1-1 Factors that influenced the development of contemporary nursing practice
Economy,increase of older adults, legislation, women's movement, collective bargaining
1-2 Dr. Imogene Rigdon
theory about bereavement of older women. Older women handle grief differently.
1-2 Nola Pender's theory
health promotion teaching done by nurses
1-2 Dr. Katherine Kolcaba
theory of holistic comfort in nursing. Provides a more holistic view than earlier theories of pain and anxiety.
1-3 Nurse practice acts
are laws that regulate nursing practice. the board is responsible for defining the practice of nursing, establishing criteria for Rn/Lpn, determine scope of practice, enforcing rules.
morals
reflect personal or religious belief
values
the belief you have about the worth of something as it serves as a principle or standard that influences your decision making.
direct care
personal interaction, such as giving meds, teaching a client about their treatment
Indirect care
work on behalf of others to improve their status ; restocking supplies, research.
1-3 Formal education
Rn program; ADN, BSN, MSN, doctural
1-3 Informal education
the knowledge gained from direct experience and observation.
1-9 evidence based practice
the integration of clinical expertise, patient values, and best research evidence into the decision making process for patient care
moral distress
situational pressures influence nurses' moral decisions as well as their ability to carry out their decisions.
1-5 Nursing Ethics
refers to ethical questions that arise out of nursing practice. Nurse must support patients who are making ethical decisions or coping with the results of decisions made by others.
Nursing Image
image influences how people view nursing. (Angel of mercy, handmaiden, battle ax, naughty, military nurse)
Therapeutic relationships
focus on improving the health of the client,whether an individual or community.
5 key characteristics of therapeutic relationships
Empathy,Respect, genuineness, concreteness, confrontation.
Whistleblowing
person who identifies an incompetent, unethical or illegal situation or action of others in workplace and reports it.
Malpractice
source of legal liability means that professional person has failed to act in a reasonable and prudent manner.
1-9 Quantitative Research
to gather data from enough subjects to be able to generalize the results to a similar population.
1-9 Qualitative Research
focus on the lived experience of people. purpose is not to generalize data, but to share the experience of the person in the study.
P.I.C.O. questions
P=problem
I=intervention
C=Comparison
O=Outcome
Qsen Competencies
Patient centered care
Teamwork/Collaboration
Evidence based practice
Quality Improvement (QI)
Safety
informatics
Components of Nursing theory
Assumptions
Phenomena
Concepts
Definitions
Statements
1-5 Nurses code of ethics
inform the public about professions minimum standards.
Demonstrate nursing commitment to the public it serves.
Outline major ethical considerations of nursing.
Provide general guidelines for professional functions
guide the profession's self-regulating fu
1-2 Maslow's hierarchy of needs
most important to least:
Physiological: air, food, water, sex, sleep, homeostasis
Safety: security of body,employment, family, health
Love/Belonging: friendship, family, sexual intimacy
Esteem: confidence,achievement, respect of others.
Self-actualization
3-3 Nursing Process
assessment, Diagnosis, Planning, evaluate
1-2 Nightingale's Environmental theory
how the environment affects client care; Foundation for all nursing care
1-2 Peplau's interpersonal relationship theory
Roles between nurse and client. Foundation for nurse-client relationship and establishing trust
1-2 Henderson's Nursing conceptual
Define's nursing. Nurse's roles in assisting clients to gain independence. (interventions in the nursing process)
1-2 Orem's general theory of nursing
Self care in promotion and maintenance of health. Care for self in order to care for others
1-2 King's goal attainment theory
Nurse client relationships in affecting goal attainment. Nurse interactions with client and the environment influences how client responds to care and the outcome of care. (Evaluation of goals and interventions in the nursing process).
1-2 Leininger's cultural care diversity and university theory
How culture affects client care. Preservation and integration of culture in the clients plan of care.
1-2 Watson's Human caring theory
caring as the central focus of nursing practice. Defines caring beyond medical interventions .
1-7 SBAR (before calling physician)
S-Situation
B-Background
A-Assessment
R-Recommendation
1-7 AIDET (communicate with patients)
A-Ackowledge : great with smile
I-Introduce
D-Duration: let patients know waiting time
E-Explanation
T-Thank you
1-2 Clara Barton
provided care in tents up close to the fighting. Continues universal care through the establishment of the American Red Cross.
1-2 Lilian Wald/ Mary Brewster
founded Henry street settlement in New York to improve the health and social conditions of poor immigrants. Considered the start of public health nursing.
