NUR 1023 UNIT 6 STUDY GUIDE REVIEW 2023 UPDATE, Exams of Nursing

Download NUR 1023 UNIT 6 STUDY GUIDE REVIEW 2023 UPDATE and more Exams Nursing in PDF only on Docsity! NUR 1023 UNIT 6 STUDY GUIDE REVIEW 2023 UPDATE Sensory Perception: Giddens (27) p. 260 and Lewis Chapter 20 p. 348a-357 Definition: the ability to receive sensory input and, through various physiological processes in the body, translate the stimulus or data into meaningful information. Key Terms: Sensation: the ability to perceive internal or external stimulation through one’s sensory organs. Perception: the process by which we receive, organize, and interpret sensation. Scope: Ranges from optimal to impaired in each of the five senses: vision, hearing, taste, smell, and touch. Normal Physiologic Processes Vision: The visual system is part of the CNS and is comprised of the eyes and the brain. ● External Eye and Periocular Structures: Orbit: - Eye socket, or bony structure that houses the eyeball - 7 Bones: frontal, zygoma, maxilla, ethmoid, sphenoid, lacrimal, palatine - 3 Fissures: optic canal, superior orbital fissure, inferior orbital fissure Ocular Adnexa: - Eyebrows, eyelids, eyelashes, and lacrimal system. - Lacrimal system: tear production and drainage - These structures and the eye muscles help to regulate visual input, protect the eye, and provide eye movement. Conjunctiva: - Transparent mucous membrane that covers the inner surface of eyelids and extends over sclera and secretes mucous and tears via glands. ● Internal Eye: Outer sclera and cornea: - Tough outer layer comprised of cornea, conjunctiva, and sclera. - Cornea: allows light into the eye and is transparent and avascular. Curved shape to refract or bend light. - Sclera: white, fibrous connective tissue to protect eye and maintain shape and structure. Middle layer: - Comprised of iris, ciliary body, and choroid - Pupil constricts or dilates via iris muscles - Ciliary muscles: focus by changing shape of lens to refract light onto retina - Choroid: highly vascular structure that nourishes ciliary body, iris, and outer retina. Risk Factors The elderly are the highest risk population Congenital Conditions and Genetics - Vision: congenital glaucoma, cataracts, and retinoblastoma - Hearing Loss: congenital malformations in structure or function of auditory system, maternal infection, family history, history of meningitis, low Apgar score, ICU admission, elevated bilirubin. Adverse Reactions and Side Effects of Medications - Antihistamines (loratadine, diphenhydramine): blurred vision, dry mouth - Antihypertensives (beta-blockers, CCB, ACE inhibitors): blurred vision, taste and smell alterations - Miotic eye drops (pilocarpine, carbachol): Vision changes, increased nearsightedness, blurred vision - Antiseizure Drugs (topiramate, acetazolamide): Peripheral numbness, dry mouth, tinnitus, blurred vision, eye pain, metallic taste - Diuretics (furosemide): Hearing loss, tinnitus, taste and smell alterations - Chemotherapy: Paresthesia, alterations in taste and smell - Antibiotics: Ototoxicity, alterations in taste and smell Acute Injury - Childhood trauma to the eye - Nonaccidental inflicted neurotrauma (shaken baby syndrome) causes traumatic retinoschisis due to retinal damage Chronic Medical Conditions - Visual/Auditory Risk Factors: Brain tumors, head injuries, cancers, infectious disease, stroke, and cardiovascular disease such as hypertension - Smell/Taste: nasal polyps, environmental chemicals, sinus/upper respiratory infections - Taste, Balance, and Visual: cerebrovascular accident (CVA) - Autism may cause sensory disturbances such as insensitivity to pain or overstimulation Lifestyle Choices and Occupation - Smoking (taste/smell) - Loud noise due to occupation or recreation (over 85 decibels) and is irreversible once damage occurs - Flying debris or chemical exposure (vision) - Assessment - Past medical, surgical, family, and social history, lifestyle, and occupation - Pediatric: prenatal and maternal history - List of medications - Sensory perceptual symptoms or problems - Glasses or hearing aids Vision - Common Symptoms: blurred vision, difficulty seeing close or far away, peripheral vision changes, eye pain, sight loss, floaters, double vision - Infant/toddler: ask caregiver about synchronous eye tracking when child watches movement - External eye structures: brows, lashes, lids should be symmetrical, appropriately sized, and extension - Palpate: eyelid and eye - Inspect: conjunctiva (should be pink and moist) for redness/irritation, sclera white in color, and the lens transparent - Penlight exam of cornea for infants/young children - 3 years and older: Snellen Chart - Example: 20/60 means they can see from 60 ft what a typical person could see from 20’ - Cranial Nerves III, IV, and VI and six extraocular muscles control eye movement - Six cardinal fields of gaze - Nystagmus: rapid involuntary eye movement - Internal eye exam: Visualization of the optic disc, arteries, veins, retina via ophthalmoscope and pupil dilation - Pupillary response to light Hearing - Common Symptoms: difficulty hearing, tinnitus, ear pain, fluid - Pediatric: otitis media (drainage, pain, fever) - Auricle inspection: symmetry, size, shape, possible discharge - Inner ear inspection: visualization of cerumen and tympanic membrane via otoscope - Tympanic membrane should be translucent, pearly, and gray Taste - Common Symptoms: thrush, metallic taste - Altered sense of taste usually caused by smell - Current medications - Inspect for atrophied tongue, yeast, ulcerations, nodules - Normal findings red and moist Smell - Current medications - Recent respiratory complaints (sinus infection, allergies, polyps) - Color and size of nasal passages and discharge - Patency: Breathing through one nostril should be quiet and effortless Touch - Common Symptoms: Numbness, tingling - Neurologic system regulates touch and balance - Romberg test: assesses balance by having pt stand with their feet together and arms at their sides with their eyes open and then closed - Observation of gait - Identifying stimuli such as dull vs sharp, location, temperature, or monofilament testing Clinical Management Primary Prevention - Protective devices: safety goggles, helmets, earplugs - Oral hygiene - Erythromycin eye ointment for newborns Secondary Prevention Vision - Under 3 years: eye evaluations at each visit include history, assessment, external inspection, ocular motility assessment, pupil exam, red reflex exam - 3 years and older: should include the above in addition to visual acuity measurement and an attempted ophthalmoscopy - Adults up to 40 or up to 60 with no pre-existing: eye exam every two years - Adults 40-60 with conditions such as diabetes, heart disease, or hypertension should be seen more often - Adults over 60: yearly eye exams and age-related disorders such as glaucoma (increase in intraocular pressure) Hearing - Neonates usually tested in 48 hours, no later than one month, using OAE’s and ABR’s (outer and inner ear inspections) - Repeated at 3 months if abnormal - Outer and inner ear inspection at each well-child visit Interrelated Concepts Impacts Sensory Perception/Closely Related: Intracranial Regulation: brain cells regulate sensory input and output. Sensory function is often impacted in brain disturbances Impacted by Sensory Perception: Pain: A necessary, but uncomfortable sensation that