Medication Administration/ Pain/Infection Control
What are reasons a patient refuses pain medication?
Fear of becoming addicted
Describe actions that take place in the "take action" step of layer 3 on the CJM.
Implement the plan of action, perform the skill or procedure, administer medication
How does long term stress effect a person?
Sleep difficulites, increased pain, decreased wound healing, HTN, dry mouth, increased respirations
What does an unstageable wound look like?
Eschar and slough in the wound bed
Describe each level of prevention.
Primary: Prevent/slow onset of disease- education/prevention
Secondary: Detect and treat illnesses in early stages-screening
Tertiary: Stop disease progression; return to
pre-illness state- rehab
What does a patient who requires increasing doses of a medication to achieve the desired effect indicate?
Tolerance
Describe what happens in each step of the nursing process.
ADPIE
Assessment: involves gathering data about the patient and their health status
Diagnosis: using critical-thinking skills, the nurse analyzes the assessment data to identify patterns in the data
Planning: encompasses identifying goals and outcomes, choosing interventions, and creating nursing care plans.
Implementation: involves performing or delegating planned interventions, carry out the care plan
Evaluation: Determine the effectiveness of the nursing care plan
True or False: Losing control of the bladder is a normal part of aging.
False
Respirations that increase then decrease in depth followed by a period of apnea describe what type of respirations?
Cheyne-Stokes
How should a nurse respond to a family of a patient who just died?
Express sympathy
What is a common side effect of opioid medication?
Constipation
Describe actions that take place in the "analyze cues" step of layer 3 on the CJM.
Determine patterns, connect the cues, discern concerning information, decide if more information is needed
What are patient barriers to learning?
What is the best position for a dyspneic patient?
High Fowler's
What is the difference between health promotion and health protection?
Health promotion= Increase wellbeing
Health protection= Prevent illness
What stage of infection is a person symptomatic?
Illness stage
Describe actions that take place in the "generate solutions" step of layer 3 on the CJM.
Determine the risk of action or lack of action, formulate the plan of care, identify desired outcomes
How can a nurse determine if patient education was effective?
Verbal explanation, demonstration, adhereing to plan of care
Describe the 3 types of healing processes.
Primary- Edges well approximated. Ex: surgical incision
Secondary- Wound left open. Heal from the inside out.
Tertiary- Delayed primary closure. Granulation tissue surfaces brought together.
What occurs in each step of the Transtheoretical Model of Change?
Stage 1 Precontemplation. Patients have no intention to change behavior in the foreseeable futuree.
Stage 2 Contemplation. Patients are seriously thinking about overcoming a problem
Stage 3 Preparation. Individuals are intending to take action in the next month a).
Stage 4 Action. The plan is implemented
Stage 5 Maintenance. Individuals are working to prevent relapse
Stage 6 Termination. Persons who enter into the termination stage have changed the behavior
What initial step should the nurse take if a patient refuses a medication?
Consult with the patient to discover the reason why they are refusing.
Describe actions that take place in the "prioritized hypothesis" step of layer 3 on the CJM.
Combine or cluster the information that go together, decide on what takes priority
What is an example of both an internal and external stressor?
Internal- Sore throat, diarrhea...
External-Death of a loved one, natural disaster...
Identify nursing interventions to prevent pressure ulcers.
Frequent repositioning, elevate heels off the bed, monitor tubing, toileting...
How do nurses promote health?
Education, provide support, role modeling