what are the 5 dimensions of Pain?
- 1. affective
- 2. sensory
- 3. behavioural
What will help assist tissue formation?
Vit c and d
what are the 3 principles or chronic pain management?
- 1. Give patient as much control as possible
- 2. use preventative approach
- 3. titrate to effect
How do you care for a client with enteral tubes?
- Oral care
- Securing NGT, GT or PEG
- Monitor bowel sounds
- Fluid balance chart
- skin integrity
- education and reassurance
What are some complications of IV/
- Heamatoma - blood under skin
- cellulits - inflammation of cells
- Extravasation - Around surrounding tissue
- Infiltration - fluid gone into surrounding area
- phlebitis - inflammation of vein
what are the 5 steps of diagnosing and treating a patient?
- nursing diagnosis
what is safety?
freedom from psychological and physical injury
what is environment?
All the many physical and psychological factors that influence or effect the life and survival of the patient
What is environmental safety?
- Basic needs - oxygen nutrition
- Physical hazards - lighting, obstacles
- pathogen - bacteria, fungi
- pollution - air, water, noise
What are the 4 risk factors in a health care agency?
- Patient inherit accidents
- equipment inherit accidents
- procedure related accidents
What are some specific hazards?
- excessive noise
what are 4 types of restraints?
- Physical- jackets, protective mittens, cast
- environmental - bed rails, locked door
- Chemical - medications
- Emotional - verbal/non verbal intimidation
What are some general factors affecting wound healing?
- underlying disease
- nutritional status
- disorders of sensation
what are some local factors effecting wound healing?
- Hydration of wound
- wound management practices
- wound temp (37)
- foreign bodies
- wound infection
What does vitamin c assist with?
What does vitamin E do?
enhances epithelisation, collagen synthesis
what helps mitosis and cell proliferation?
What role does fluid play in would healing?
Essential for all cell function
What are 4 status of skin integrity?
- closed-nobreak, e.g haemorrhage
- Acute - trauma
- chronic - ulcer
What are the 4 pressure ulcer stages?
- 1 - intact skin, non blanching erythema (redness) of localised skin
- 2- Partial thickness loss of dermis without slough
- 3- full thickness tissue loss - sub fat may be visible slough maybe present
- 4 - Full thickness tissue loss with exposed bone, tendon or muscle. slough and eschar may be present
What does the Braden scale rate?
what is a good wound healing environment?
- Warm, moist, non toxic
- oxygen and perfusion
- body temp - 37
- free from excess exudate and dead tissue
- adequate nutrition
What are 6 wound complications?
- evisceration - protrusion of visceral organs
What can alter bowel function?
- Paralytic ileus
- bowel obstruction
- bowel diversion - stoma
What would you assess when assessing bowel function?
mouth, abdomen, rectum
what faecal characteristic do you look for?
State and describe the 5 types of urinary incontinence?
- Functional - change in environment/some sort of deficit
- overflow - loss of small amount
- reflex - involuntary loss (spinal cord dysfunction)
- Stress - leakage of small amount, caused by sudden increase in intra-abdominal pressure, weak pelvic muscles
- Urge - involuntary passage of urine after a sense of urgency
What are 5 exercise activity types?
- Isotonic (Dynamic)
- isometric (Static)
What are 4 factors affecting mobility?
- Prescribed limitation - RIB, cast
- medication - narcotics
- Nutrition - under/over
List some effects of immobility
- cardiovascular (thrombus, increase work load)
- metabolic - decreased metabolic rate
- Urinary (urinary stasis)
- GIT (Constipation/impaction)
- integumentary (reduced skin turgor)
- Psychosocial (personal values)
what should the nurse do post operatively?
- explore patient feelings and alley fears
- Be aware that no surgery is minor to the patient
- be empathetic and listen to patient
- education should encompass, physical and psychological care
- Provide TED stockings
what do ted stockings do?
Maintain pressure one lower extremities, promote venous return
What is hypoxia and some causes
Insufficient O2 anywhere in the body from inspired gas to tissue.
- decrease haemoglobin (Anaemia)
- decrease diffusion into alveolar
- impaired ventilation
what are some signs and symptoms of hypoxia?
- tachycardia, tachypnoea, shallow reps, dyspnoea
- Light headedness
- behavioural changes
- cyanosis in late stages
What do neurovascular obs check?
What is compartment syndrome?
Occurs after an injury, when there is not sufficient amount of blood supply to nerves and muscles with oxegen and nutrients because of raised pressure in the compartment. The fascia layer that defines the compartment does not stretch so a small amount of bleeding into the compartment, or swelling of the muscles within the compartment can cause the pressure to rise greatly.
What are the symptoms of compartment syndrome? (5 ps)
- and pulses (absence of)
what is DVT?
Occlusion of the deep veins
what are the risk factors for DVT ad S and S
- sedentary life style
- post op
- can dislodge = stroke
- S and S
- Often none
- warm and or discoloured skin
- visible surface veins
- leg fatigue
What are the 6 levels of consciousness and describe a bit about each
- alertness - awake, attentive, appropriate responses to stimuli, orientated
- Confusion - attention drifts, easily distracted, disorientated
- Lethargy - drowsy, falls asleep, but easily arouses at sound of voice
- Delirium - severely confused, disorientated perception, react inappropriately to stimuli.
- Stupor - Awake intermittently, aroused for only short periods requires loud noise or painful stimuli's for arousal. responds only with movement and moaning
- Coma - not able to be aroused, moves only involuntary
What does a neurological assessment look like?
- Level of consciousness
- pupillary check
- vital signs
- movement and strength of extremities
What does the Glasgow coma scale assess?
- eyes opening - spontaneous, to speech, pain or no response.
- Assess patient orientation - name, month, season year
- Assess motor response - single response command (touch toes)
What is self concept and the 4 components?
is an integrated set of conscious and unconscious feelings, attitudes and perceptions about self
- body image
- role performance
- self esteem
what are 4 psychological challenges?
- self concept
- loss grief and death; fear unkown
what are the 4 types of loss?
What are 5 manifestations of grief?
What are the 4 natures of death?
What are the 4 process of death?
- Social death - withdraw
- Psychological death - personality changes
- Biological death - no longer exits as human entity
- Physical death - complete cessation of vital organs
List the 4 sources of loss?
- Loss of external objects
- Loss of known environment
- loss of significant other
- Loss of aspect of self
- loss of life