alerts us of injury potential Mobility: Sensory alterations can affect mobility Nutrition: Inability to taste and smell reduces desire to eat Development: children with hearing or vision limitations can have developmental delays Functional Ability: may be impeded when an individual experiences impaired sensory perception due to inability to interact efficiently with the environment. Palliative Care - A theoretical framework for palliative care practice, education, and research across the lifespan and settings - Consists of four editions and community specific guidelines - Promote high-quality care, reduce variation in new and existing programs, encourage continuity of care across settings, and facilitate collaborative partnerships among programs, hospices, and other healthcare settings. - National Quality Forum (NQF): project of the Clinical Practice Guidelines to promotes recognition, stable reimbursement structions, and accreditation initiatives - Framework for Hospice and Palliative Care: initiative created by NQF that is out of date - The Joint Commission: uses NCP Clinical Practice Guidelines as the basis of Advanced Certification in Palliative Care - Hospice and Palliative Nurses Association: uses NCP guidelines as educational framework Context to Nursing and Healthcare In 2014, more than 20.4 million people needed palliative care, 69% of whom were over 60, 6% were children. 7 out of 10 Americans can expect to live with their diseases several years before dying. 8 million baby boomers are now Medicare age. - As nurses, our ethical obligation is to relieve suffering. This includes giving medications that may produce harm. Double effect means that it is morally permissible to give a medication that has harm potential if it is given with the intent of relieving pain, not to hasten death. - Euthanasia is the deliberate act of hastening death - Physician-assisted suicide is providing the means and/or information about how the patient can commit suicide themsllvs - Palliative sedation is the use of medications to intentionally produce sedation to relieve intractable symptoms and distress in an imminently dying patient. - Plan of Care is first based on the patient and family’s goals and wishes and second on the team’s assessment and recommendations. Team-Based Palliative Care ● Core Services - Chaplaincy: spiritual counseling and support - Nursing: assess and evaluate ongoing needs including physical, emotional, social, cultural, and spiritual wellbeing; advocacy; provide referrals - Social Services: psychological care, identify issues including communication, educational, financial, guardianship, legal, and assist with support and resources - Medicine: DO and MD offer diagnosis, care planning, and oversight of care. ● Expanded Services - Psychological Support - Care coordination and care management - Rehabilitation services: physical, speech, OT - Expressive therapies: child life, art, music - Volunteers: bereavement counselors, family support specialists, and volunteers ● Levels of Palliative Care - Primary Palliative Care Providers: healthcare professionals with a working knowledge of issues surrounding patients with serious illness who assess, diagnose, manage, or treat conditions or issues such as advance directives, common pain syndromes, and symptoms. - Speciality Palliative Care Providers: Specialists in palliative care with expert knowledge in psychical, spiritual, emotional, psychological, and cultural aspects. Strategic Directions for Palliative Care IOM 2014 report: - Palliative care should be covered by every insurer - Care should be evidence based and updated continually - HCP’s must achieve competence in palliative care Call For Action: Nurses LEading and Transforming Palliative Care: - Interdisciplinary model of clinical practice - Collaboration to provide evidence based care and respect patients wishes - Nurses at ALL levels must receive palliative care education - Recommended that nurses pursue End-of-Life Nursing Education Consortium training Changing Models of Care - Hospice initially based on cancer disease trajectory - Patients may now live for many years with their chronic disease (including cancer) and have varying fluctuations in functional status - Attention to cost-effective management of chronic disease and symptoms - Palliative care gives higher satisfaction and decreased symptom burden - Expert pain and symptom management - Improved quality of life and family support - Ongoing education will offer early referral to palliative care, promoting more continuity of care and better partnership - Continuous evaluation of the care plan to ensure “best practice” and “evidence based” care, as well as addressing individual patient needs and wishes Interrelated Concepts Domain One: Structure and Processes of Care - Love, affection, empathy, compassion, holistic care Attributes: - Ability to care - Adapting to the situation - Being a good listener - Showing affection - Being responsible for someone other than self - Strong, protective, organized, patient, understanding - Serving as an advocate - Assisting with ADLs - Providing emotional and social support - Managing and coordinating healthcare services Teaching-Learning Process - Motivational Learning: uses nonconfrontational interpersonal communication techniques to motivate behavior change. 1. Precontemplation: is not considering a change. Is not ready to learn. - Nursing implications include providing support, increase awareness of condition. Describe benefits of change and risks of not changing. 2. Contemplation: thinks about a change. May state recognition of need of need to change. Says “I know I should, but identifies barriers” - Introduce what is involved in changing behavior. Reinforce need to change 3. Preparation: Starts planning the change, gathers information, sets date to start change, shares decision to change with others - Reinforce the positive outcomes of change, give information and encouragement, develop a plan, help set priorities, and identify sources of support 4. Action: Begins to change behavior through practice. Tentative and may experience relapses - Reinforce behavior with reward, encourage self-reward, discuss choices to help minimize relapses and regain focus. Help pt plan to deal with relapses 5. Maintenance: Practice the behavior regularly. Able to sustain the change - Continue to reinforce behavior. Provide more teaching on need to maintain 6. Termination: Change has become lifestyle. No longer considered a change - Evaluate effectiveness of new behavior. Context to Nursing and Healthcare Caregiver’s Experience Caregivers’ Perception and Coping - Perception: mental process of viewing and interpreting a person’s environment - Caregiver experiences (potential stressors) are only stressful when they are perceived as such - Influencing Factors: level of knowledge, anticipatory loss/grief, availability of material, practical, and spiritual resources for self care, coping ability - Positive coping: exercising, maintaining social relationships - Negative coping: substance abuse, denial Uncertainties and Inadequate Understanding - Unprepared to deal with variations and changes in cognitive or physical status - Uncertainties about present/future and inadequate understanding of disease - Refusal to accept or caregiver guilt - Receiving a clear diagnosis and understanding the implications of disease process