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52 Cards in this Set
- Front
- Back
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• Discuss the role of the nurse in community-based practice.
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A community-based nurse is competent as a caregiver, collaborator, educator, counselor, change agent, client advocate, case manager, and epidemiologist.
First and foremost is the role of caregiver you manage and care for the community’s health. You apply the nursing process in a critical thinking approach to ensure appropriate, individualized nursing care for specific cli-ents and their families. You recognize actual and potential health care needs and identify needed community resources. As a caregiver, you also help to build a healthy community, which is one that is safe and includes elements to enable people to achieve and main-tain a high quality of life and function. Case Manager develops and implements a plan of care that is based on assessment of clients and famillies and coordinates the provision of needed resources and services across a continuum of care Change Agent involves identifying and implementing new and more effective approaches to problems. Client advocacy is someone who helps clients waltthroug the system, identifies services, and plans for accessing appropriate resources Collaborator is an individual who engages in a combined effort with other individuals to develop a mutually acceptable plan that will achieve common goals.. A counselor helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. The educator's helps clients, families, and commlunities gain greater skills and knowledge to provide their owncare. As a epidemiologist you may be involved in case finding, health teaching, and tracking incident rates of an illness, a master’s degree is usually necessary. You are responsible for community surveillance for risk factors and to protect the community’s level of health, develop sensitivity to changes in the health status of the community, and help identify the cause of these change |
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• Discuss the role of the community health nurse.
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Provides direct care to subpopulations who make up the community as a whole Community healt nursing focuses on the individual, family, and community.
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Discuss the goals of Healthy People 2010.
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Healthy people 2010 was established to create ongoing health care goals including increasing life expectanc;y and quality of life and eliminate health disparites through improved delivery of health care services. Gathering information assessing needs, and developing and implementing public health policies are steps in achieving the goals set forth by Healthy People 2010.
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Discuss the role that caring plays in building a nurse-client relationship.
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Caring is always specific and relational for each nurse-client encounter. Nurses typically learn that caring helps them to focus on the clients for whom they care. