxidation (end product of metabolism of food , specifically carbohydrates, fats, and protein). |
| Output (Fluid Losses; termed sensible water losses.) | Through the kidneys as urine. Intestinal tract in feces. Skin as perspiration. |
| hypovolemia or isotonic fluid loss | Fluid volume deficit can be caused by a loss of both water and solutes in the same proportion from the ECF (extracellular fluid ) space. |
| hypovolemia | A weight loss of 5% in adults and 10% in infants can occur rapidly. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. |
| hypervolemia or excess of isotonic fluid | Excessive retention of water and sodium in ECF in near-equal proportions results in a condition termed fluid volume excess. |
| hypervolemia | Common causes include malfunction of the kidneys, causing an inability to excrete the excesses, and failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. |
| Edema | Accumulation of fluid in the interstitial space (observed around the eyes, fingers, ankles, and sacral space, and can also accumulate in or around body organs.) |
| Patient's evaluation of hydration status | balance between your fluid intake and output,difficulty breathing, edema, dry skin and mucous membranes, thirst. |
| electrolytes | Substances capable of breaking into electrically charged ions when dissolved in a solution |
| Sodium (Na+) | Controls & regulates the volume of body fluids, Maintains aq balance throughout the body, primary regulator of ECF volume Influences ICF volume Participates in the generation and transmission of nerve impulses. Electrolyte in the sodium-potassium pump |
| Potassium (K+) | chf regulator of cellular enzyme activity and cellular aq content Vital role in transmission of electric impulses (nerve, heart, skeletal, intestinal, lung tissue); protein and carbohydrate metabolism; cellular building. Reg of Acid-base balance and H+ |
| Calcium (Ca2+)most abundant | Nerve impulse transmission and blood clotting. Is a catalyst for muscle contraction Is needed for vitamin B12 absorption and for its use by body cells Catalyst for many cell chemical activ. Strong bones and teeth Strength, thickness of cell membr. |
| Magnesium (Mg2+) PART 1 | Metabolism of carbohydrates and proteins Is important for many vital reactions involving enzymes Is necessary for protein and DNA synthesis, DNA and RNA transcription, and translation of RNA Maintains normal intracellular levels of K+ |
| Magnesium (Mg2+) PART 2 | Helps maintain electrical activity in nervous tissue membranes and muscle membranes. |
| Chloride (Cl-)Part 1 | Acts with sodium to maintain the osmotic pressure of the blood Plays a role in the body's acid-base balance Has important buffering action when oxygen and carbon dioxide exchange in red blood cells |
| Chloride (Cl-)Part 2 | Is essential for the production of hydrochloric acid in gastric juices |
| Bicarbonate (HCO3-) | Is essential for acid-base balance; bicarbonate and carbonic acid constitute the body's primary buffer system |
| Phosphate (PO4-)Part1 | Helps maintain the body's acid-base balance Is involved in important chemical reactions in the body; eg, phosphorus is necessary for many B vitamins to be effective, helps promote nerve and muscle action, and plays a role in carbohydrate metabolism. |
| Phosphate (PO4-)Part2 | Is important for cell division and for the transmission of hereditary traits |
| NDx (data point to fluid and electrolyte problems amenable to nursing therapy) | One of three:Excess Fluid Volume, Deficient Fluid Volume Risk for Imbalanced Fluid Volume |
| Fluid and Electrolyte Disturbances as the Etiology (r/t) PART1 | Activity Intolerance related to imbalance between oxygen supply and demand, Ineffective Breathing Pattern related to compensatory mechanism by lungs (hypoventilation or hyperventilation), Anxiety related to hyperventilation, |
| Fluid and Electrolyte Disturbances as the Etiology (r/t) PART2 | Decreased Cardiac Output related to decreased blood volume, shock, Risk for Injury related to neuromuscular irritability, cardiac arrhythmia |
| Fluid and Electrolyte Disturbances as the Etiology (r/t) PART3 | Deficient Knowledge: Harmful Effects of Abuses of Dieting, Alcohol, Diuretics, Laxatives, and Enemas related to no previous experience # Impaired Oral Mucous Membrane related to fluid volume deficit |
| Fluid and Electrolyte Disturbances as the Etiology (r/t) PART4 | Impaired Skin Integrity related to fluid volume deficit or fluid volume overload Disturbed Thought Processes related to cerebral edema, mental confusion or disorientation, or convulsions |
| Fluid and Electrolyte Disturbances as the Etiology (r/t) PART5 | Ineffective Tissue Perfusion: (specify type) related to decreased cardiac output Impaired Urinary Elimination related to decreased kidney perfusion secondary to decreased plasma volume |
| Consciousness | is the degree of wakefulness or the ability of a person to be aroused. This is not the same as orientation; a patient may be conscious but not oriented. |
| Level of Consciousness (Awake and alert) | fully awake; oriented to person, place, and time; responds to all stimuli, including verbal commands |
| Level of Consciousness (Lethargic) | appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying patient's name |
| Level of Consciousness (Stuporous) | unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements |
| Level of Consciousness (Comatose) | cannot be aroused, even with use of painful stimuli; may have some reflex activity (such as gag reflex); if no reflexes present, is in a deep coma |
| Glasgow Coma Scale | Three parameters are evaluated: eye opening, motor response, and verbal response. A score of 7 or less defines coma. |
| complementary and alternative therapies (CAT) | interventions that are complementary (they can be used with traditional medical interventions and thus complement them) as well as alternative (not included in the scope of conventional medical care). |
| Allopathic medicine (or biomedicine) (not effective with chronic illness ) | dominant for about 100 years and has spearheaded remarkable advances in biotechnology, surgical interventions, pharmaceutical approaches, and diagnostic tools. effective when aggressive treatment is needed in emergency or acute situations. |
| CAT Categories | whole medical systems, mind–body therapies, energy medicine, biologically based practices, and manipulative and body-based practices |
| Whole (or alternative) medical systems | similar to the Western, allopathic model in that they are complete systems of theory and practice. They consist of a set of beliefs about the origin of diseases, ways to promote health, and types of treatment. |
| Mind–body medicine | uses a variety of techniques designed to enhance the mind's ability to affect bodily function and symptoms. |
| Energy medicine | involves the use of energy fields, such as magnetic fields or biofields (energy fields that some believe surround and penetrate the human body). |
| Manipulative and body-based practices | work with the structures and systems of the body, including bones and joints, soft tissues, and circulatory and lymphatic systems. |
| Biologically based practices | include the use of botanicals (herbs), animal-derived extracts, vitamins, minerals, fatty acids, amino acids, proteins, prebiotics and probiotics, whole diets, and functional foods. |
Created by:
russianalaskan
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