MDC1 / NUR 2356 Multidimensional Care 1 Exam 1 Rasmussen Graded A 2025

What does Maslow believe about the hierarchy of needs? - a person could not meet the needs of love and belonging and self-esteem without meeting basic physiological needs herbal supplements & their usage Ginko Biloba: Depression, memory Ginseng: depression Kava: Depression, anxiety Echinacea: common cold Chamomile: calming and soothing properties. Goldenseal: Stimulates immune system and bile secretion Melatonin: sleep Kava - Herbal Antianxiety Agent and Depression Name the pain scales - 1-10 FACES FLACC CRIES FLACC pain scale – F:face L:legs A:activity C:cry C:consolability Things to know about pain assessment - PQRST If treatment works It's subjective Ginko Biloba - Depression and memory (dementia) Ginseng - fatigue and depression Echinacea - common cold Goldenseal - Stimulates immune system and bile secretion Chamomile - calming and soothing properties. Melatonin - sleep MDC1/NUR2356 Multidimensional Care 1 Exam 1 Rasmussen Graded A 2025 When dealing with maslow hierarchy of needs, what is done first? - ABCs!! Maslow Hierarchy of needs - Self-Actulaization, Esteem, Safety & Security, Love & Belonging, & physiological SelfActualization - Met when the person reaches maximum potential and acts in an unselfish manner. Examples of self actualization - (e.g., extent to which goals are achieved, role performance, Personal growth, reaching one's highest potential) Catholic End-of-Life indviduals may be - brought to hospitalized patients by a priest, deacon, or designated lay Eucharis- tic minister A Roman Catholic who is seriously ill might - wish to receive the sacrament of anointing the sick. (last rites) Last Rites - Anointing of the Sick (Catholic) Mormons follow a strict - health code, known as the Word of Wisdom Word of Wisdom (Mormon Culture) - advises healthful living and pro- hibits the use of tea, coffee, alcohol, and tobacco Mormons believe in - life before and after death; thus, death repre- sents the passage into another life phrase (Mormon) Nurses may remove garments - before surgery, but it must at all times be considered intensely private and be treated with respect Mormons wear garments at all times except for - hygiene, elimination, or being intimate in marriage Nursing Interventions to achieve self actualization - Provide art supplies Esteem - Met when a person feels a sense of accomplishment and are recognized by others for that achievement. Esteem tier consists of? (Maslow Hierarchy of needs) - 1. Feeling of accomplishment 2. Body image 3. Pride in achievements 4. Admiration from others Self-Actualization tier consists of? (Maslow Hierarchy of needs) - 1. Achieving one's full potential 2. Extent to which goals are achieved 3. Role performance Nursing Interventions to achieve esteem - Facilitating visits from loved ones Safety and security - freedom from physical harm and feelings of fear and anxiety. Safety and security tier consists of? (Maslow Hierarchy of needs) - 1. Protection from physical harm 2. Adequate shelter 3. Freedom from fear and anxiety 4. Safe from falls 5. Treatment 6. Side effects 7. The need for psychological security Physiological tier consists of (Maslow Hierarchy of needs) - -Air-Food - Nutrition -Water - Temperature regulation - Elimination -Rest - Sleep effects -Sex - Physical Activity - mobility assessment - Blood flow (perfusion) is necessary to meet other basic needs Nursing Interventions to achieve safety and security - Prevent falls & Communicating concerns Love and belonging - needs are met when the person seeks personal relationships with others. Love/Belonging tier consists of? (Maslow Hierarchy of needs) - 1. Intimate relationship 2. Friends 3. Social supports Nursing Interventions to achieve love & belonging - Referring a patient to a support group Physiological needs - are essential for maintenance of life Examples of physiological needs - (e.g., oxygen, water, food, air, water, shelter, sleep and rest, elimination, activity, temperature regulation) Nursing Interventions to achieve physiological needs - 1. Helping patient to eat dinner 2. Changing a patients oxygen tank 3. Ensure patient is getting enough rest Basic physiological needs (needs that are essential for the maintenance of life) - Air, Food (Nutrition), water, temp regulation, elimination, rest (sleep effects), sex, physical activity (mobility assessment), blood flow (perfusion) is necessary to meet other basic needs One of the most critical nursing