can help validate caregiver experience Caregivers’ Financial and Social Distress - Negative Financial Consequences: late to work, leaving work early, taking time off, reduction of hours, taking a less demanding job, quitting, early retirement, draining retirement or life savings (especially with no long term care insurance), selling home Changing Family Roles, Relationships, and Dynamics - Original roles of patient or caregiver cannot be maintained - Primary care will fall to one person with or without helpful (or unhelpful) input from other family members - Ineffective communication, exacerbation of past familial tension - Ideal: One or several family members assume role of caregiver with support of other members by providing emotional, financial, and spiritual support, providing relief to caregiver. Goal is to achieve equilibrium, or family homeostasis. Influence of Culture on the Caregiving Experience - Culture determines how duties are assumed, managed, and perceived - Some cultures value individualism, competition, independence versus collectivism - High aspect of familism in Asian and Latino/Hispanic cultures - Resources seeked out by caregivers dependent on culture - Sense of duty and responsibility toward family members seen as either an honor, duty, obligation, or burden. Outcomes of Caregiving (part of family caregiver assessment) Positive Consequences: - sense of pride, esteem, accomplishment - Acts as a buffer against traumatic grief or overwhelming burgen - Positive aspect concentration can “reframe” their role Negative Consequences: - Physically, emotionally, financially overwhelmed - Negative health events - Caregiver stress signs: denial, anger, social withdrawal, anxiety, depression, exhaustion, irritability, sleeplessness, lack of concentration, health problems - May result in burnout, negligence, or abuse Nursing and Caregiver Support - Holistic approach includes nurse, patient, caregiver, and family - Listen attentively to caregiver’s stories - Share their perceptions, experiences, and coping - Collaborative plan of care - To teach, nurse must have knowledge of subject matter and communication skills Identifying and Accessing Resources - Encourage them to seek and accept support of family, friends, and resources - Act as facilitators to access and provide information about resources - Palliative care and hospice are often not mentioned - May have difficulty asking for help or not know where to turn Caring for the Caregiver - Provide sense of empathy and help understand and cope with stressors - Monitor caregiver (hidden patient) for indications of declining health and emotional distress - Acknowledge stress and plan self-care with caregiver - Support groups - Respite care such as adult day care, in-home care, or assisted living facilities - Caregiver quality of life is cornerstone of effective caregiving interventions - Encourage caregiver to exercise, maintain a healthy diet, get adequate sleep - Advise them to keep a journal, use humor when appropriate, and continue social activities - Maintain physical contact with friends, family, and HCP - Encourage them to appraise their perception of situations and maintain positivity - Nourish their spirits, help provide spiritual/religious resources when appropriate Interrelated Concepts Family dynamics, Culture, & Spirituality: Closely interrelated due to caregiver role’s trigger of changes in family structure. Culture influences view on family and roles. Cultural and religious values may support positive family dynamics. Adherence: Adhering to caregiver role may be because of a positive relationship with the care recipient, lack of purpose without someone to care for, feeling the role is unavoidable, keeping a promise, or lack of alternatives. Self-Management: The caregiver may feel unable to keep up with own health/disease management Stress and Coping: Actual or perceived threat to caregiver’s mental, emotional, and spiritual well-being Fatigue: A physiological response of ineffective coping, burnout, etc. Mood and Affect: Influenced by ability to cope Anxiety: Caregivers are often overwhelmed Addictions: Negative coping mechanism Communication: Essential in order to support positive aspects and minimize negative ones Health Promotion: Expected result of effective communication process and education Palliative Care: Deciding on the right moment to request palliative consult in patients with declining health can make a difference in healthcare and treatment decisions going forward. Care Coordination: Achieved when the needs of the patient and family caregivers are discussed with other members of the interprofessional team. Healthcare Law Giddens (57) p.522, Varcarolis Chapter 6 (up until documentation of care), Nursing Today Chapter 20 Advance Directives: A document made by an individual to establish desired health care for the future or to give someone else the right to make health care decisions if the individual becomes incapacitated; examples include living wills and durable powers of attorney for health care Malpractice: Improper performance of professional duties; a failure to meet the standards of care, resulting in harm to another person. Nurse Practice Acts: Each state defines the qualifications for nursing licensure and establishes how the practice of nursing will be regulated and monitored within that state’s jurisdiction. Nurse Practice Acts generally describe nursing scope of practice boundaries, unprofessional conduct, and disciplinary action In most states, the Nurse Practice Act and the regulations that interpret it do the following: - Describe how to obtain licensure and enter practice within that state. - Describe how and when to renew a nursing license. - Define the educational requirements for entry into practice. - Provide definitions and scope of practice for each level of nursing practice. - Describe the process by which individual members of the board of nursing are selected and describe the categories of membership. - Identify situations that are grounds for discipline or circumstances in which a nursing license can be revoked or suspended. - Identify the process for disciplinary actions, including diversionary techniques. - Outline the appeal steps if the nurse feels the disciplinary actions taken by the board of nursing are not fair or valid. Nurse Licensure Compact: Enhanced Nurse Licensure Compact (eNLC) is a “mutual recognition agreement” between states that have adopted the Compact legislation that allows both registered and practical nurses with a license in good standing in their “home state” to practice nursing in any of the other Compact states. Negligence: Failure to act as an ordinary prudent person when such failure results in harm to another. - Duty: Accepting employment as a nurse and representing yourself as being capable of nursing practice assumes a duty of care from yourself to the patient. - Breach of Duty: Not meeting the standard care that other prudent, reasonable nurses would meet under the same or similar circumstances - Causation: If it were not for what the nurse did or failed to do, this injury would not have occured - Harm: Actual damages, pain and suffering, incidental or consequential damages. Scope: A collection of laws that have a direct impact on the delivery of healthcare or on the relationships of those in the business of healthcare Sources of Law: ● Constitutional