lOMoAR cPSD| 60399657
NUR 2356 MULTIDIMENSIONAL CARE I - MDC
1 EXAM
FINAL EXAM STUDY GUIDE
MODULES
ABCDE
1.
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Airway/Cervical Spine: most important step in primary survey; If patient airway is not
established, subsequent steps of the primary survey are futile
2. Breathing: After achieving patient airway, assess for the presence and effectiveness of
breathing
3. Circulation: After ensuring adequate ventilation, assess circulation
4. Disability: Perform a quick assessment to determine the client’s level of consciousness
5. Exposure: Perform a quick physical assessment to determine the client’s exposure to
adverse elements (heat or cold)
EMPATHY IN THERAPEUTIC COMMUNICATION
§ Desire to understand and be sensitive to feelings, beliefs and situation.
§ As the nurse, adaptation to different style, tone, vocabulary and behavior is
important to create the best approach for each patients’ situation.
§ Place your-self in the patient situation. Think about “how would I want to be treated if it
was me? This will help you:
§ Appreciate everyone uniqueness
§ Understand the needs
COMMUNICATING WITH CLIENTS FROM OTHER CULTURES
Increasing non-speaking patients have called for changes in the hospital environment culture.
The provision of translators is an example on how healthcare institutions are facilitating proper
communication.
Nurse Cultural Self-Awareness § Be aware of own bias’s
§ Learn about other culture in your geographical location
§ Convey empathy and respect
§ Be aware of cultural preferences related to eye contact, space, and touch
§ Address the client appropriately
§ Appropriate use of interpreters (Make sure to get familiar with the institution policy
regarding the use of only certified translators or interpreters)
CHANGINGS IN SKIN OF THE OLDER ADULT
-Decreased skin turgor, subcutaneous fat, & connective tissue, which leads to wrinkles & dry,
transparent skin
-Loss of subcutaneous fat, which makes it more difficult for older adults to adjust to cold
temperatures
-Thickening of fingernails and toenails
-Thinning and graying of hair, as well as more sparse distribution.
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PAIN
■ A pain assessment plays a role in the client’s rest and comfort needs and in the area of
anxiety related to illness recovery. It’s considered the fifth (5th) vital sign.
■ The patient is the most reliable source of pain level
■ Goal is to keep pain below a 3/10
■ Common signs and symptoms of pain include:
– Grimacing, guarding, verbalization, and holding or touching the affected area.
Descriptive words might include mild, sharp, dull, aching, constant, and
intermittent.
TYPES OF PAIN
ACUTE Short duration, rapid onset, and associated with some kind of injury.
CHRONIC Last 6 months or longer and interferes with activities of daily living.
Idiopathic pain: form of chronic pain without known cause, or pain that
exceeds typical pain levels associated with the client’s condition
NOCICEPT -Damage to or inflammation of tissue, which is a noxious stimulus that triggers
IVE the pain receptors called nociceptors and causes pain
-Usually causes throbbing, aching, and localized TYPES:
Somatic: in bones, joints, muscles, skin, or connective tissues
Examples: fractures or sprains
Visceral: in internal organs (the stomach or intestines); it can cause referred
pain in other body locations separate from the stimulus
Examples: menstrual cramps, labor pains, or GI infections
Cutaneous: in skin or subcutaneous tissue
Examples: burning skin on hot iron, any hot surface
NEUROPA Abnormal or damaged pain nerves
THIC Includes phantom lib pain, pain below the level of spinal cord injury, and
diabetic neuropathy
Usually intense, shooting, burning, or described as “pins and needles”
Pain Assessment
P: Provocation/Palliation-What were you doing when the pain started? What caused it? What
makes it better? What makes it worse?
Q: Quality/Quantity- What does it feel like? Sharp, dull, stabbing, burning, etc
R: Region/Radiation: Where is the pain located? Does it radiate? Where?
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Does it travel/move around?
S: Severity Scale- How severe is the pain on a scale from 0 to 10?
T: Timing- When/at what time did the pain start? How long did it last? How often? Sudden or
gradual?
SAFETY
Who The Joint Commission- provides national safety patient goals ( a set of
publishes the criteria) such as reducing patient falls, healthcare associated infections,
National Patient medication errors , and accuracy in patient identifications.
Safety Goals?
Sentinel Events -Serious injuries or death to a patient that should have never happen in a
hospital
-Examples: Air embolism, Wrong transfusion, Falls, Trauma or injuries, DVT or
PE after knee surgery, CAUTIs, CLABSIs, HAPIs, etc.
Child Safety -Keep small objects out of reach & check toys for loose or small parts &
sharp edges
-Do not feed the infant hard candy, peanuts, popcorn, or whole or sliced
pieces of hot dog
-Do not place the infant in the supine position while feeding or prop the
infants bottle
Needle-stick 1st step- wash hands
Injury
Home Safety -Remove items that can increase falls: remove throw rugs, line cords
against walls, ensure steps/sidewalks are in good repair, nonskid
bathroom mats and in shower, handrails or shower chair, adequate
lighting -Fire safety
Narcolepsy -Sudden attacks of sleep that are often uncontrollable
-Often happens at inappropriate times and increases the risk for injury
Patient. Education:
-Exercises regularly
-Eat small meals that are high in protein
-Avoid activities that increase sleepiness
-Avoid activities that could cause injury if patient falls asleep
-Take naps when needed
-Take prescribed stimulants
BED BATHS
1. Collect supplies, provide privacy, and explain the procedure
messages.downloaded_by
NUR 2356 MULTIDIMENSIONAL CARE I - MDC
1 EXAM
FINAL EXAM STUDY GUIDE
MODULES
ABCDE
1.
messages.downloaded_by
, lOMoAR cPSD| 60399657
Airway/Cervical Spine: most important step in primary survey; If patient airway is not
established, subsequent steps of the primary survey are futile
2. Breathing: After achieving patient airway, assess for the presence and effectiveness of
breathing
3. Circulation: After ensuring adequate ventilation, assess circulation
4. Disability: Perform a quick assessment to determine the client’s level of consciousness
5. Exposure: Perform a quick physical assessment to determine the client’s exposure to
adverse elements (heat or cold)
EMPATHY IN THERAPEUTIC COMMUNICATION
§ Desire to understand and be sensitive to feelings, beliefs and situation.
