unit 4
The basic principles of learning
relevance, self-directed, life experience, readiness, task-centered, motivation
common sleep disorders
insomnia, sleep apnea, narcolepsy
Nutritional interventions
therapeutic diets
NPO, regular, soft, pureed, liquid, cardiovascular, renal, diabetic
factors that contribute to tissue integrity
immobility, obesity, malnutrition, sensory loss, incontinence, existing pressure injury, circulatory disorders
physiology of sleep
circadian rhythm and sleep wake cycle
The fire safety acronyms
RACE and PASS
Nursing pain assessment
PQRST
Precipitating cause, Quality, Region, Severity, Timing
sensory alterations
deficits, deprivation, overload, processing disorder
priority setting frameworks
maslows hierarchy, ABDCE, safety and risk reduction, least restrictive/invasive, survival potential, acute vs chronic, unstable vs stable, urgent vs nonurgent
findings associated with a clients nutritional status
physical appearance, weight, BMI, BP, cholesterol, heart disease, inflammation, poor dentition, brittle hair/hair loss, aging skin, constipation
Assessment, Analysis, Planning, Implementation, Evaluation (AAPIE)
Pain scales
Numeric rating scale, visual analog scale, wong-baker FACES pain rating scale, FLACC scale, nonverbal pain scale, CRIES scale for neonates
abnormal urine findings
dark yellow, dark brown, red, malodorous, fruity scent, cloudy
considerations to provide effective client education
learning style, health literacy, impaired cognition, language barriers, culture, visual and auditory impairments, age,
the use of diversions to manage altered elimination
urinary diversions - catheter, urostomy, nephrostomy, cystostomy, neobladder, stent
bowel diversions- ostomy
used when the client cannot eliminate properly
SMART goals
Specific, Measurable, Attainable, Relevant, Timely
Pressure injury staging
Stages 1-4
assess for non-blanching, amount and depth of skin loss, condition of tissue bed, presence of dead tissue, tunneling, and undermining
potential urinary problems
urinary retention, urinary incontinence, urinary tract infections and catheter associated urinary tract infections
national patient safety goals
identify clients correctly, improve staff communication, use medications safely, use alarms safely, prevent hospital acquired infections, identify client safety risks, reduce the risk of suicide, universal protocol: prevent adverse events during surgery
nursing interventions to facilitate or maintain a clients sensory perception
eye and ear protection, education about noise exposure, speech therapy, avoid use of hot water bottles/pads, oral hygiene, avoid smoking and tobacco, provide meaningful stimulation or minimize stimulation as needed
The bottom/physiological row of Maslow's hierarchy
Airway, Breathing, Circulation, Pain, Nutrition and Hydration, Body Temp, Elimination, Mobility, Sleep, Shelter
Factors that affect wound healing
DIDNT HEAL
Diabetes, Infection, Drugs, Nutritional problems, Tissue necrosis, Hypoxia, Extensive tension, Another wound, Low temperatures
nursing interventions to promote bowel elimination
lifestyle changes, suppositories, enemas, medications, rectal tube, bowel training, skincare
nonpharmacological pain interventions
positioning, cutaneous stimulation, cognitive strategies, therapeutic touch, mind-body practices
complications of wound healing
infection, dehiscence, evisceration, bleeding/hemorrhage, fistula formation