Law - Fundamental principles by which government exercises authority - Article I, Section 8: “To make all laws, which shall be necessary and proper for carrying into execution the foregoing powers” - AKA taxing and spending power as well as the power to regulate interstate commerce - Due Process Clause of the 14th Amendment: provides protection under the constitution for certain “liberty rights” related to privacy. - Right to privacy: Right to use contraception (Griswold v. CT); right to have an abortion (Roe v. Wade); Right to refuse medical treatment that sustains life (Cruzan vs MO). ● Statutory (Legislative) Law - Arise from legislative action and enacted with intent to directly impact businesses or provider relationships in healthcare or provide care for defined groups of people - Social Security Act Amendments of 1965: federal legislation that established Medicare and Medicaid programs ● Administrative Law and Regulations - Agencies that protect public interest and act as agents for executive branches - Enact rules and regulations to promote public health by, promoting quality services, preventing communicable disease, protecting publix against bioterrorism, ensuring disaster preparedness of HCPs, reducing healthcare costs, oversight of health insurance programs, promoting access to care, protecting consumers who are buying insurance - US Dept of Health and Human Services - US Dept of Veterans Affairs - State licensing boards: vested with executive powers to implement regulations through statutory practice acts ● Tort Law - Tort: wrongful and unreasonable action or omission to an individual or entity against a person who suffers harm from the act or omission - Plaintiff suffers loss, liability lies with defendant - A civil wrong under statue statute or common law; basis for civil suits - Medical negligence or malpractice falls under this scope - Goals: to provide relief to harmed party; to impose liability on those responsible; deter others from harmful acts - Intentional Torts: assault or battery - Negligent or Unintentional Torts: slip and fall or car accident - Strict Liability: no degree of care matters, such as ultrahazardous materials or dangerous animals ● Common Law - Judge law, case law, or judicial precedent ● Contract Law - Governs mutual agreements between two or more parties - Mechanism under which healthcare services and transactions are conducted ● Criminal Law - Prohibits conduct that threatens or harms others or endangers the property or health or safety of individuals - Medicare or insurance reimbursement fraud, abusive billing or referral practices, misrepresentation of practitioner qualifications - Federal Anti-Kickback Statute: prohibits the exchange, or an offer of exchange, of anything of value to induce referrals to federal or state healthcare programs Attributes and Criteria: 1. Laws are created by Congress or state legislatures on behalf of healthcare consumers to achieve healthcare policy goals 2. Regulatory agencies draft and implement regulations to ensure effectiveness without overly burdensome activity 3. Enforcement procedures associated with subsequent punishment such as fines, exclusion from government payment sources, auditing and monitoring, and jail. Accreditation standards are not legally binding but if such guidance is followed, a provider is likely to be deemed in compliance. Context to Nursing and Healthcare: Federal Statutory Laws Impacting Healthcare - Social Security Amendments of 1965 and 1983 - Consolidated Omnibus Budget Reconciliation Act (COBRA) and Omnibus Budget Reconciliation Act (AKA federal nursing home reform act) - Patient Self-Determination Act of 1991 - Health Insurance Portability and Accountability Act (HIPAA) - Patient Protection and Affordable Care Act (ACA): requires CMS to draft and implement vast array of regulations - Documentation should comply with requirements set forth by CMS - Nurse notes should be accurate, timely, and reflect compliance with standards of care and quality initiatives Administration and Regulation ● Federal Regulation and Administrative Agencies - Dept of Health and Human services heads agencies such as CMS. - Informed Consent: obligation to disclose and explain procedures and treatment and must be given voluntarily in writing by patient with capacity to consent ● Competence and Capacity - Competence: legal term that means a person has sufficient capacity and ability to make reasoned decisions. Determination of incompetence is a judicial decision. Adults presumed to be competent. Court may appoint guardian. - Capacity: evaluation or assessment of a person’s ability to understand, appreciate, and manipulate information to form rational decisions. Determined by physician or other practitioner. Capacity may be affected by drugs or medical condition and can change over time. ● Substituted Judgement and Best Interest Standards - Surrogate or agent that can give consent on patient behalf - Most states liste surrogate decision-makers based on relationship with patient (spouse, adult child, etc) - Substituted judgment: discussed wishes of patient beforehand so surrogate is ethically bound to abide by them - Best interest standard: ethically obligated to act in patient’s best interest if wishes were unknown ● Advance Directives - Entities required to provide patients with written information about right to make their own decisions, including right to execute directives in advance, right to refuse treatment, and right to appoint a person to make decisions on their behalf - Provider must ask patients if they have an advance directive and document patient’s response - Providers who act in reliance with these documents have immunity from civil or criminal liability ● Laws Affecting End of Life - Death with Dignity Act in some states allows physicians to write a prescription for a lethal dose of medication that a metnally competent but terminally ill patient can use to end their life if patient has less than 6 months to live, made two oral requests at least 15 days apart, a written request signed in presence of two witnesses, and 2 physicians confirmed prognosis of patient and competency. Providers can opt out of participating. Confidentiality Laws - HIPAA laws: strict requirements about protection of patient information and distribution Ethical Concepts - Bioethics: study of specific ethical questions that arise in healthcare - Beneficence: The duty to act to benefit or promote the good of others - Autonomy: respecting the rights of others to make their own decisions - Justice: Duty to distribute resources or care equally - Fidelity (nonmaleficence): Maintaining loyalty and commitment to the patient and doing no wrong - Veracity: Duty to communicate truthfully - Ethical dilemma: conflict between two or more courses of action, each with favorable or unfavorable consequences Patient Rights - Right to refuse treatment (even if involuntarily committed) - Right to be free from excessive or unnecessary medication - Psych patients can be involuntarily medicated via court order if the patient has serious mental illness, ability to function is deteriorating or exhibiting threatening behavior, benefits outweigh harm, person lacks capacity to make reasonable decisions, less-restrictive services are inappropriate. - Right to privacy and dignity - Right to least restrictive environment - Right to an attorney, clergy, and