Sleep environment
Includes a dark room, quiet, calm, no lights or TV
Sleep schedule
Consistently regular sleep schedule
Pre-bed routine
Routine to help fall asleep
Avoidance
Avoiding caffeine or stimulating substances
Sleep or mental disorders
Conditions like sleep apnea, depression, anxiety
Lifestyle/environment
Factors like inconsistent sleep schedule, electronic use in bed, noise, or light
Physical or medical issues
Pain secondary to a diagnosis, medications, nerve disorders, cardiac issues
Self-report
Most reliable source to measure pain
Maslow's Hierarchy of Needs
Hierarchy including physiological, safety, love/belongingness, esteem, and self-
actualization needs
Acute pain
Short-lived pain, sharp, stabbing, burning, or throbbing. Short duration, rapid
onset, associated with injury
Chronic pain
Lasts for more than six months, can range from mild to severe. Less likely to have
a physiological response: more likely to have depression, fatigue, and decreased
quality of life. (Interferes with ADLs)
Neuropathic pain
,Caused by nerve damage. Ex: Diabetes→peripheral nerves→foot pain
Nociceptive pain
Caused by tissue damage, further categorized as visceral or somatic pain
Psychogenic pain
This pain is affected by psychological factors, such as fear, depression, stress,
or anxiety. Psychogenic pain often has a physical origin, but the pain worsens or
lasts longer due to psychological factors.
Visceral pain
Originates from internal organs in the abdomen, chest, pelvis, or intestines
Somatic pain
Deep or superficial pain, deeper pain from skeletal structure, tendons, and
muscles (fractures or sprains)
Cutaneous pain
Injury to skin or subcutaneous tissue. Burning your skin like on a hot pan/iron
Radiating pain
Starts at origin, extends to other locations. Ex: Sore throat that extends to ears
and head
Referred pain
Occurs in an area distant from the site of origin. Ex: pain from heart attack felt in
jaw or left arm
Phantom pain
Perceived in an area that has been surgically or traumatically removed
(amputation)
Pain assessment
First intervention when caring for a patient with pain
Non-pharmacologic interventions
Includes distraction, cognitive behavioral therapy, relaxation techniques, physical
methods, heat/cold, repositioning, massage, alternative therapies, aromatherapy,
acupuncture, exercise, yoga, physical therapy, neurostimulation
Fluid volume changes
,Indicators include weight gain, swelling, discomfort, shortness of breath,
hypertension, heart issues, and edema
Intake & output
Best option for monitoring fluid volume changes
Physiological effects of fluid volume deficit
Include dizziness, hypotension, headache, inability to concentrate, low heart rate,
fatigue, dry skin, weak pulse
Factors influencing body temperature
Include weather, exercise, illnesses, hormones, emotions, medications
Confusion Assessment Method (CAM)
Used to identify and recognize delirium quickly and accurately
DASH diet
Diet for hypertension, based on eating more fruits, vegetables, whole grains, fiber,
and low-fat dairy products while reducing saturated fat, total fat, and meat intake
Foods for skin breakdown and wound healing
Include Vitamin C, Zinc, Protein, Unsaturated fats, Vitamin A.
- Vitamin C: Helps your body make collagen. Good sources include citrus fruits and
juices, strawberries, tomatoes, peppers, potatoes, spinach, broccoli, and
cauliflower.
- Zinc: Helps your skin heal and grow. Good sources include fortified grains,
protein foods like beef, chicken, seafood, or beans, fish and seafood like oysters,
clams, crab, and halibut, yogurt, eggs, spinach, nuts and seeds like pumpkin seeds
and cashews, whole grains like oats and quinoa, and lentils and chickpeas.
- Protein: Helps your body rebuild tissue. Good sources include meat, fish, poultry,
eggs, cheese, vegetables, nuts, and Quorn.
- Unsaturated fats: Found in nuts, which are also a concentrated source of
vitamins, minerals, and other phytochemicals. Almonds can help boost the
appearance of skin, while Brazil nuts can support immunity and wound recovery.
- Vitamin A: It's best to get vitamin A through your diet, not from supplements, as
too much vitamin A in supplement form can cause health issues like dry skin.
, Hypoxia
Deficiency in the amount of oxygen reaching the tissues
Indicators of hypoxia
Include behavioral changes, breathing issues, skin color changes
- Behavioral changes: Early signs of hypoxia include anxiety, confusion, and
restlessness. As hypoxia worsens, patients may experience altered mentation,
coma, or euphoria. Other behavioral changes include irritability, slurred speech,
and diminished thinking capacity.
- Breathing issues: As hypoxia worsens, patients may experience increased
respiratory rate, difficulty breathing, or shortness of breath. Other breathing
issues include wheezing and coughing.
- Skin color changes: Cyanosis, a bluish discoloration of the skin, may indicate
severe hypoxia. This is caused by a decreased amount of oxygenated hemoglobin
on red blood cells
Subjective data
Information from feelings, experiences, opinions, and thoughts (patient rating
pain)
Secondary subjective data
Information from another party/source (daughter of an elderly person explaining
that her mom has been dizzy lately)
Hypothermia
(Normal temp 96.4-99.5)
<96.4 temperature range
Hyperthermia
(Normal temp 96.4-99.5)
>99.5 temperature range
Hypotension
Blood pressure <120/<80
Hypertension