Sensory Alterations
Inadequate quality or quantity of stimulation; Pt bored, restless, and irritable
What is sensory deprivation?
Fastest acting route for administering pain medication
What is intravenous?
Localized injuries to skin/underlying tissue, usually over a boney prominence.
What is a pressure injury?
This cleansing agent should NEVER be used to clean a wound and your instructor will do unspoken things if you do.
What is hydrogen peroxide?
This refers to individuals being and taking responsibility for their own actions
What is accountability?
A patient updates their will or adjusts their living arrangements to plan for the inevitable.
What is acceptance?
Nausea, pain 5/10, dizziness is this kind of data.
What is subjective data?
No pain in the feet when pricked with needles would indicate this disease
What is diabetes induced peripheral neuropathy?
What is assess pain using appropriate pain scale?
This phase of healing helps in controlling the bleeding.
What is hemostasis phase?
Drainage that is pale, with a combination of plasma and red cells, may be blood streaked
What is serosanguineous drainage?
Freedom of choice and responsibility for those choices
What is autonomy?
Making promises to God in exchange for a better outcome.
What is bargaining?
The step in the nursing process where the nurse obtains current medications and medical history.
What is assessment?
What is a cataract?
Pain from damaged tissues such as bones, skin, and organs
What is nociceptive pain?
The force exerted against the skin while the skin remains stationary and the bony structure moves.
What is shearing?
Serous fluid filled intact blister is this stage of a pressure injury.
What is a stage II pressure injury?
RN, LPN, UAP all working together to care for several patients is this concept of nursing.
What is team nursing?
Patient is expressing sadness and grief over the situation.
What is depression?
Blood pressure, potassium level 4.6, crackles in LUL of lungs is this type of data
What is objective data?
Reception of multiple sensory stimuli leads to this.
What is sensory overload?
Pain that is sensed from a distant site of the actual cause of pain
What is referred pain?
This phase of healing produces new tissue, epithelialization, and contraction of tissue.
What is proliferation phase
A blood filled blister is this stage of pressure injury.
What is an unstageable pressure injury?
In this delivery care model the nurse is responsible for collaborating and supervising to meet cost-effective care that other staff members deliver.
What is case management?
Someone who is planning vacation and looking forward to it next year that has a terminal diagnosis.
What is denial?
This is the 5 steps of the nursing process in order.
What is assessment, diagnosis, planning, implementation, evaluation?
This disease affects the central vision to where they can only see periphery.
What is macular degeneration disease?
Chronic pain in the absence of an identifiable physical or psychological cause.
What is idiopathic pain?
(complex regional pain syndrome)
When using this scale you assess mobility, sensory perception, moisture, activity, nutrition, friction, and shearing to identify risk for pressure injuries.
What is the Braden scale?
Full-thickness tissue loss into the subcutaneous tissue that adipose tissue is visible. May contain slough in the wound. No bone, muscle, tendon is visible.
What is a stage III pressure injury?
This priority is non-life threating and involves mental status changes, acute pain, abnormal lab values, untreated medical issues
What is intermediate priority (second level problems)?
Someone who is blaming others for the situation in which they are in.
What is anger?
What is safety?