interventions the nurse has is the ability to monitor and interpret the client's? - vital signs. Interventions for elevated/decreased vitals - continue to monitor patient recheck vitals Regulation or thermoregulation is determined using - the client's temperature. Normal Temp - 96.4 to 99.5 degrees Fahrenheit Different methods temperature can be taken - Orally, Axillary Rectally Temporal Artery Tympanic Hypothermia: - temperature below the normal range that may be related to exposure to a cold environment -Temp lower than 95 Hypothermia Preventions - ii. Cover the pt with blankets iii. Use heating devices iv. Increase room temp v. Infuse warm solutions vi. Remove wet clothing Hyperthermia - temperature above the normal range that may be related to exercise or exposure to an abnormally hot environment -Temp is greather than 104 degrees What is perfusion? - Adequate arterial blood flow to the peripheral tissue. What does peripheral and central perfusion relate to? - Peripheral=peripheral tissue Central=major organs Definition of pulse? - rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by contraction of the heart. Bradycardia pulse rate - less than 60 bpm Tachycardia pulse rate - beats higher than 100/min Influences for pulses? - o Exercise o Age o Gender o Anxiety o Pain Documentation for pulse? - o Rhythm - even tempo o Strength (0-4+, absent, weak or thready, normal, strong, bounding) o Regular rhythm: 30 seconds x 2- or 15-seconds x 4o Irregular rhythm (regular/irregular); full minute; apical. o •Amplitude is what is measured o •Rate, rhythm (regular or irregular), and quality (strong, weak or bounding) Quality of pulse - strong, weak or bounding Strength of pulse - 0 = absent 1+ = thready or weak 2+ = normal 3+ = strong 4+ = bounding Rhythm of pulse - regular or irregular Peripheral pulses (Normal, bradycardia, tachycardia) - - Normal= 60-100 beats per minute o Bradycardia = beats below 60/min o Tachycardia= beats higher than 100/min rhythm of respiration - even, regular Depth of respiration - deep, moderate, shallow Inspiration - drawing air into the lungs (diaphragm contracts lungs expand); Breathing in expiration - expulsion of air from the lungs (diaphragm relaxes lungs recoil); breathing out systolic blood pressure - ventricles contract, 90-120, maximum pressure on the arteries Pain assessment before and after treatment - Scale of 0-10(0 being no pain 10 being the worst pain you have ever felt) Assessment of pain history - · P: Provocation and Palliati o no What causes it? o What makes it better? o What makes it worse? · Q: Quality and Quantity o How does it feel, look, or sound? o How much of it is there? · R: Region and Radiationo Where is it? o Does it spread? · S: Severity and Scale o Does it interfere with activities? o How does it rate on a severity scale of 1-10? · T: Timing and Type of Onseto When did it begin? o How often does it occur? o Is it sudden or gradual? What is communication? - Two-way process of sending & receiving messages Diastolic Blood Pressure (DBP) - ventricles relax, 60-80, minimum pressure on the arteries Hyperthermia Preventions - ii. Wear lightweight, loose-fitting clothing. iii. Avoid excessive sun exposure. iv. Stay indoors with fans or air conditioning when outside v. temperatures are elevated. vi. Limit consumption of alcohol and caffeine. vii. Apply sunscreen of at least 30 SPF. viii. If overheated, take a cool water shower or bath. Pulse - Pulse allows the nurse to assess the how adequate the heart is pumping the blood to the body Normal Pulse Values - 60 to 100 beats per minute Pulse points - carotid radial femoral popliteal posterior tibial dorsalis pedis arteries Rate of pulse - number of times the heart beats per minute; varies person to person rhythm of pulse - regular or irregular quality of pulse - strong, weak or bounding Normal BP values - 120/80 cuff size the length needs to be - 80% of the arm circumference width of the cuff should be - 40% of the arm circumference What can occur if you have the wrong cuff size? - false reading Hypotension related to dehydration - from inadequate fluid intake, from diarrhea, elevated temp fits well with this unit. Hypotension Nursing interventions - · Vital signs Initially increase HR and BP · Discuss other signs and symptoms associated with fluid loss · Identify high-risk populations · I & O, daily weights as examples Normal Resp Values - 12-20 breaths per minute Resp Rate, Rhythm, and depth - Normal, deep, or shallow Determine clients