private care providers - Right to not be subjected to lobotomies, electroconvulsive treatment, and other treatments without willfully informed consent Interrelated Concepts: Health Policy: encompasses the goal or outcomes healthcare law is enacted to meet Ethics: Set of values under with policy and laws are made Health Care Economics: Many laws have a financial incentive to compel compliance Health Care Quality: Certain quality standards are required by law and compliant entities are incentivised. Evidence Giddens (47) p. 446; Lewis Chapter 1 p.15-16; Nursing Today Chapter 24 Definition: Testimony of facts tending to prove or disprove a conclusion Key Terms Quantitative Research: Being focused on the testing of a hypothesis through objective observation and validation Randomized control studies, cohort studies, case reports Qualitative Research: Answers questions that cannot be answered by quantitative studies by focusing on a person’s experience and uses analysis of textual, or non- numeric data, such as interviews, surveys, or questionnaires. Primary Literature: Original research studies Secondary Literature: Summarize findings from an individual or multiple studies Meta-analysis: Summarizes statistical results of numerous studies and analyzes that evidence. Data Collection: - Quantitative Research: Follows specific sequence, Similar to scientific method; numeric data collected through questionnaires, surveys, established instruments, Large sample size - Qualitative Research: Data collected through observing, interviewing, audio/video recording; Small sample size; Study participants are typically selected by researcher Data Analysis: - Quantitative Research: Statistical analysis; numeric data reported; Data analyzed is unbiased and objective - Qualitative Research: Researcher interprets data by developing themes based on participants’ views and observations, Data analyzed is subjective in nature; may include words, artifacts, images, anecdotal statements Evidence-Based Practice: The conscientious, explicit, and judicious use of theory- derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences. - An ongoing process by which evidence, nursing theory, and the practitioners’ clinical expertise are critically evaluated and considered, in conjunction with patient involvement, to provide delivery of optimum nursing care for the individual. Research Utilization: The ability to transfer research into clinical practice is essential for ensuring quality in nursing via preutilization (1); assessing (2); planning (3); implementing (4); and evaluating (5) Literature Review: synthetic review and summary of what is known and unknown regarding the topic of a scholarly body of work, including the current work's place within the existing knowledge. Attributes and Criteria - Replicability: Findings verified when done in other studies - Reliability: Findings are consistent - Validity: successfully measured what was set out to be measured/ Accuracy of findings - Publicly available, understandable, usable. Scope Discovery “Bench” Research > Translational Research > Patient Care - Bench Research: discovery of evidence - Translational Research: studying its application in clinical practice - CRAPP checklist: Currency, Relevance, Authority, Accuracy, Purpose - Date last updated, author and sponsor, limit bias, web domain, references Nurses as Researchers: Evidence Discovery - Nurse researchers at doctorate level employed at academic health science centers, private organizations, or government agencies - Quality Improvement projects: improve pt care at local level based on current knowledge Nurses as Consumers of Evidence - Nurses should; 1) practice policies and procedures; 2) find solution to practice problems ● Policies and Procedures - Policy and procedure manuals outline practice standards, should be regularly updated to reflect current evidence ● Finding Solutions to Practice Questions/Steps to EBP - Problem-solving approach to clinical decision making. Using the best available evidence (e.g., research findings, QI data), combined with your expertise and the patient’s unique circumstances and preferences, leads to better clinical decisions and improved patient outcomes. 1. Develop an answerable question - PICO/T (Population, Intervention, Comparison, Outcome, Time) - Example: “In adult abdominal surgery patients (P = patients/population) is splinting with an elasticized abdominal binder (I = intervention) or a pillow (C = comparison) more effective in reducing pain associated with ambulation (O = outcome) on the first postoperative day (T = time period)?” 2. Search the literature to uncover evidence to answer question - Evaluate sources using hierarchies 3. Evaluate evidence found via critical appraisal - (1) What are the results? (2) Are the results reliable and valid? and (3) Will the results help me in caring for my patients? 4. Apply evidence to practice question - Combining the evidence, clinical judgment, and preferences and values of patients and caregivers 5. Evaluate the outcome - Determine if evidence improved patient outcomes 6. Share The Evidence Interrelated Concepts Safety: Evidence used to create safety standards (IOM) Health Policy: Evidence provides foundation for creation of policy Technology and Informatics: Technology allows increased access to evidence Health Care Economics: Evidence plays a vital role through cost containment. Reproduction Concept 20 & 21 p. 189, Lewis Chapter 50, Perry Chapter 3 p. 39-49; Varcarolis Chapter 20 p. 380-382. Definition: The total process by which organisms produce offspring. Key Terms Conception: Occurs when sperm fertilizes an egg Contraception: Measures to avoid pregnancy Fertilization: Sperm travels through cervix into uterus and then into fallopian tubes for ovum Implantation: Blastocyte embeds into endometrium Menarche: First episode of menstrual bleeding, reaching puberty Gametogenesis: formation of germ cells via meiosis (oocytes and spermatocytes) Scope: ● Reproduction: Non-pregnant state > Pregnant state By choice/not by choice | Unplanned/planned - Those who are not pregnant, not by choice: 1) not yet sexually mature 2) sexually mature but infertile or post menopausal 3) fertile and partnerless Normal Physiology Formation of Reproductive Cells ● Oogenesis: Process of egg (ovum) formation - Begins during womans fetal life, ovaries contain all meiotic cells at birth - During menstruation, one oocyte matures and completes first meiotic division. Second division begins but is only completed if sperm penetrates zona pellucida ● Spermatogenesis: Formation of germ cell to sperm cell - Begins at puberty due to testosterone - Takes place in seminiferous tubules within testes - Travels through efferent tubules to epididymis to mature - Move through vas deferens to ejaculatory duct to wait for ejaculation Pregnancy - Expected outcome among women of childbearing years who have sexual intercourse without contraceptive methods, or when these methods fail - Begins with fertilization, involves a 40-week-gestation (from first day of last menstruation), and results in live birth (normal physiology) ● Fertilization - Sperm travels through cervix into uterus and then into fallopian tubes for ovum - Usually in lower third of fallopian tube - Sperm penetrates ovum membrane - Cortical Reaction: prevents other sperm from entering ovum - Zygote: new cell resulting