NUR 121 test 4

  1. 3 Dimensions of Self concept:
    • 1) Self knowledge- Who am I? Global self,
    • 2) Self expectation- Who/what do I want to be? Ideal self.
    • 3) Self evaluation- How well do I like myself? Self-esteem.Social support from others.
  2. Stages and development of self concept
    • 1) Needs met as infant: Physical vs environmental, basic needs met, internalizing
    • 2) Model parental behavior: Significant role, peers are second, behaviors from early
    • 3) Model social standards: Standards vs. social creation (rural vs. city)
  3. Assessing personal identity
    Patient description of self. Example- list 10 labels identifying self & number in order of importance.
  4. Assessing personal strengths
    Ask pointed questions about person’s strengths would help a patient identify positive factors
  5. Assessing body image
    Subjective view of one’s own body. Assess for risk/threat to self
  6. Assessing self-esteem
    Does patient have shared perception of self? Do they like themselves? What do they think of themselves?
  7. Assessing role-performance
    The patient’s role in life. Example: occupation, role in family
  8. 4 Disturbances in self-concept
    • 1) Disturbed body image
    • 2) Chronic,situation, or risk for low self-esteem
    • 3) Ineffective role performance
    • 4) Disturbed personal identification
  9. Helping patients identify and use personal strengths
    • -Nurse must be comfortable with self before they can address patient
    • -Encourage independence
    • - Help patient realize & use their own strengths
  10. Components & Conditions (sensory experience)
    • -Reception
    • -Perception
    • -Arousal mechanism
  11. Sensory perception
    -Conscious process of selecting, organizing, and interpreting data from the senses to meaningful info.
  12. Arousal Mechanism
    -Brain is alerted or aroused. example: “I’m very aroused!” (Ron Burgundy, 2004)
  13. Disturbed sensory perception
    -Sensory deprivation, sensory overload, sensory deficit.
  14. Sensory deprivation
    -Decreased input or input is monotonous, un-patterned, or meaningless.
  15. Sensory overload
    -Too much stimuli, brain is unable to respond or ignore thestimuli, feel out of control
  16. Presbyopia
    -Lens of eye loses its ability to focus making it difficult to see objects up close.
  17. Transsexual-
    Gender id. Disorder where male identifies self as female and vise versa.
  18. Transvestite-
  19. Characteristics of premenstrual (tension) syndrome PMS
    - 50-90% experience, mood changes, back/uterine cramping, irritability, emotional tension, anxiety, headache, breast tenderness, water retention.
  20. Penis erection
    -Blood vessels in shaft become congested and penis becomes hard
  21. Human Papilloma Virus (HPV)
    • -DNA virus.
    • -Pale, soft lesions external/internal rectal area.
    • -Genital warts-Profuse watery vaginal discharge
    • -Increase risk for cervical cancer-male partner may or may not have lesions
  22. Dyspareunia
    -Painful sexual intercourse due to medical or psychological reasons.
  23. Hypertensive medication’s effect in sexy-time
    • -Can cause impotence in men (modifying meds can alleviate impotence as a side effect)
    • -Decrease libido in men & women.
  24. Physical assessment regarding sex
    -Health, Reproductive, & Sexual health history.(infertility, pregnancy, sexual dysfunction, illness that effects sexual function/behavior)
  25. How to implement sex assessment/teaching
    • -Develop trust
    • -Play a little Salt & Peppa
  26. Teaching of teaching about sexuality & sexual health
    • -Change knowledge
    • -Change in patient attitude
    • -Change in behavior
  27. What taught about sexuality & sexual health
    • -Offer advice
    • -Provide pos. reinforcement
    • -Dispel myths
    • -Promote sexual health
    • -Teach Kegal exercises
    • -Self-examination
    • -STI’s and contraception
  28. Circadian rhythm
    -The body’s rhythmic biological clock (24hr cycle)
  29. NREM
    • -Non-rapid eye movement
    • -75% of sleep-Stages 1-4 of sleep
  30. Sleep stages 1-4
    • 1- Light sleep, easily aroused, theta wave
    • 2- Burstsof rapid, rhythmic brain activity.
    • 3- Deltawaves begin to emerge (slow waves)
    • 4- Deepsleep, bed-wetting/sleep walking
    • 5- REM,dream sleep
  31. What occurs with the Parasympathetic Nervous System (PNS)
    during sleep?
    • -It dominates
    • -Decrease pulse, B/P, Temp, Resp., & metabolic rate
  32. Research about safe infant sleeping pattern…
    • -Place infant on back to sleep.
    • -Decreases incidence of SIDS
    • -Nurse must model and teach it!
