MDC 2356
Key concepts in nursing interventions
[RASMUSSEN UNIVERSITY]
MDC 1 EXAM 1
, FINAL EXAM STUDY GUIDE
MODULES 1-3
ABCDE
1.
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.
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
IVE stimulus that triggers 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?
Does it travel/move around?
Key concepts in nursing interventions
[RASMUSSEN UNIVERSITY]
MDC 1 EXAM 1
, FINAL EXAM STUDY GUIDE
MODULES 1-3
ABCDE
1.
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.
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
IVE stimulus that triggers 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?
Does it travel/move around?