from fertilization with 2 sets of chromosomes - XX: female; XY: Male - Zona pellucida: membrane like sac forms around zygote - 30 hours post-fertilization: cleavage occurs (division of zygote) - Morula: cell mass of 12 to 16 blastomeres 3 days post-fertilization ● Implantation - 4 days post-fertilization: Cavity within morula forms - Blastocyte floats freely in uterus for two days - Fluid passes through zona pellucida, collecting in spaces Female Reproduction: ● Roles - Ova production - Hormone secretion - Protect and facilitate development of fetus ● Pelvic Organs - Ovaries (Primary) - Found on either side of uterus below fallopian tubes - Almond-shaped, firm, solid - Ovulation, secretion of estrogen and progesterone - Outer zone contains follicles with oocytes - Fallopian Tubes - Transport ovum toward uterus to facilitate fertilization or implantation - Fimbriae sweep the ovum from ovarian follicle into fallopian tube - 1 ovarian follicle reaches maturity each month during reproductive years. This follicle is ovulated (expelled) from ovary via gonadotropic hormones: FSH and LH. Ovum then travels to the fallopian tube to be fertilized (usually within outer ⅓ of tube) within 72 hours, or reabsorbed. - Uterus - Pear-shaped, hollow, muscular organ between bladder and rectum - Layers: Perimetrium; Myometrium; Endometrium - Fundus, body (corpus), cervix - Cervical os: opening of cervix - Cervix should be pinkish and smooth - Pap smear tests squamocolumnar junction (two types of epithelial cells) - Vagina - Tubular structure of 3-4 inches lined with squamous epithelium - Rugae (transverse folds) in reproductive women - Secretions: cervical mucus, desquamated epithelium, watery secretion (during sexual stimulation) - Pelvis - 4 bones (two pelvic, sacrum, coccyx) held together by ligaments - Larger diameter than men, circular ● External Genitalia (Vulva) - Mons pubis: fatty layer over pubic bone with coarse, triangular patterned hair - Labia majora: folds of adipose tissue forming outer borders of vulva - Labia minora: Forms borders of vaginal orifice and enclose clitoris - Vestibule: Opening between labia minora when they are held apart - Clitoris: Erectile tissue that becomes engorged during sexual excitation - Skene’s glands: lie alongside urinary meatus (comparable to prostate glands, help lubricate urinary meatus) - Vaginal introitus (opening): surrounded by hymen - Bartholin’s glands: correspond to Cowper’s glands in males ● Breasts - Secondary sex characteristic developed during puberty due to estrogen and progesterone Neuroendocrine - Regulate processes of ovulation, sperm formation, and fertilization, as well as formation and function of secondary sex characteristics. ● Hypothalamus and Pituitary Gland: - Hypothalamus secretes gonadotropin releasing hormone to stimulate anterior pituitary to secrete FSH and LH. - FSH: in women, stimulates growth/maturation of ovarian follicles In men, stimulates seminiferous tubules to make sperm - Mature follicles make estrogen which suppresses FSH - LH: causes follicles to complete maturation and ovulation ● Gonads: - Estrogen, progesterone, testosterone - Estrogen suppresses FSH and is essential to development/maintenance of secondary sex characteristics, proliferative phase of menstrual cycle, and uterine changes in pregnancy. - Progesterone maintains secretory phase in preparation for fertilization and implantation. Necessary to maintain implanted ovum - Testosterone is responsible for development and maintenance of secondary sex characteristics and spermatogensis. Menstrual Cycle - Major functions are ovulation and hormone secretion - Monthly process mediated by hormones of hypothalamus, pituitary, and ovaries - Occurs during each month that ovum is not fertilized - 21 to 35 days (28 day average) 1. Proliferative (follicular) phase: a single follicle matures fully due to FSH which stimulates estrogen (causing neg feedback to decrease FSH). Endometrial lining increases in length of blood vessels and glandular tissue. 2. Secretory (luteal) phase: ovulation and progesterone initiate this phase. LH causes complete maturation/ovulation. Estrogen levels peak around day 12 when there is a surge of LH, triggering ovulation 1 or 2 days later. LH promotes development of corpus luteum after ovulation (temp functional cyst forms within ruptured follicle). Corpus luteum continues to secrete estrogen and initiates progesterone. These decrease without fertilization causing blood vessel contraction and tissue slough, causing menses. 3. Menstrual (ischemic) phase: Lack of estrogen/progesterone causes menstruation. Cycle begins on first day of menstruation (4-6 days). addictive lifestyle - Positive Affect: beneficial outcomes r/t length of gestation - Negative Affect: shortened gestation, preterm birth ● Sociodemographic Factors - Low income, inadequate prenatal care, younger than 15 years, older than 35 years, parity, marital status, geographic location (urban/rural), race/ethnicity - Disproportionate nonwhite women die of pregnancy related causes (3:1) ● Environmental Factors - Industrial pollution, radiation, chemical exposure, bacterial and viral infections, drugs, and stress Assessment History - Sexual history: number and sex of partners - Contraceptive history: methods used and reason for discontinuing - Surgical history: polyps, fibroids, neoplasms of GU - Altered pelvic support - Papanicolaou test history - Menstrual history - Immunization status: mumps infection may cause sterility in men. Rubella during first three months of pregnancy increases risk of congenital abnormality. - Mental health history - Endocrine disorders such as diabetes, hypo or hyperthyroidism - Dietary history: including deficiencies or disordered eating - Alcohol, caffeine, drug us, smoking - Genetic familial disorders - Medications: Post MI meds or hypertension may cause ED. Diuretics and psychotropics also of importance. - Hormone therapy in women: increased risk of stroke, breast cancer, DVT, and gallbladder disease - Cholecystitis and hepatitis may be contraindications of oral contraceptives - Subjective assessment - Human Chorionic Gonadotropin: fatigue, nausea, vomiting at 4-12 weeks - Estrogen/Progesterone: breast enlargement, fullness, tenderness, heightened sensitivity, urinary frequency - 16 Weeks: Braxton Hicks contractions - 20 Weeks: palpable fetal movements Objective Data: Males ● Pubis - Hair distribution should be diamond shaped and coarse - Assess for skin irritation, inflammation, or body lice ● Penis and Scrotum - Inspect for lesions, bleeding, or swelling - Location of urethral meatus and presence of foreskin - Retract foreskin and note redness, discharge, irritation, lesions, or swelling - Inspect scrotum by lifting each testis - Palpate testes for tenderness or masses - Left testis usually hangs lower than right - Undescended testis: major risk for testicular cancer and cause of infertility ● Anus - Note any lesions, swelling, inflammation - Inspect anal sphincter and perineal regions for fissues, lesions, masses, and hemorrhoids Objective Data: Females ● Breasts - Visual: symmetry, size, shape, skin color, vascular patterns, dimpling, lesions - Arms at sides, overhead, lean forward, press hands on hips - Palpate axillae and clavicular areas for enlarged lymph nodes - Supine: arm above and behind head to palpate using vertical line with distal finger pads of three