Handmaiden
the nurse who is subservient to the physician, following orders with out questioning. providing all physical care to the patient.
1-2 Florence Nightingale 5 major contributions to profession of Nursing
the establishment of nursing as a distinct profession.
Introduction of a broad-based liberal education for nurses.
Major reform in a delivery of care in hospitals.
the introduction of standards to control the spread of disease in hospitals.
Major reform i
the NSNA is the professional organization for what
student nurses
According to the ANA, nursing is the diagnosis and treatment of:
human responses to actual and potential health problems
to be considered a discipline, a profession must have a _________ that has the theoretical and practical boundaries.
Domain of knowledge
RN may delegate and supervise which of the following levels of staff
Nursing assistant personal. Licensed practical nurses.
2-1 Normal range temp
97-100.8F
Conduction
transfer of heat from warm to a cool surface by direct contact
Convection
transfer of heat through currents of air or water
radiation
loss of heat through electromagnetic waves emitting from surface that are warmer than the surrounding air
Evaporation
water is converted to vapor and lost from the skin or mucus membranes.
2-1 Fever (pyrexia)
>100F
2-1 Hyperpyrexia (exceptionally high fever)
>105.8F
2-1 Hypothermia
abnormally low body temp. <95F
2-1 adult normal range Pulse
60-100 Bpm
2-2 Every degree temp increase
pulse rate increases by 10 Bpm
2-1 Systole
the peak of the wave, or contraction of the heart
2-1 Diastole
the trough or resting phase of the heart
2-1 what pulse is the most accurate
Apical
2-1 Bradycardia
<60 Bpm Slow heart rate
2-1 Tachycardia
>100 Bpm fast heart rate
Stroke Volume
the quantity of blood pumped out by each contraction of the left ventricle
Cardiac Output
Stroke volume X Pulse (heart) rate
Pallor
Paleness of skin
Cyanosis
Bluish/ Gray discoloration of the skin due to excessive C02 and deficient O2 in the blood.
2-1 Normal respiratory range
12-20 Bpm
2-2 Every Degree temp the respiratory rate increases
4 bpm
Apnea
Cessation of breathing
2-1 Bradypnea
Abnormally Slow respirations <10 Bpm
2-1 Tachypnea
Abnormally fast respirations. >24 bpm
Dyspnea
labored breathing
orthopnea
inability to breathe when horizontal
Wheeze
high pitched continuous musical sounds, Usually heard on expiration
Rhonchi
low pitched continuous caused by secretions in the large airways
crackles
discontinuous sounds usually heard in inspiration, may be high pitched popping sounds or low pitched bubbling sounds
Stridor
a piercing high pitched sound heard primarily during inspiration
Stertor
labored breathing that produces a snoring sound.
hypocapnea
excess loss of C02
blood pressure
the pressure of the blood as it is forced against arterial walls during cardiac contraction
Pulse pressure
the difference between systolic and diastolic pressures
BP regulation influenced by
Cardiac function, peripheral vascular resistance, blood volume
2-1 Hypotension
Systolic BP <100mmhg
Orthostatic/ postural hypotension
a sudden drop in BP while moving from a lying or sitting position to standing position.
Primary or essential hypertension
Diagnosed when there is no known cause for the increase in BP
Superficial
Skin
Visceral
Deep inward, abdomen
Deep somatic
tissue, muscle, ligaments, tendons, bone, blood vessels
2-4 transduction of pain
activation of nociceptors by stimuli
2-4 transmission of pain
conduction of pain message to spinal cord
2-4 Pain perception
recognizing and defining pain in the cortex
2-4 pain modulation
changing pain perception
2-4 Gate control theory
prevents pain from traveling to CNS
Comprehensive Exam
Interview plus head to toe exam
Focused exam
focusing on presenting problem
Ongoing exam
performed as needed to asses status . Evaluates client outcomes
Physical Assessment skills
I-inspection- look
P-Palpation- feel
P-Percussion-Drum
A-Auscultation-listen
** Make sure you know this sequence!
Abdominal Exam
I-Inspection
A-Auscultation
P-percussion
P-palpation
PERRLA
pupils equal round reactive light accommodation
Erythema
Skin redness
Turgor
Elasticity of the skin
2-2 Pulse deficit
there is a difference in count between heart beat, Apical, and peripheral pulse.
2-1 Normal Blood pressure range
110-119/60-80
2-1 Prehypertensive Blood pressure ranges
120-139/80-89
2-1 Hypertensive blood pressure ranges
140-159/90-99
2-4 Pain scales
Visual analogue Scale (VAS)
Numeric rating scale (NAS)
simple descriptor scale
Wong-bakerface pain rating scale
2-1 hyperthermia
elevated body temp higher than the set point
2-1 hypertension
persistently higher than normal BP. above 140/90
hypoxia
absence of enough O2 in the blood
Korotkoff sounds
sounds of blood pulsating through the arteries
Oxygentation
how well cells, tissues, organs are supplied with 02
perfusion
continuous supply of oxygenated blood to all body cells
Point of maximal impluse
small pulsation at 5th ICS midclavicular line
Secondary Hypertension
there is a clearly identified cause for BP elevations
thermoregulation
process of maintaining a stable temperature
Tidal volume
is the amount of air taken in on inspiration
Health assessment
evaluation of health status by performing a physical exam after taking a health history
3-3 Nursing assessment
focus on clients functional abilities and physical responses to illness and other stressors
2-4 Pain management
medical approach that draws disciplines in science alternative healing to study prevention, diagnosis and treatment of pain
Normal Pulse Ox
93
3-3 Phases of Nursing Process
A-Assessment: gather data
D-Diagnosis
P-planning outcomes: decide goals
Planning interventions:interventions to achieve goals
I-Implementation: carry out actions
E-Evaluation: evaluate actions
full spectrum nursing
A blend of thinking, doing, caring for the purpose of affecting good outcomes from a patient situation
3-4 Objective
what you observe
3-4 Subjective
what person says. I feel pain . pain cant be seen
Verbal/telephone orders
Must have date, time, medication name, dose, strength, route, frequency, Always RBAC (read back and confirm)
(MDS) minimum data set
for resident assessment. must be completed within 4 days of admission and updated every 3 months.
3-3 Nursing diagnosis
describes a problem response that is likely to develop in a vulnerable patient if the nurse and patient do not intervene to prevent it
Dependent interventions
prescribed by physician but carried out at bedside
Independent interventions
the registered nurse is licensed to prescribe, perform, or delegate based on their knowledge.
1-9 Evidence based practice
uses firm scientific data in making decisions about medical and nursing practice.
Nursing interventions
include activities for observation, assessment, prevention, treatment, health promotion
clinical reasoning
reflective, concurrent, creative thinking about patient and patient care. Is used in the nursing process. Reasoning is logical thinking that links thoughts together to create meaning.
3-5 Concept mapping
map or diagram that depicts suggested relationship between concepts
NANDA standard diagnosis
describes health problems that can be addressed by independent nursing actions, forms the body of knowledge that is unique to nursing.
Nursing care plan
central source of information needed to guide holistic care
Benner's 5 stages of nursing competence
1. novice- onset of education
2. advanced beginner- exposure to clinical settings
3. competence- able to handle patient load
4. proficient-resource for newer nurses
5. expert- able to see what needs to be achieved
1-3 In the U.S. the practice of nursing is regulated by
state nurse practice acts
the purpose of nursing care is to achieve the goals of ___________, illness, prevention, ________________ and end of life care
health promotion, health restoration
Health promotion
activities that foster the highest state of well-being of the recipient
illness prevention
focus on avoidance of disease
Health restoration
activities that foster a return to health for those already ill
list 5 settings in which nurses can work
hospitals, ambulatory care centers, extended care facilities, physician offices, health insurance offices, community health organizations
Identify forces that influence the nursing profession
national economy, consumer, direct to consumer marketing, women's movement, collective bargaining
identify forces within healthcare that influence the nursing profession
increased autonomy and advanced practice roles, increase use of NAP, increase variety of work settings, Increase use of complementary and alternative medicine, nurse's ability to influence healthcare policy, Increase use of technology
3-1 * 5 skills/attitudes that reflect critical thinking
objectively gather info on a problem or issue
recognizing need for more info
recognizing gaps in one's own knowledge
listen carefully, reading thoughtfully
separating important/ unimportant data
organizing or grouping info in meaningful ways
independent thinking
critical thinkers do not believe everything they are told
intellectual humility
aware do not know everything
intellectual courage
consider their values, as well as others
intellectual perserverance
do not settle quick, obvious answer
3-3 what stage does nurse collect data
Assessment
3-3 what stage involves problem identification
Diagnosis
3-3 what does nurse do in evaluation step
reassess the patient
what are the 4 main concepts of the full spectrum model of nursing
thinking, doing, caring, patient situation
what is the ultimate purpose of full spectrum nursing
is to benefit paitents and to effect positive outcomes for clients
3-3 Assessment
portion of the nursing process when data is collected 1st step
list four components of full spectrum nursing
critical thinking, nursing knowledge, nursing process, patient situation
A set of interrelated concepts is a
model
3-3 the nursing process is _____________ following a logical progression
cyclincial
3-3 a nursing assessment is
holistic and focuses on client responses to disease, pathology and other stressors
A medical assessment focuses on
disease and pathology
Four common features to all definitions of assessment
assessment involves data collection, use of systemic/ ongoing process, categorizing of data, recording of data
3-4 Primary data
obtained the information from patient
3-4 Subjective data
patient's perspective, told directly to you. Intake forms
3-4 Objective data
observed by someone other than the patient
3-4 Secondary data
obtained from any source other than the patient
10 components of nursing history
biographical data, chief complaint, history of present illness, client perception of health status, past health history, social history, medications, complementary alternatives modalities, review of body systems.
