What's in a pain?
Whatever the person experiencing says it is, existing whenever the person says it does.
What is the definition of pain?
Valves associated with the "dub" (S2) sound.
What is closure of the aortic and pulmonic valves or semilunar valves?
Therapies (list 2) used to treat constipation and/or fecal impaction.
What are enemas, suppositories, or digital removal?
Procedure used for stomach decompression or enteral feeding.
What is placement of a naso or orogastric tube?
Stage of sleep that is associated with deep sleep and total relaxation.
What is stage 3 or NREM3 sleep?
Type of pain associated with autonomic responses and generally associated with a physical cause.
What is acute pain?
Abnormal heart sound, but commonly heard in older adults and associated with stiff ventricles.
What is S4?
Two expected (normal) assessment findings of a stoma.
What is moist, above skin level, pink/red, intact peristomal skin integrity, stool consistency appropriate for location?
List two complications associated with nasogastric tubes.
What are aspiration, placement into the skull or lung, esophageal trauma, pressure injury to nasal mucosa?
List 3 subjective questions related to sleep.
What is sleep pattern, sleep history, hours of sleep/night, sleep problems, need to void at night, number of pillows used?
Three factors that affect the pain experience.
What are age, fatigue, genetic sensitivity, prior experience, anxiety, support systems, coping mechanisms, and culture?
List the sequence of the cardiac conduction pathway.
What is SA - AV- Bundle of His - R & L bundle branches - Purkinje fibers?
Used to manage diarrhea, but can cause weakened rectal tone and fecal incontinence if used for a prolonged period.
What is a rectal tube or flexiseal?
Type of diet recommended for a patient with increased risk for aspiration.
What is thickened liquids, or soft/low residue diet?
Identify 3 lifestyle considerations (population differences) regarding sleep.
What are infants need 10-15 hours/night, sleep needs decline with age, elderly have more disturbed sleep patterns due to medications, bathroom, sleep apnea?
Pain scale that would be appropriate for assessing pain in a 4-year old child.
What is Wong-Baker or FACES scale?
Describe at least 5 expected (normal) findings of the cardiac assessment.
What are S1/S2, no visible pulsations, no heaves or lifts, no adventitious sounds, normal skin color/temp, no JVD, absence of bruits/thrills, absence of pulsations over valves, palpable PMI, no pulse deficit?
Define rebound tenderness and what it indicates.
What is Blumberg's sign? What is pain that worsens upon releasing pressure while palpating? What is appendicitis?
Identify three routine assessments to make on a patient with a nasogastric tube.
What is cm marking, presence of bowel sounds, passing gas, stooling, skin integrity, presence of N/V?
Describe how a CPAP is used to treat obstructive sleep apnea.
List & Define 3 types of alternative/complementary therapies used to treat pain?
What are acupuncture, Biofeedback, guided imagery, massage, essential oils, hypnotherapies, etc.?
Describe compensation and include hemodynamic changes noted with dehydration.
Compensation is the ability of the cardiovascular system to alter heart rate, blood pressure, vascular tone, and direction of blood flow in an effort to maintain cardiac output.
Dehydration would cause a decrease in preload, therefore stimulate the SNS and RAAS system to activate causing vasoconstriction, increased heart rate, and increased contractility.
Describe the auscultation assessment of the abdomen include what you are listening for and how this should be performed.
Auscultate all 4 quadrants in sequence, using the diaphragm of the stethoscope. Bowel sounds should occur every 5-15 seconds. Auscultate over abdominal arteries to assess for the presence of bruits.
Describe the pre-procedure steps of placing an NG tube (after verifying orders, ID client, etc).
What is positioning client in high-fowlers, assessing gag reflex, nare patency, O2 saturation, measurement from tip of nose to ear lobe and down to xiphoid process + 10 cm?
Describe 5 ways nurses can promote sleep in healthcare settings.
What is asking the client about their normal bedtime routine, offering ear plugs, clustering cares, closing the door, limiting alarms, keeping clients stimulated during the day, turning off lights/TV, educate visitors to leave?