Respiratory effort - (nasal flaring; use of accessory muscles, and body positioning) Pulse Ox - measures the oxygen level in the blood Hypoxia is - a low oxygen level in the blood, which leads to symptoms that may affect the client's basic care and comfort needs. Interventions to treat hypoxia - i. Monitor for manifestations of respiratory depression, such as decreased respiratory rate and decreased level of consciousness. Notify the provider if findings are present. Respiratory distress interventions - iii. Position the client for maximum ventilation (Fowler's or semi-Fowler's position). iv. Complete a focused respiratory assessment. v. Promote deep breathing, and use supplemental oxygen as prescribed. vi. Stay with the client, and provide emotional support to decrease anxiety. vii. Promote airway clearance by encouraging coughing and oral/oropharyngeal suctioning if necessary. stridor, wheezing, crackles, pleural rubs or crepitus, as these are associated with - respiratory distress. Stridor - harsh, high pitched, crowing like sound Stridor is generally caused by - an obstruction or narrowing of the upper airway resulting from infections, blockages, foreign bodies, or tracheal anomalies. Wheezing - high or low pitched whistling sound wheezing is generally caused by - a combination of bronchoconstriction, mucus plugging and edema of the bronchioles Crackles - sharp sounds heard on inspiration Dry crackles - the sound one might hear when rubbing several hairs together close to the ear are associated with small airway collapse and lung disease. Moist crackles - sound wet on auscultation and are related to the accumulation of alveolar fluid. Pleural rubs - sounds of inflamed pleural surfaces rubbing over each other, they are loud, low pitched and localized Grunting is a - short, deep, guttural sound heard during expiration. Grunting is caused when - the child exhales against a partially closed glottis in an attempt to keep the bronchioles open and prevent closure of the alveoli. Grunting can be associated with - pulmonary edema, pneumonia or atelectasis, a partially expanded lung. Crepitus is a - crinkly, crackling or grating sound or feeling in the subcutaneous tissue. It can be an indication that free air has entered the tissue. Review signs and symptoms of hypoxia Hypoxia is a - low oxygen level in the blood, which leads to symptoms that may affect the client's basic care and comfort needs. Hypoxia S/S - Dyspnea Elevated blood pressure Increase respirations Increased pulse Pallor/pale skin Cyanosis/blue-tinged lips or oral cavity Anxiety Restlessness Confusion Drowsiness Hypoxia Interventions - · Oxygen therapy (O2 delivery methods, amount of O2 delivered per device, safety education) · Incentive spirometry · Turn, Cough and Deep Breath · Pursed lip breathing · Collecting a sputum specimen as examples who is the most reliable source of pain? - Patient Non verbal cues for pain - Grimacing, guarding, and holding or touching the affected area Verbal cues for pain - describing quality -sharp, dull, aching, mild, constant Pharmacological Interventions - i. Analgesics are the mainstay for relieving pain. ii.NSAIDs iii.Opioids 1.PCA 2. IM 3. Transdermal 4.Epidural Non pharmacological interventions - i. Mind-body practices (yoga,chiropractic manipulation) ii. Cognitive approaches (meditation, distraction) iii. Natural products (herbs, oils) iv. Exercise v. Relaxation techniques vi. Cutaneous Stimulation vii. Warm and colf therapies How to do pain assessment - PQRST - Pain rating scales 0-10 - reassess pain after interventions given to reduce pain (eg. Analgesia) have had time to work - Assessment of pain history Types of pain - Acute Cutaneous Visceral Phantom Somatic Radiating Referred Neuropathic Chronic Fall safety - Lighting Visualize patient Orient to enviornment 2 bed rails Fire safety - Oxygen RACE PASS Smoke detectors Code Red Priority safety for different age groups - Middle age drugs Adolescent suicide Elderly falls Infant Suffocation Sentinel Event - an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof within hospital Examples of Sentinel Events - Suicide Death during/after labor Wrong place surgery Surgical error Infant abduction in hospital Medication errors Safe patient transfer techniques - Use mechanical lift Nonslip shoes/socks Don't twist back Don't pull on neck Priority hygiene practices - Dry skin folds Moisturized skin promote venous retour Oral hygiene principles - Encourage pt assist HOB (Head of bed) elevated