The ANA code of ethics for nursing-provisions states; the nurse determines the appropriate ________ of tasks consistent with the nurses obligation to provide optimum_____________.
Delegation, patient care
1-3 Delegation of nursing care is regulated by:
state practice acts
after inspecting wound what additional component of physical assessment will you perform
Palpation: feel the skin around the wound determine swelling, or any foreign objects
focused data
in depth information about abnormal cues, or problem with a body part of function
psychosocial assessment
gathers info about lifestyle, previous psychiatric disorders
Cues
are what the client says, what you observe
3-3 Nursing diagnosis must be _______________ . because it is the basis for the goals and interventions you will plan and implement for your patients
Accurate
what two nursing organizations have been responsible for making diagnosis a part of the nursing role
ANA (american national association)
NANDA international
3-3 5 types of nursing diagnosis
1. actual nursing diagnosis
2. risk (potential) nursing diagnosis
3. possible nursing diagnosis
4. syndrome nursing diagnosis
5. wellness nursing diagnosis
4 parts of the NANDA-I nursing diagnosis
1. Diagnostic label- symbolizes a pattern of assoc cues
2. definition- distinguishes the label from similar nursing DX
3. defining characteristics- recognize indications when organized into groups
4. related or risk factors- description clinical cues, con
3-3 the Nursing diagnosis describes
a problem or strength, a human response to disease, injury or stressors
A collaborative problem is a ______________________ problem
potential
etiology
contains the factors that cause, contribute to, or create risk for the problem
3-3 Nursing diagnosis is a statement of a client's health status that nurses can ___________,________________,or _______________ independently.
identify, prevent, treat
3-3 A medical diagnosis describes a _______________, illness, or injury
disease
the NANDA-I taxonomy is organized according to:
human response patterns
key elements of the nursing care plan are
nursing diagnosis, client goals, and nursing interventions
mechanistic nursing
getting the task done
holistic nursing
meeting the needs of the whole person
Framingham study
to identify the health/healthcare practices of one specific community. Diseases, heart disease, diabetes mellitus, breast cancer, osteoarthritis
1-2 Virginia Henderson
definition of Nursing
Nursing research
systemic, objective process of analyzing phenomena of importance to nursing
phases of nursing research
define the problem
select research design
collect data
analyze data
use the research findings
1-2 essential components of nursing theory
Environment , Nurse, person, health
_____________ contains highly concrete specific concepts and propositions
theory
____________ nursing practice considers a client, the family and the community.
Holistic
1-2 in maslow's theory __________ is the need to develop ones maximum potential
self actualization
what age groups are most susceptible to the effects of environmental temperatures?
infants
older adults
2-2 mod - 5 factors that affect body temp
developmental level, circadian rhythm, environmental temps, gender, emotions, stress, stimulation of the sympathetic nervous system, increased production of epinepherine/norepinepherine.