fingers - Axillary Tail of Spence: adjacent to upper outer quadrant where most breast cancer develops - Palpate around areola for masses ● External Genitalia - Inspection and palpation of mons pubis, vulva, and anus - Assess hair distribution, body lice, lesions, redness, edema, or discharge - Separate labia to inspect clitoris, urethral meatus, vaginal orifice - Anus: fissures, lesions, hemorrhoids ● Internal Pelvic Exam - Speculum Exam: HCP inspects vaginal walls and cervix for inflammation, discharge, polyps, and growths - Bimanual Exam: size, shape, consistency of uterus and ovaries (ovaries and tubes not normally palpable) Exam Findings - Vitals: normal - No significant pain/discomfort - Weight gain within normal limits r/t BMI - Hegar Sign: softening and compression of lower uterine segment - Goodell Sign: softening of cervical tip - Chadwick Sign: violet blue vaginal mucosa and cervix at 6 weeks - Aerola and nipples may darken, breasts will enlarge - 5 weeks: visualization of fetus on real-time ultrasound - 6 weeks: fetal heart activity observed via transvaginal ultrasound - 8 weeks: fetal heart tones via external Doppler - 19 weeks: palpable fetal movement Pregnancy Monitoring influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious, and spiritual factors. Sexual Identity: A sense of being attractive and being attracted to others in terms of being heterosexual, lesbian, gay, bi, transgender, or queer. Gender Identity: Sense of maleness or femaleness Scope: Sexual well-being or function > Sexual dysfunction Normal Physiological Process Sexual Response - Excitement, plateau, orgasmic, resolution ● Motivation - Libido: desire to engage in sexual activity - Biological, psychological, sociological, spiritual - Impact: medical conditions, medications, personality, lifestyle, relationships, stressors ● Arousal - Physiological response to release of neurotransmitters - Sexual excitement: awareness of being sexually aroused - Excitatory: dopamine, norepinephrine, melanocortins - Inhibitory: serotonin, prolactin, GABA ● Genital Congestion - Reflexive autonomic response resulting in increased blood flow to genitals - Female: clitoral swelling and vulval engorgement - Male: penile erection - Facilitated by parasympathetic/inhibited by sympathetic ● Orgasm - Rapid contractions of genital and anal area that slowly relieves congestion - Female: contractions of lower part of vagina, uterus, anus, and pelvic floor. 10% of women ejaculate clear fluid from urethra produced by Skene glands, similar to prostate fluid - Male: pelvic floor muscle contractions result in ejaculation of seminal fluid ● Resolution - Sense of well-being, muscular relaxation, or fatigue following orgams - Neurotransmitters: prolactin, ADH, oxytocin Age-Related Differences ● Childhood (birth to 7 years) - Physiological capacity for sexual response observed as infant boys get erections and infant girls exhibit vaginal lubrication - Fondling - Form gender identity - Positive physical contact ● Preadolescence (8 to 12 years) - Division of boys and girls - Sexual curiosity between same sex - Masturbation ● Adolescence (13 to 19 years) - Physical puberty changes - Psychosocial factors can facilitate or inhibit adult-like sexual activity - 2 Developmental Tasks: learning to manage physical and emotional aspects of sexuality to form intimate relations; resolving conflict between identity and role confusion - Further development of gender and sexual identity ● Adulthood (over 20 years) - Sexual maturation continues - Two developmental tasks: learning to effectively communicate in intimate relationships; making informed decisions about sexual health - Sexual lifestyle options: celibacy, long-term monogamy, serial monogamy, polyamory Positive Sexual Attitudes and Behaviors Six Components of Optimal Sexuality: 1. Being Present: utter immersion and intensely focused attention 2. Authenticity: Feeling free to be themselves with partener 3. Intense Emotional Connection: heightened intimacy 4. Sexual and Erotic Intimacy: deep sense of caring 5. Communication: verbal communication, empathy, making one’s needs known via touch 6. Transcendence: heightened mental, emotional, physical, relational, and spiritual states of mind. Sexual Dysfunction - Disturbance in the desire, excitement, or orgasm phases of sexual response or pain during intercourse Sexual Desire Disorders ● Male Hypoactive Sexual Desire Disorder - Low interest in sex - Acute/situational or lifelong and can be with a specific person or generalized - Physiological, psychological, or both - Can be caused by testosterone deficiency or depression ● Female Sexual Interest/Arousal Disorder - Desire and excitement category - Characterized by emotional distress caused by absent or reduced interest - Gradual or lifelong - Neurobiological, hormonal, or psychosocial factors - Excitatory: dopamine, progesterone, estrogen, testosterone - Inhibitory: Serotonin, prolactin, opioids Sexual Excitement Disorders ● Erectile Disorder - ED or impotence - Failure to obtain/maintain erection - Disordered if occurs on 75% or more of sexual occasions and lasts at least six months Orgasm Disorders ● Female Orgasmic Disorder - Anorgasmia or inhibited female orgasm - Recurrent or persistent inhibition of orgasm after normal sexual excitement phase over at least six months during most sexual encounters - Associated with painful intercourse or postmenopause - Fear of pregnancy, rejection, loss of control, hostility from or toward men, cultural restrictions ● Delayed Ejaculation - Male orgasmic disorder, retarded ejaculation - Uncommon condition that may result from rigid background in which sex is believed to be a sin - Acquired delayed ejaculation may be due to interpersonal problems, physical conditions, substance use, and medication and is more common ● Premature Ejaculation - Ejaculation recurrently achieved before he wishes to (before or immediately after penis enters vagina) Genito-Pelvic Pain/Penetration Disorder - Interferes with penile insertion due to spasms and constriction, causing fear in next encounter Risk Factors At-Risk Populations ● Adolescents - Influence: socioeconomic status, family structure, future perspectives for education, and lived experiences - Health disparities among LGBTQ - HIV, STI, unintended pregnancy, and sexual violence risks ● Disabilities: Cognitive, Developmental, and Physical - Right and essential aspect to those with disabilities - Risk of poor decision-making, loneliness, manipulation, or force - Geriatric Population: chronic illness (CVD, COPD, cancer), cognitive decline, LGBTQ, issues, STIs. ● Newly Unpartnered - May begin dating again new or unknown partners causing STI and HIV risk ● Sexual Orientation and Identification: LGBTQ - LGBTQ may engage in high-risk behavior Individual Risk Factors ● High Risk Behaviors - Increased risk for multiple or casual partners or refraining from safe sex - Alcohol, marijuana, illicit substance use ● Underlying Medical Conditions/Medications - Acute or chronic pain, chronic fatigue, anxiety, depression, intercourse, multiple partners, adolescent-onset intercourse, sharing needles, STI history - High risk screening: chlamydia, gonorrhea, syphilis, HIV ● Intimate Partner Violence Screening - All patients, or all women of childbearing age (14 to 46)l - Hurt, Insult, Threaten, Scream Interrelated Concepts Reproduction: highly interrelated