  33. Prescribed for short-term treatment of insomnia
    • -Ambien (Zolpedemtartrate)
    • -Sonata (Zaleplon)
  34. Prescribed for long-term treatment of insomnia
    -Lunesta (eszopiclone)
  35. What effect does barbitnates, amphetamines, & antidepressants have on REM sleep?
    -Decrease REM sleep, residual sleepiness
  36. What effect does diuretics, anti-Parkinson, some anti-depressants, antihypertensives, decongestants, caffeine, asthma
    medications have on sleep quality?
    -Decrease sleep quality, residual sleepiness
  37. Narcolepsy
    -Condition characterized by an uncontrollable desire to sleep.
  38. Sleep apnea
    -Person experiences the absence of breathing/diminished breathing efforts during sleep between snoring intervals. Use CPAP to keep airway open and pt. breathing.
  39. Somnambulism
    -Sleep walking, talking, night terrors, bruxism (teeth grinding)
  40. Who determines pain level?
    -The patient
  41. Types of pain…
    • -Chronic Pain-
    • -Referred pain-
    • -Phantom pain-
  42. -Chronic Pain-
    Limited, intermittent, or persistent beyond the healing period. Periods of remission & exacerbation.
  43. -Referred pain-
    Originates in one part of the body but is perceived in another area of the body. Example: Heart attack-pain neck/shoulders; cold headache-vagal nerve gets cold
  44. -Phantom pain-
    Receptors & nerves are absent but patient experiences pain (amputation)
  45. Modulation of Pain
    -Process where sensation of pain is inhibited or modified
  46. Endorphins
    - Opioid Neuromodulators. Powerful pain-blocking chemicals that have a prolonged analgesic effect & produce euphoria.
  47. Common misperceptions about pain…
    • -Pain relievers will be given routinely
    • -Fear of addiction
    • -Better to deal with pain then side effects
    • -Should be able to deal with pain
    • -Better to wait until pain is severe
    • -Natural to have pain
  48. Components of pain assessment
    • Site- Where is the pain?
    • Onset- When did the pain start, and was it sudden or gradual?
    • Character- What is the pain like? An ache? Stabbing?
    • Radiation- Does the pain radiate anywhere?
    • Associations - Any other s/s associated with the pain?
    • Time course - Does the pain follow any pattern?
    • Exacerbating/Relieving factors - Does anything change the pain?
    • Severity- How bad is the pain?
  49. Non-pharmacological pain relief measures (10 types)
    • 1 Distraction
    • 2 Humor
    • 3 Music/relaxation
    • 4 Imagery
    • 5 Therapeutic touch
    • 6 Heat/cold
    • 7 Cutaneous stimulation
    • 8 Acupuncture
    • 9 Hypnosis
    • 10 Biofeedback
  50. Analgesics for pain relief
    • -Non-opioids- Tylenol, Motrin, ASA, Naproxen
    • -Opioids- Morphine, codeine, Demerol, methadone
    • -Adjuvant drugs- anticonvulsants, antidepressants,
    • -Epidural analgesia
  51. Basal metabolism
    -Energy required to carry on the involuntary activities ofthe body at rest. Sustain activities of cells &tissues, maintain circulatory, respiratory, GI, & renal processes.
  52. Water requirements
    -Vital to sustain life. 8oz glass/water x8 (64oz)
  53. Anorexia
    -Lack of appetite
  54. How nurse can stimulate appetite
    • Assist with feeding
    • Make food available
    • Offer foods they like
  55. Clear liquid diet
    -Transitional diet after surgery/acute illness. Anything that will melt down to liquid.
  56. Best form of feeding next to oral
    -Providing enternal nutrition
  57. Tube feeding administration
    • -Short-tern- NI or NG tube
    • -Long-term- PEG
  58. Tube-feeding schedules
    • -Nutritionist makes recommendations
    • -Continuous tube feeding schedule -
    • -Intermittent tube feeding schedule -
  59. -Continuous tube feeding schedule -
    Promotes max absorptionr/t gradual introduction to GI tract. Often causes reflux & aspiration when fed into stomach, less mobility.
  60. -Intermittent tube feeding schedule -
    Preferred for gastric feedings. Allows more freedom to eat during normal meal times. Gradual- better absorption, slower. Bolus- possible aspiration & distention.
  61. Promoting Pt. safety w/ tube feedings
    • -Check tube placement
    • -Check residual before each feeding or q4-6 hrs
    • -Assess for abdominal abnormalities
    • -Check pH
    • -Pt. upright as possible
    • -Prevent contamination
    • -Meds never given into/during infusion
  62. Parenteral nutrition
    - Nutritional support via IV
  63. Total parenteral nutrition (TPN)
    • Use central venous catheter device
    • Highly concentrated
    • Hypertonic nutrient solution
    • Provides calories
    • Replaces vitamins, fluids, electrolytes, minerals, & trace elements
    • Promotes tissue & wound healing
Card Set
NUR 121 test 4
test 4 review