2-2 what are the compensatory mechanisms for increasing body temp
vasoconstriction, release of epinephrine, shivering , piloerection
2-2 Examples pulse rate to be greater than 80 bpm
newborn infant
adolescent who just finished running track
client who underwent a painful procedure
client with a fever
accident victim who is hemorrhaging
2-2 examples pulse rate less than 80 bpm
a healthy professional tennis player
a 90 year old man
what 2 gases are exchanged through respiration
02/C02
what respiratory process invloves movement of air into and out of the lungs
Pulmonary ventilation (breathing)
what is the primary stimulus for breathing
an increase C02 level in the blood
external respiration
is the exchange of O2 and Co2 between blood in the pulmonary vessels and air in the alveoli.
what mechanical forces allow the lungs to expand
the contraction and downward movement of the diaphragm allows lung expansion; Contraction of thoracic muscles, accessory muscles, this expands thoracic space and thorax.
how can we estimate client's tidal volume
by observing the depth of the client's respirations
what other characteristics of clients respirations should be observed?
depth, rhythm, effort, breath sounds, chest movement
some clinical signs associated with poor oxygenation
pallor, cyanosis, nails, lips, skin, restlessness, apprehension, confusion, dizziness, fatigue, changes in pulse or BP, decreased level of consciousness
pulse pressure is
the difference between systolic and diastolic . for it to be normal pulse pressure should not be more than 1/3 of the systolic pressure.
which client has primary hypertension
one who has family history of hypertension
autonomic Nervous system
affects both pulse and blood pressure
Anpea
absence of respirations
-pnea
breathing
hypothalamus
body's thermostat
the amount of blood ejected from each ventricle with each heart beat is
stroke volume
2-2 this can cause falsely high BP reading
BP cuff is too small
2-2 this can cause falsely low BP reading
lying in supine position, blood pressure cuff is too large, arm positioned below level of the heart
2-2 opoid analgesics typically decrease
respiration, blood pressure, heart rate
2-2 how long to wait before taking temp, after drinking hot tea
30 minutes
to assess patients blood pressure nurse would
inflate the cuff to 30 mmhg higher than the point he last palpated a pulse
A quality of 1+ is
very weak pulse,
2+-4+ indicate progressively stronger pulse
1-8 3 levels of communication
intrapersonal: internal dialogue
interpersonal: two or more individuals
group: several people
1-8 communication is affected by
environment, lifespan variations, gender, personal space, territoriality, sociocultural factors, roles, relationships, attitudes
1-8 phases therapeutic relationships
pre-interaction: before meet client, gather info
orientation: meet client, establish rapport, trust
working: active part, caring, feeling, mutual respect
termination: conclusion of relationship
1-8 therapeutic communication
being helpful by facilitating interactions that focus on the client and his concerns
1-6 positive regard
warm, caring, interest and concern for the person
1-8 encouraging ellaboration
tell me more..... or I see
trust is developed in what phase of therapeutic communication
Orientation
1-8 assertive communication
includes expressions of both positive and negative thoughts and feelings, openly, honestly, nonjudgemental
fogging
helps you accept criticism without becoming anxious or defensive
purpose of physical exam
obtain baseline data about the patient
how to prepare for physical exam
prepare the environment
prepare yourself
prepare the patient
best position for examining lungs, heart, pulses, abdomen
Heart/ Lungs- Fowler's/ semi fowlers
abdomen/ pulses- supine
warning signs for a suspicious lesion
A-asymmetry
B-border
C-color
D-diameter
E-elevation
cranial nerves involved in eye movement
II (optic)- control pupil reaction to light
III(oculomotor)- same
IV(trochlear)
VI(abducens)
neuro exam
Cerebral: level of consciousness, mental status
cranial nerve: assessment 12 cranial nerves
reflex: superficial reflexes
sensory: light touch, pain, temp, vibration
motor/ cerebellar: muscoskeletal assessment
assessment techniques male genitourinary system
inspection, palpation
most common hernia occuring in men
abdominal wall, inguinal canal
best type of assessment in emergency or urgent patient situations
focused assessment
data obtained during a general survey during physical exam
bp, speech, gait steady
abnormal assessment finding related to the external eye
crusting, swelling, pterygium, ectropion, entropion, ptosis
mitosis
pupil
otitis media
ear
glossitis
tongue
egophony
lung
borborygmi
abdomen
to determine the location, size, density of the liver a nurse would use
Percussion
2-4 what must occur to generate a pain response
nociceptors must receive a sufficient number of noxious stimuli
2-4 Four physiological steps involved in pain process
transduction, transmission, perception, modulation
2-4 Unrelieved pain in endocrine system
release excess amounts of hormones, hyperglycemia, weight loss, tachycardia, fever, increased respiratory rate, even death
2-4 unrelieved pain in cardiovascular system
hypercoagulation, increased heart rate/ BP, cardiac workload, o2 demand
2-4 unrelieved pain musculoskeletal
impaired muscle function, fatigue, immobility,
2-4 unrelieved pain immune system
predisposes the patient to infection
2-4 unrelieved pain genitourinary
excessive amounts of hormones lead to decrease urinary output, urinary retention, fluid overload, hypokalemia.