and both involve concepts such as puberty, contraception, STIs, safer sex, fertility, infertility, and sexuality Pain: One barrier to healthy sexual expression and function is pain. Gas Exchange: Medical conditions that lead to alterations can lead to SOB, fatigue, depression, and anxiety and can inhibit sexual response. Anxiety: “Being present” is a positive attribute of sexuality; anxiety cna preoccupy mind, body, and spirit. Stress and Coping: If a patient is undergoing extreme stress from other life issues, this may have a negative impact on sexual function. Stress Concept 30 p. 291; Lewis Chapter 6 Stress & Stress Management p. 77-82, p. 86 (Nursing Assessment); Lewis Chapter 4 p. 60; Varcarolis Chapter 10 p. 166-174 Definition: Inability to cope with a perceived (real or imagined) demand or threat to one’s mental, emotional, or spiritual well-being Key Terms: Stress and Coping: A continual process that starts with an event that is experienced by the individual, perceived through intact information processing channels, appraised for scope and meaning, assessed as neutral, manageable, or threatening within current capacity of coping skills, resources, and abilities, ending ideally in a positive outcome of homeostasis and feeling of well-being. Stressors: Any stimuli that can produce tension and cause instability within the system Fight or Flight: Physiological response to perceived threat due to release of catecholamines epinephrine and norepinephrine, stimulating sympathetic response. Scope: - Stress-Neutral: Coping effective - Challenge/Manageable: Coping effective; new coping skills may be needed - Stress Not Manageable: Coping ineffective; exceeds capacity to manage, requires outside assistance. Normal Physiological Process Neuroendocrine Response - Anticipatory response begins in limbic system - Serious stressor triggers sympathetic response of neuroendocrine systems - Hypothalamus secretes corticotropin-releasing factor (CRF) activates SNS and pituitary gland Activated SNS: - Release of catecholamines (norepi, epi, dopamine) - Norepinephrine: stimulates arousal, vigilance, anxiety, and labile emotions - Fight or flight: psychological response due to release of catecholamines resulting in: increased heart rate, BP, cardiac output; bronchial dilation; pupil dilation; increased blood flow to skeletal muscle; increased glucose; decrease blood flow to nonessential organs Activated Pituitary: - Releases ADH, prolactin, GH, adrenocorticotropic hormone (ACTH) - ACTH: triggers cortisol and aldosterone from adrenal cortex - Cortisol: mobilizes cellular metabolism (glucose and protein metabolism) and increases blood glucose and amino acids Age-Related Differences - Stress response remains across lifespan but cognitive development and life experience can shape cognitive appraisal of events that determine threat and coping strategies. Risk Factors Populations ● Infants and Children - Self-efficacy and control not yet developed - Cannot cope with hunger, pain, or fear - Dysfunctional households may raise children with ineffective coping - Young children with hospitalizations at higher risk for ineffective coping ● Adolescents - Psychosocial, emotional, cognitive, and moral development in Endocrine System - Stimulated by hypothalamus - Adrenal medulla stimulated by SNS to release epinephrine and norepinephrine resulting in fight-or-flight - ACTH stimulates adrenal cortex to secrete cortisol and aldosterone to increase blood glucose, intensify catecholamine vasodilating action, and inhibit inflammation - Corticosteroids also blunt stress response which can be harmful if prolonged - Stress response increases cardiac output (increases HR and stroke vol); blood glucose; oxygen consumption; metabolic rate. Immune System - Psychoneuro-immunology: interdisciplinary science that studies interactions of psychological, neurologic, and immune responses - Acute and chronic stress can cause immunosuppression by decreasing number and function of natural killer (T) cells; decreasing lymphocyte proliferation; altering production of cytokines; and decreasing phagocytosis Mind-Body-Spirit Connection - Balance needed to positively impact each individual portion Effects of Stress on Health - Chronic stress response harmful to the body - Linked to leading causes of death: cancer, accidents, suicides - Effects on cognition: poor concentration, memory problems, distressing dreams, sleep disturbance, impaired decision making, behavior changes - Long-term catecholamine exposure increases CVD risk (hypertension, atherosclerosis) - Migraines, IBS, peptic ulcers all worsened by stress - Higher susceptibility to infection - Common Disorders with Stress Component: depression, dyspepsia, eating disorders, erectile dysfunction, fatigue, fibromyalgia, headaches, hypertension, insomnia, IBS, low back pain, menstrual irregularities, peptic ulcer disease, sexual dysfunction Coping Strategies - Coping: person’s effort to manage stressors - Problem-focused coping: attempts to resolve problems causing stress - Emotion-focused coping: managing emotions felt when a stressful event occurs Relaxation Strategies ● Relaxation Breathing - Forms basis for most relaxation strategies by breathing deeply and slowly ● Biofeedback - Helps a person become more aware of involuntary body responses (breathing, heart rate, muscle activity) by attaching electrodes to the skin or use of hand-held sensors to allow a person to see and control their responses. ● Meditation - Practice of concentrated focus on a sound, object, visualization, breath, or movement to increase awareness, reduce stress, promote relaxation, and enhance personal and spiritual growth. ● Imagery - Use of one’s mind to generate images that have a calming effect by incorporating all of the senses ● Massage - Manipulation of soft tissues and joints involving touch and movement to reduce tension and affect mental and emotional states. ● Music - Focus diversion, relaxation, healthy emotional and physical state changes - Decreases anxiety, elicits relaxation, promotes sleep in insomniacs, decreases muscle tension, pain sensation, and emotional stress - Music with 60 to 80 beats/min is soothing, usually low-pitched tones without vocals is most soothing. Fast-tempo music can be uplifting and stimulating ● Prayer - Can be a form of meditation of deep comfort for religious people ● Physical Exercise - Protection from harmful physical and mental effects of stress ● Cognitive Reframing - Stems from cognitive-behavioral therapy - Goal is to change individual’s perception of stress by reassessing a situation and replacing irrational beliefs ● Journaling - Helpful in identifying stressors ● Humor - Cognitive approach that helps dissipate intensity of stressful thought Nursing Assessment: Stress 1. Assess stress in patients and caregivers (number, type, duration, prior experience) 2. Help identify high-risk periods for stress 3. Implement stress management strategies Assessment of Caregiver Needs 1. How are you coping with your role? 2. Do you have any problems performing caregiver responsibilities? 3. How much support do you get from outside sources? 4. Are you aware of and do you use community resources? 5. Do you know about resources that are available for respite? 6. What kind of help or services do you need now and in the future? 7. How can I or other HCP help you in your caregiving role?