Multidimensional Care 1 Exam 1 (1st Exam) Questions and Answers

Multidimensional Care 1 Exam 1 (1st Exam) Questions and Answers 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 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