2-4 unrelieved gastro pain
intestinal secretions, smooth muscle tone increases gastric emptying, mobility decreases
2-4 how do NSAID's induce pain relief?
NSAID's relieve pain by interfering with the production of prostaglandins, there by blocking the inflammatory process
2-4 NSAIDs contradict with which patients
patients with impaired blood clotting, gastro bleeding ulcers
Most common side effects of opoids
nausea, vomiting, constipation, drowsiness
things you should monitor when administering opoids
sedation/ respiratory depression, difficulty with urination, dry mouth, sweating, tachycardia, palpitations, bradycardia, rashes, urticaria, pruritius, response to medication, break through pain
the _________ has more nociceptors than solid organs
skin
the use of per cutaneous electrical stimulation as an effective means to control pain is based on
gate-control theory
the presence of ascites is an example of a type of _____________________ stimuli
mechanical
2-4 the __________pain rating scale would be used to assess pain in a patient with expressive aphasia.
wong-baker
A fentanyl analgesic patch must be changed every _____ hours.
72
1-3 patient self-determination act
requires that patients be given info about advanced directives
1-3 Emergency medical treatment active labor act
ensures public access to emergency services regardless of client's ability to pay
1-3 HIPPA provides following precautins
prevent discrimination, protect privacy, ensure access
Negligence
wrong committed against an individual by one who has failed to use ordinary care
Civil law
courts seek to resolve a dispute between private parties, may result damages or payment of money
Criminal law
federal or state government seek to penalize the accused for an offense against society
A defendant claiming the right not to incriminate himself under the 5th amendment
constitutional, statutory, case law
1-3 A nurse having her License revoked by the state board of nursing is
administrative law
four requirements for nurse duty to assess
must have necessary knowledge
must actually carry out assessment
must report symptoms to appropriate provider
must continue to assess/ monitor patient until stable
ways nurse may fail to implement a plan of care
failure to respond, educate, follow standards/ policies, to communicate, to document, to act as an advocate
1-4 nurse's legal duty to evaluate
observing changes
recognize the significance of the change
documenting/ reporting symptoms
follow up
durable power of attorney
a document that identifies a person who will male healthcare decisions for you if you become incapacitated
ultilitarianism
the ethical theory stating that the value of a situation is determined by its usefulness
deontology
ethical theory that it considers the action as right or wrong independent of its consequences. Based on rules principles and uses the language of rights and duties
1-5 6 ethical principles
autonomy-an individuals right to choose
nonmaleficence-is the duty to do no harm
beneficence-the duty to do no harm
fidelity-the obligation to keep promises made
veracity-the duty to tell the truth
justice-is fairness and equal treatment
typical urinary output normal adult
1,500ml, ph 4.6-6.0, specific gravity 1.010-1.030 yellow-amber
breath sounds vesicular sounds
soft and low pitched breey sounds heard over most of the peripheral lung fields.
bronchial breath sounds
normal loud coarse, blowing sound over trachea
Rhonchi:
musical sounds/ vibrations heard over expiration. adventitious sounds caused by fluid or inflammation
bronchovesicular sounds
normal harsh sounds heard over mainstream bronchi
visual acuity test: snellen chart 20/60
the distance at which a person with normal vision can read the chart
assessing patient for tactile fremitus: what part of hand do you use
ulnar and palmar surface of hand
after completing data collection process of clients health history interview, nurse should take 1st
summarize the highlights of the interview and permit the client to add or clarify information
assessing the abdomen, nurse should place patient in what position
supine with knees flexed, relaxes muscles and provides comfort.
abstract reasoning
is the ability to think an adaptable flexible manner, using generalizations and abstractions.
after demographic data is collected during an initial health history what should be the next focal area of assessment
reason for seeking healthcare, current health care concerns
which of the following will have the MOST impact on nursing assessment
assistive devices such as glasses/ hearing aids indicate impairments in these physical areas.
gag reflux
touch back of throat with cotton tipped applicator
sound expect to hear percussing lungs of a client with emplysema
hyperresonance- very loud, booming, loud pitched sound, long duration
Cheyne-stokes respirations
irregular pattern of rapid waxing and waning alternating with periods of apnea
pupils
compare sizes of both pupils/ check reaction to light
most likely to contribute to elevated Bp
a high pressure job
2-1 ph childs urine
ph 6.0
pleural friction rub
grating sound or vibration heard during inspiration and expiration
patient complains of rash
patient taking new meds?
pedal pulse
top of foot
capillary refill test
hold finger 1-3 secs
nystagmus
rapid eye movement
problem with fluid volume deficit
tenting of the skin
prepare for hearing/ ear
tunning fork, otoscope
oximetry
measures the amount of O2 circulating in the blood
2-1 apical pulse
5th intercoastal space at left midclavicular line - The Apex of the heart
What are direct-care interventions?