§ As the nurse, adaptation to different style, tone, vocabulary and behavior is
important to create the best approach for each patients’ situation.
§ Place your-self in the patient situation. Think about “how would I want to be treated if it
was me? This will help you:
§ Appreciate everyone uniqueness
§ Understand the needs
COMMUNICATING WITH CLIENTS FROM OTHER CULTURES
Increasing non-speaking patients have called for changes in the hospital environment culture.
The provision of translators is an example on how healthcare institutions are facilitating proper
communication.
Nurse Cultural Self-Awareness § Be aware of own bias’s
§ Learn about other culture in your geographical location
§ Convey empathy and respect
§ Be aware of cultural preferences related to eye contact, space, and touch
§ Address the client appropriately
§ Appropriate use of interpreters (Make sure to get familiar with the institution policy
regarding the use of only certified translators or interpreters)
CHANGINGS IN SKIN OF THE OLDER ADULT
-Decreased skin turgor, subcutaneous fat, & connective tissue, which leads to wrinkles & dry,
transparent skin
-Loss of subcutaneous fat, which makes it more difficult for older adults to adjust to cold
temperatures
-Thickening of fingernails and toenails
-Thinning and graying of hair, as well as more sparse distribution.
messages.downloaded_by
, lOMoAR cPSD| 60399657
PAIN
■ A pain assessment plays a role in the client’s rest and comfort needs and in the area of
anxiety related to illness recovery. It’s considered the fifth (5th) vital sign.
■ The patient is the most reliable source of pain level
■ Goal is to keep pain below a 3/10
■ Common signs and symptoms of pain include:
– Grimacing, guarding, verbalization, and holding or touching the affected area.
Descriptive words might include mild, sharp, dull, aching, constant, and
intermittent.
TYPES OF PAIN
ACUTE Short duration, rapid onset, and associated with some kind of injury.
CHRONIC Last 6 months or longer and interferes with activities of daily living.
Idiopathic pain: form of chronic pain without known cause, or pain that
exceeds typical pain levels associated with the client’s condition
NOCICEPT -Damage to or inflammation of tissue, which is a noxious stimulus that triggers
IVE the pain receptors called nociceptors and causes pain
-Usually causes throbbing, aching, and localized TYPES:
Somatic: in bones, joints, muscles, skin, or connective tissues
Examples: fractures or sprains
Visceral: in internal organs (the stomach or intestines); it can cause referred
pain in other body locations separate from the stimulus
Examples: menstrual cramps, labor pains, or GI infections
Cutaneous: in skin or subcutaneous tissue
Examples: burning skin on hot iron, any hot surface
NEUROPA Abnormal or damaged pain nerves
THIC Includes phantom lib pain, pain below the level of spinal cord injury, and
diabetic neuropathy
Usually intense, shooting, burning, or described as “pins and needles”
Pain Assessment
P: Provocation/Palliation-What were you doing when the pain started? What caused it? What
makes it better? What makes it worse?
Q: Quality/Quantity- What does it feel like? Sharp, dull, stabbing, burning, etc
R: Region/Radiation: Where is the pain located? Does it radiate? Where?
messages.downloaded_by
, lOMoAR cPSD| 60399657
Does it travel/move around?
S: Severity Scale- How severe is the pain on a scale from 0 to 10?
T: Timing- When/at what time did the pain start? How long did it last? How often? Sudden or
gradual?
SAFETY
Who The Joint Commission- provides national safety patient goals ( a set of
publishes the criteria) such as reducing patient falls, healthcare associated infections,
National Patient medication errors , and accuracy in patient identifications.
Safety Goals?
Sentinel Events -Serious injuries or death to a patient that should have never happen in a
hospital
-Examples: Air embolism, Wrong transfusion, Falls, Trauma or injuries, DVT or
PE after knee surgery, CAUTIs, CLABSIs, HAPIs, etc.
Child Safety -Keep small objects out of reach & check toys for loose or small parts &
sharp edges
-Do not feed the infant hard candy, peanuts, popcorn, or whole or sliced
pieces of hot dog
-Do not place the infant in the supine position while feeding or prop the
infants bottle
Needle-stick 1st step- wash hands
Injury
Home Safety -Remove items that can increase falls: remove throw rugs, line cords
against walls, ensure steps/sidewalks are in good repair, nonskid
bathroom mats and in shower, handrails or shower chair, adequate
lighting -Fire safety
Narcolepsy -Sudden attacks of sleep that are often uncontrollable
-Often happens at inappropriate times and increases the risk for injury
Patient. Education:
-Exercises regularly
-Eat small meals that are high in protein
-Avoid activities that increase sleepiness
-Avoid activities that could cause injury if patient falls asleep
-Take naps when needed
-Take prescribed stimulants
BED BATHS
1. Collect supplies, provide privacy, and explain the procedure
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