Answers/ Verified/ latest Update (2024/2025)
Assessment: - ✔️✔️collecting vital signs, pain levels, other signs/ symptoms
Diagnosis: - ✔️✔️nurse makes a nursing diagnosis based on assessment of patient; not a medical
diagnosis
Planning: - ✔️✔️nurse comes up with client-centered goals; need to be measurable (client will
ambulate 10 meters 3x daily for 2 wks)
Implementing: - ✔️✔️following through with plan that was developed for the patient
Evaluation: - ✔️✔️goal was met, partially met, not met; how effective the plan was for the patient
and what should be changed for the patient
Normal range for temperature - ✔️✔️96.8-100.4
Normal range for pulse - ✔️✔️60-100
Normal range for respirations - ✔️✔️12-20
Normal range for BP - ✔️✔️100/60-140-90
Normal range for pulse ox. - ✔️✔️>95%
SOLER - ✔️✔️sit close, observe, lean forward, eye contact, relax
Types of pain - ✔️✔️acute, chronic, cancer, by inferred pathology, idiopathic
Pain threshold - ✔️✔️level of stimulus needed to produce the perception of pain
,Pain tolerance - ✔️✔️amount of pain a patient endures without its interference of ADLs
Factors influencing pain - ✔️✔️age, fatigue, genes, neurological functions, social factors, spiritual
factors, psychological factors, cultural factors
Behavioral responses to pain - ✔️✔️clenching teeth, holding painful part, bent posture, grimaces,
cries or moans, restlessness, frequent requests of the nurse; confused patient may not show
reaction
Pharmacological pain relief - ✔️✔️analgesics (NSAIDS & non-opioids, opioids, adjuvants)
NSAIDS & non-opiates - ✔️✔️has analgesic/ antipyretic effects; available OTC; used for moderate to
mild pain; blocks pain impulses by inhibiting prostaglandin synthesis; lethal when overdosed; do not
take with alcohol; do not take if liver dysfunction, possible liver failure
Opioids - ✔️✔️pain relivers that contain opium or chemically related to opium; ordered for
moderate to severe pain such as post-op, chronic non-cancer, or cancer; depresses respiratory
center, causes constipation, itching, altered mental status
Naloxone (Narcan) - ✔️✔️opiate antagonist, reverses opioid induced resiratory depression
Patient Controlled Analgesia (PCA) - ✔️✔️client has control with minimum risk of overdose; system
designed to deliver no more than specific number of doses
Anesthetics - ✔️✔️depresses CNS from consciousness to unconsciousness; loss of responsiveness
to sensory stimuli including pain; muscle, skeletal, and visceral smooth muscle relaxation; general or
local
Basal metabolic rate (BMR) - ✔️✔️energy needed to maintain life
Carbohydrates - ✔️✔️main source of energy; glucose needed for brain, skeletal muscles,
production of RBC/WBC, all functions of renal medulla; obtained from grains, fruits, veggies, milk,
sugar, honey
, Proteins - ✔️✔️essential from growth, maintenance, and repair of body tissue; amino acids;
complete and complementary; nitrogen balance
Fats - ✔️✔️triglycerides and fatty acids; saturated or unsaturated; monounsaturated or
polyunsaturated fatty acids; essential or nonessential
Water - ✔️✔️comprises 60-70% of body weight; cell function depends on a fluid environment, you
can only survive a few days without it, illness increases need for fluids
Vitamins - ✔️✔️essential to normal metabolism; fat soluble(A,D, K,E) can be stored in body except
D; water soluble(C and B complex) cannot be stored in body; obtained from fruits, milk, veggies, fish,
cereal, grains, nuts, sunlight
Minerals - ✔️✔️inorganic elements essential as catalysts in biochemical reactions; obtained in milk,
eggs, meats, grains; maintains acid/base balance, osmotic pressure, oxygen transport
Free Radical Theory - ✔️✔️presence of free radicals produced through normal respiration and
metabolism cause damage to existing cells, some believe this can be reversed through consumption
of vitamins and other products
Erikson's 8 stages of development - ✔️✔️trust vs mistrust
autonomy vs shame and doubt
initiative vs guilt
industry vs inferiority
identity vs identity confusion
intimacy vs isolation
generativity vs stagnation
integrity vs despair
Pharmacokinetics - ✔️✔️the study of how meds enter the body; are absorbed and distributed into
cells, tissues, or organs; alter physiological functions
Medication absorption - ✔️✔️the passage of medication molecules into the blood from the site of
administration