Performed through interaction with the client ex. physical care, emotional support, and patient teaching).
What are indirect-care interventions?
Performed away from the client but on behalf of a client or group of clients ex. advocacy, managing the environment, consulting with other members of the healthcare team, and making referrals).
2-1 How often should a patient in the hospital get their vital signs checked?
Every 4-8 hours
2-1 Why are baseline vitals important?
Because it gives us something to refer back to if there is a change. A change in vitals could indicate a change in disease state, efficacy or failure of therapies, or changes in activity or environment.
If a patient's body needs to be cooled, what is one physiological event that occurs?
Vasodilation
If a patient's body needs to be warmed, what is one physiological event that occurs?
Vasoconstriction
What do these signs indicate: weak pulse, and cool, pale skin.
Ineffective tissue perfusion (peripheral)
Types of abnormal pulse to listen for:
Weak and thready, full and bounding, irregular, or absent.
2-1 What is the normal range for tidal volume (the amount of air taken in on inspiration)?
300-500mL for a healthy adult
After how many minutes of apnea does brain damage occur?
4-6 minutes
You can make a subjective evaluation of tidal volume in a client by watching chest rise. What are the three terms to describe respiratory depth?
Deep: Taking in large volume and fully expanding the chest or abdomen.
Shallow: When a chest barely rises and is difficult to observe.
Normal: Between deep and shallow.
What is orthopnea?
Difficult or inability to breathe when in a horizontal position.
What is dyspnea?
Labored breathing.
Which abnormal breath sounds like this: High-pitched, continuous musical sounds, usually heard on expiration.
*This breath sound is caused by narrowing of the airways.
Wheezes. Can often be heard without the use of a stethoscope.
Which abnormal breath sounds like this: Low-pitched, continuous gurgling sounds, caused by secretions in the large airways.
*This breath sound often clears with coughing.
Rhonchi.
Which abnormal breath sounds like this: Discontinuous sounds usually heard on inspiration, but may be heard throughout the respiratory cycle.
May be high-pitched, popping sounds, or low-pitched, bubbling sounds.
*They have been described as similar to the
Crackles
Which abnormal breath sounds this way: A piercing, high-pitched sounds that is heard without a stethoscope, primarily during inspiration, in infants who are experiencing respiratory distress or in someone with an obstructed airway.
Stridor.
Which abnormal breath sounds this way: Labored breathing that produces a snoring sound, common with mouth breathing due to nasal congestion.
Another name for it is, "The Death Rattle.
Stertor
2-1 What does A,B,C stand for in vital sign assessments?
Airway, breathing, circulation.
3-3 What is the first step in the nursing process?
Assessment
What is the most common reason people seek medical care?
Pain
2-4 Cutaneous/Superficial Pain:
Arises in the skin or the subcutaneous tissue. Ex. paper cuts, hot surfaces, etc.
2-4 Visceral Pain:
Caused by the stimulation of deep internal pain receptors, most often the abdominal cavity, cranium, or thorax. Ex. Menstrual cramps, labor, gastrointestional infections, bowel disorders, or organ cancers.
The description of quality of pain and the locati
2-4 Deep Somatic Pain:
Originates in the ligaments, tendons, nerves, blood vessels, and bones. Deep somatic pain is more diffuse than cutaneous pain and tends to last longer. Ex. fracture or sprain, arthritis, and bone cancer.
2-4 Radiating Pain:
Starts at the origin, but extends to other locations. For instance, the pain from a sore throat could extend to the ears and head. Or the pain from acid reflux could extend to involve the entire upper thorax.
2-4 Referred Pain:
Occurs in an area that is distant from the original site. For example, the pain from a heart attack may be experienced down the left arm, through the back, or into the jaw.
2-4 Phantom Pain:
Pain that is perceived to originate from an area that has been surgically removed.
