NUR 121 test 4

• 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.

• 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)

Patient description of self. Example- list 10 labels identifying self & number in order of importance.

Ask pointed questions about person’s strengths would help a patient identify positive factors

Subjective view of one’s own body. Assess for risk/threat to self

Does patient have shared perception of self? Do they like themselves? What do they think of themselves?

The patient’s role in life. Example: occupation, role in family

• 1) Disturbed body image
• 2) Chronic,situation, or risk for low self-esteem
• 3) Ineffective role performance
• 4) Disturbed personal identification

• -Nurse must be comfortable with self before they can address patient
• -Encourage independence
• - Help patient realize & use their own strengths

• -Reception
• -Perception
• -Arousal mechanism

-Conscious process of selecting, organizing, and interpreting data from the senses to meaningful info.

-Brain is alerted or aroused. example: “I’m very aroused!” (Ron Burgundy, 2004)

-Sensory deprivation, sensory overload, sensory deficit.

-Decreased input or input is monotonous, un-patterned, or meaningless.

-Too much stimuli, brain is unable to respond or ignore thestimuli, feel out of control

-Lens of eye loses its ability to focus making it difficult to see objects up close.

Gender id. Disorder where male identifies self as female and vise versa.

Cross-dresser

- 50-90% experience, mood changes, back/uterine cramping, irritability, emotional tension, anxiety, headache, breast tenderness, water retention.

-Blood vessels in shaft become congested and penis becomes hard

• -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

-Painful sexual intercourse due to medical or psychological reasons.

• -Can cause impotence in men (modifying meds can alleviate impotence as a side effect)
• -Decrease libido in men & women.

-Health, Reproductive, & Sexual health history.(infertility, pregnancy, sexual dysfunction, illness that effects sexual function/behavior)

• -Develop trust
• -Play a little Salt & Peppa

• -Change knowledge
• -Change in patient attitude
• -Change in behavior

• -Offer advice
• -Provide pos. reinforcement
• -Dispel myths
• -Promote sexual health
• -Teach Kegal exercises
• -Self-examination
• -STI’s and contraception

-The body’s rhythmic biological clock (24hr cycle)

• -Non-rapid eye movement
• -75% of sleep-Stages 1-4 of sleep

• 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

• -It dominates
• -Decrease pulse, B/P, Temp, Resp., & metabolic rate

• -Place infant on back to sleep.
• -Decreases incidence of SIDS
• -Nurse must model and teach it!

• -Ambien (Zolpedemtartrate)
• -Sonata (Zaleplon)

-Lunesta (eszopiclone)

-Decrease REM sleep, residual sleepiness

-Decrease sleep quality, residual sleepiness

-Condition characterized by an uncontrollable desire to sleep.

-Person experiences the absence of breathing/diminished breathing efforts during sleep between snoring intervals. Use CPAP to keep airway open and pt. breathing.

-Sleep walking, talking, night terrors, bruxism (teeth grinding)

-The patient

• -Chronic Pain-
• -Referred pain-
• -Phantom pain-

Limited, intermittent, or persistent beyond the healing period. Periods of remission & exacerbation.

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

Receptors & nerves are absent but patient experiences pain (amputation)

-Process where sensation of pain is inhibited or modified

- Opioid Neuromodulators. Powerful pain-blocking chemicals that have a prolonged analgesic effect & produce euphoria.

• -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

• SOCRATES
• 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?

• 1 Distraction
• 2 Humor
• 3 Music/relaxation
• 4 Imagery
• 5 Therapeutic touch
• 6 Heat/cold
• 7 Cutaneous stimulation
• 8 Acupuncture
• 9 Hypnosis
• 10 Biofeedback

• -Non-opioids- Tylenol, Motrin, ASA, Naproxen
• -Opioids- Morphine, codeine, Demerol, methadone
• -Adjuvant drugs- anticonvulsants, antidepressants,
• -Epidural analgesia

-Energy required to carry on the involuntary activities ofthe body at rest. Sustain activities of cells &tissues, maintain circulatory, respiratory, GI, & renal processes.

-Vital to sustain life. 8oz glass/water x8 (64oz)

-Lack of appetite

• Assist with feeding
• Make food available
• Offer foods they like

-Transitional diet after surgery/acute illness. Anything that will melt down to liquid.

-Providing enternal nutrition

• -Short-tern- NI or NG tube
• -Long-term- PEG

• -Nutritionist makes recommendations
• -Continuous tube feeding schedule -
• -Intermittent tube feeding schedule -

Promotes max absorptionr/t gradual introduction to GI tract. Often causes reflux & aspiration when fed into stomach, less mobility.

Preferred for gastric feedings. Allows more freedom to eat during normal meal times. Gradual- better absorption, slower. Bolus- possible aspiration & distention.

• -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

- Nutritional support via IV

• Use central venous catheter device
• Highly concentrated
• Hypertonic nutrient solution
• Provides calories
• Replaces vitamins, fluids, electrolytes, minerals, & trace elements
• Promotes tissue & wound healing