Unconscious-suction NPO-Oral care q2hrs Perineal Care Principles - Wipe front to back Clean rag and water Away urethral meatus Cutaneous pain - Arises from burning your skin like on a hot iron or from touching a hot pan on the stove. Visceral pain - Caused from deep internal disorders such as menstrual cramps, labor pains, or gastrointestinal infections. Deep Somatic pain - Originates from the ligaments, tendons, nerves, blood vessels and bones. Examples would be fractures or sprains. Radiating pain - Starts at an origin but extends to other locations. Example: pain from a sore throat might extend to ears and head. Referred pain - Occurs in an area distant from the site of origin. Example: pain from a heart attack might be felt in the left arm or jaw. Phantom pain - Pain that is perceived from an area that has been surgically or traumatically removed. Example: pain from an amputated limb. Neuropathic pain - Results from an injury of one or more nerves where messages regarding pain are transmitted without a pain stimulus occurring. Acute pain - Short duration, rapid onset, and associated with some kind of injury. Chronic pain - Last 6 months or longer and interferes with activities of daily living. Therapeutic communication - Client-centered communication directed to achieve the patients' goal. (Avoid asking "why") Five qualities of therapeutic relationship - Empathy Respect Genuineness Concreteness Confrontation Empathy - A desire to understand and be sensitive to the feelings and situation of another person. Put yourself in the client's place, mentally and emotionally. Respect - Allow the client to make choices. Be flexible when meeting the needs of each client. Genuineness - Respond honestly. If the answer is not known to you, do not guess. Tell the client you need assistance prior to answering the question. Concreteness - Provide your answers in specific understandable terms. Confrontation - Request the client express his or her thoughts clearly so you can understand the meaning of the communication. Therapeutic Responses & Techniques - - Active Listening - Cultural competence - Don't interrupt - Veracity - Fidelity - Establishing Trust - Being Assertive - Restating, Clarifying, and Validating Messages - Interpreting Body Language and Sharing Observations - Exploring Issues - Using Silence - Summarizing the Conversation Why incident reports? - Lessen future risks Medication errors Needle sticks Falls Non therapeutic responses & Techniques - -Asking Too Many Questions - Asking Why - Fire-Hosing Information - Changing the Subject Inappropriately - Failing to Probe - Offering Advice - Providing False Reassurance - Stereotyping - Using Patronizing Language Opened questions - a. specify a topic to be explored, but phrase it broadly to encourage the patient to elaborate Closed ending questions - a. those that can be answered with a "yes," "no," or other short, factual answer. Barriers of communication will - discourage the client from sharing information openly with the nurse. Barriers of communication - a. Asking too many questions b. Offering advice c. Changing the subject d. Expressing approval or disapproval e. Providing false reassurance f. Stereotyping g. Using patronizing language Communication with visual, hearing, speech and cognitive patients - a. Be positive and patient b. Provide forms of nonverbal communication c. Use gestures d. Use short sentences when communicating e. Be concrete and specific f. Call client by name g. Minimize environmental noise h. Face the client when speaking Communication with hearing impaired patients - o Inquire about possible hearing aid devices o Talk slowly, and enunciate o Avoid slang words or complex jargon Communication with visual impaired patients - -Guide dogs -Braille -Auditory communication -Assisted devices such as walking sticks Communication with speech impaired patients - o Nonverbal communication is key (hand gestures, picture board) o Family assistance o Provide comfortable environment that allows pt to practice speaking o Possible refer to speech pathologist Communication for cognitive impaired patients - o Do not use in-room intercom to speak to pt o Reduce environmental distractions o Approach patient directly o Don't rush the client Nursing actions/interventions for communication - o Be positive and patient o Call client by their preferred nameo Minimize environmental noise o Provide forms of nonverbal communication o Use gestures o Be concrete and specific o Keep eye