2-4 Psychogenic Pain:
Pain that is believed to arise from the mind. The patient perceives the pain despite the fact that no physical cause can be identified. Psychogenic pain can be as severe as pain from physical abuse.
2-4 Nociceptive Pain:
The most common type of pain. Occurs when pain receptors (nociceptors), respond to stimuli that are potentially damaging - Noxious, thermal, chemical, or mechanical.
Trauma, surgery, inflammation.
2-4 Two types of Nociceptive Pain:
Visceral - Pain originating from internal organs
Somatic - Pain originating from the skin, muscles, bones, or connective tissues.
2-4 Neuropathic Pain:
A complex & often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals, even in the absence of painful stimuli.
Could originate from many causes: Poorly controlled diabetes mellitus, stroke, tumor, al
2-4 Acute Pain:
Short duration and rapid onset. Varies in intensity and may last up to 6 months. Usually caused by injury or surgery.
Protective.
2-4 Chronic Pain:
Lasts for 6 months or longer. Often marked with periods of remission and exacerbation. Often dismissed by family or care givers - often leads to emotional distress.
2-4 Intractable Pain:
Both chronic & highly resistant to relief - should be approached with multiple types of pain management.
2-4 Quality of Pain:
Sharp, dull, aching, throbbing, stabbing, burning, ripping, itching, searing, or tingling.
Episodic, intermittent, or constant.
Mild, distracting, moderate, severe, intolerable.
2-4 What is the most reliable indicator of pain?
The patient self report.
1-3 Standards of care
Evaluates and sets precedents for quality of care. Defined by the State, nursing organization, and hospitals code of ethics
1-4 Nurses Legal responsiblities
failure to document, assess and monitor, act as an advocate, educate, communicate, follow standards of care, and use equipment in a responsible manner
1-6 Identify ways nurses demonstrate caring
Getting to know client, putting yourself in their shoes, educating the patient, and empowering the patient
1-7 Nursing Communication
pre-interaction phase-gather info before meeting
Orientation phase- get to know client
Identification Phase- ID problems and needs
Exploration/ working phase- explore treatment options, service, and needs
Resolution/ termination phase- find solution for c
Critical Thinking
a combination of reasoned thinking, openness to alternatives, an ability to reflect, and desire to seek the truth
Assessment is related to other steps of the nursing process such as
Diagnosis, planning outcomes, planning intervention, implementation, evaluation
Patients with an infected wound will have an _________ ___________
Elevated Temp
Patients in pain will have a high ____ _____
blood pressure
The nurse would monitor the body temperature most closely/frequently in the care of:
A. The client with an infection
B. The client who is an infant
C. The client who has experienced heat stroke
D. The client with a head injury
Correct answer: D
All of the clients depicted would need to have their temperatures monitored closely. However, a client with a head injury may have damage to the hypothalamus and therefore loss of global thermoregulation. The temperature of this client w
Common Pulse Points
Apical: At the apex of the heart
Carotid: Between mid-line and side of neck;
Brachial: Medially in the antecubital space USED FOR B/P
Radial: Laterally on the anterior wrist
Femoral: In the groin fold
Popliteal: Behind the knee
The nurse is assessing the dorsalis pedis pulses on an 88-year-old client. She notes the feet to be cool and assesses weak, thready pulses. The nurse's next action would be to
A. Assess the popliteal and femoral pulses
B. Assess a 1-minute apical pulse
C.
Correct answer: A
Completing an assessment of other peripheral pulses will provide further data about the adequacy of circulation to the legs
Orthopnea:
inability to breathe when horizontal
The nurse will expect to find a slower respiratory rate in the client who has smoked for many years.
A. True
B. False
Correct answer: B
Clients who have smoked over many years will have an increased respiratory rate to compensate for loss of elasticity of the airway.
Pulse oximetry
Noninvasive method of monitoring respiratory status
BP Regulation
Influenced by three factors
Cardiac function
Peripheral vascular resistance
Blood volume
A ___-____ communication factor when the nurse is engaged in therapeutic communication would be the patient's personal appearance
non-verbal
Greeting the patient by his or her name when entering into the patient's room helps to develop ____ in the nurse to patient relationship.
trust
____ ____ and listening go hand in hand, eye contact when talking to your patient demonstrates you are an active participant of the information being received.
eye contact
expressive aphasia
is when your patient is able to understand what you are saying, but is not able to express himself
Patients with _____ tend to have asymmetrical chest expansion
...
Patients with _____ tend to have asymmetrical chest expansion
pneumonia