NUR 121 test 4
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3 Dimensions of Self concept:
- 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.
Stages and development of self concept
- 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)
Assessing personal identity
Patient description of self. Example- list 10 labels identifying self & number in order of importance.
Assessing personal strengths
Ask pointed questions about person’s strengths would help a patient identify positive factors
Assessing body image
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
4 Disturbances in self-concept
- 1) Disturbed body image
- 2) Chronic,situation, or risk for low self-esteem
- 3) Ineffective role performance
- 4) Disturbed personal identification
Helping patients identify and use personal strengths
- -Nurse must be comfortable with self before they can address patient
- -Encourage independence
- - Help patient realize & use their own strengths
Components & Conditions (sensory experience)
- -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)
Disturbed sensory perception
-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.
Characteristics of premenstrual (tension) syndrome PMS
- 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
Human Papilloma Virus (HPV)
- -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.
Hypertensive medication’s effect in sexy-time
- -Can cause impotence in men (modifying meds can alleviate impotence as a side effect)
- -Decrease libido in men & women.
Physical assessment regarding sex
-Health, Reproductive, & Sexual health history.(infertility, pregnancy, sexual dysfunction, illness that effects sexual function/behavior)
How to implement sex assessment/teaching
- -Develop trust
- -Play a little Salt & Peppa
Teaching of teaching about sexuality & sexual health
- -Change knowledge
- -Change in patient attitude
- -Change in behavior
What taught about sexuality & sexual health
- -Offer advice
- -Provide pos. reinforcement
- -Dispel myths
- -Promote sexual health
- -Teach Kegal exercises
- -STI’s and contraception
-The body’s rhythmic biological clock (24hr cycle)
- -Non-rapid eye movement
- -75% of sleep-Stages 1-4 of sleep
Sleep stages 1-4
- 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
What occurs with the Parasympathetic Nervous System (PNS)
- -It dominates
- -Decrease pulse, B/P, Temp, Resp., & metabolic rate
Research about safe infant sleeping pattern…
- -Place infant on back to sleep.
- -Decreases incidence of SIDS
- -Nurse must model and teach it!
Prescribed for short-term treatment of insomnia
- -Ambien (Zolpedemtartrate)
- -Sonata (Zaleplon)
Prescribed for long-term treatment of insomnia
What effect does barbitnates, amphetamines, & antidepressants have on REM sleep?
-Decrease REM sleep, residual sleepiness
What effect does diuretics, anti-Parkinson, some anti-depressants, antihypertensives, decongestants, caffeine, asthma
medications have on sleep quality?
-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)
Who determines pain level?
Types of pain…
- -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)
Modulation of Pain
-Process where sensation of pain is inhibited or modified
- Opioid Neuromodulators. Powerful pain-blocking chemicals that have a prolonged analgesic effect & produce euphoria.
Common misperceptions about pain…
- -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
Components of pain assessment
- 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?
Non-pharmacological pain relief measures (10 types)
- 1 Distraction
- 2 Humor
- 3 Music/relaxation
- 4 Imagery
- 5 Therapeutic touch
- 6 Heat/cold
- 7 Cutaneous stimulation
- 8 Acupuncture
- 9 Hypnosis
- 10 Biofeedback
Analgesics for pain relief
- -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
How nurse can stimulate appetite
- Assist with feeding
- Make food available
- Offer foods they like
Clear liquid diet
-Transitional diet after surgery/acute illness. Anything that will melt down to liquid.
Best form of feeding next to oral
-Providing enternal nutrition
Tube feeding administration
- -Short-tern- NI or NG tube
- -Long-term- PEG
- -Nutritionist makes recommendations
- -Continuous tube feeding schedule -
- -Intermittent tube feeding schedule -
-Continuous tube feeding schedule -
Promotes max absorptionr/t gradual introduction to GI tract. Often causes reflux & aspiration when fed into stomach, less mobility.
-Intermittent tube feeding schedule -
Preferred for gastric feedings. Allows more freedom to eat during normal meal times. Gradual- better absorption, slower. Bolus- possible aspiration & distention.
Promoting Pt. safety w/ tube feedings
- -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
Total parenteral nutrition (TPN)
- Use central venous catheter device
- Highly concentrated
- Hypertonic nutrient solution
- Provides calories
- Replaces vitamins, fluids, electrolytes, minerals, & trace elements
- Promotes tissue & wound healing
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