contact (hearing impaired patients will read your lips) What is socialization? - learning how to become a member of a society or a group. What is acculturation? - an individual assumes the characteristics of a culture they just immigrated too What is assimilation? - a new member will learn and eventually take essential values, beliefs, and behaviors of the dominant culture gradually. What are stereotypes? - considers everyone are the same (ex. Cultural practices, health treatments, illnesses) under their racial or ethnic group What are the phases of therapeutic relationships? - Pre-interaction Orientation Working phase Termination phase Pre interaction phase - gathering info about client before meeting client Orientation phase - begins when you meet the client and introduce yourself and role in the relationship ● Build rapport and trust Working phase - the bulk of the therapeutic communication; the active part of the relationship ● Nurse communicates caring, the patient expresses thoughts and feelings, and mutual respect is maintained Termination phase - conclusion of the relationship ● Ex: end of shift; client is discharged Personal space is - boundary lines that determine how close another person can come Intimate Distance is - the area immediately surround- ing people that they define as their "private space." Personal Distance - 18 inches to 4 feet. Social Distance - 4 to 12 feet. It is used in more formal interaction or when communicating with a group of individuals at the same time. Public Distance - 12 feet. This distance requires loud and clear enunciation for communication. An interpreter is specially trained to - provide the meaning behind the words Serve as a cultural broker by conveying the client's responses to questions and by providing general information about the client's culture. Recognize empathy by - a. Adapt to different styles, tone, vocabulary and behavior b. Place yourself in the patients situation c. Understand the needs (be sensitive) Is silence a communication barrier? - No, Remaining attentive and waiting for the client to compose the next statement in the conversation enhances therapeutic communication. What does the acronym stand for (SBAR)? - Situation, Background, Assessment, Recommendation-Readback What types of situations are appropriate for use of SBAR? - i. Interdisciplinary communication ii. Critical situations iii. Rapid response needed iv. Nurse- physician communication v. Team communication and collaboration Socialization - learning how to become a member of a society or a group. Acculturation - An individual assumes the characteristics of a culture they just immigrated too. Assimilation - A new member learn and take essential values, beliefs and behaviors of the dominant culture gradually. Stereotype - Considering everyone are the same under their racial or ethnic group. i. Assuming everyone from that culture practices health or treats illnesses the same way. Example pf stereotype - All Asians are naturally intelligent. All Africans are naturally athletes or runners. Archetype - Something recurrent that makes beliefs that everyone has under the same racial or ethical group Ex. of Arcgetype - All Irish population will have reddish tone hair color. All Mexican will have brown eyes. All Europeans will have light color skin. Social effect in meeting basic care & comfort needs - o Close social organization (Man is dominant and female is housemaker) o Social organization related to birth, death, illness, grieving & mourning (Delaying treatment with home remedies)o Kinship and social ties (VIP care compared to homeless) Health effects in meeting basic care & comfort needs - o Scientific (hospitals, clinics, medications)o Magico-Religious: alternative or indigenous (supernatural forces of healing, rituals) o Holistic: need for harmony and balance of the body with nature (yoga, meditation) Folk medicine effects in meeting basic care & comfort needs - o Beliefs and practices an individual performs when ill than conventional medicine (eating soup, resting, folk healer, teas, circumcision) o Passed down by generations to generations Environmental effect in care - i. person's beliefs that they could change the outcomes of an illness without seeking help. Biological effect in care - i. Genetic and physical aspects that determine situations ii. Ex. African American Females have a higher risk for breast cancer, Pacific Islanders and Native Hawaiians have a higher rate of uncontrolled diabetes and hypertension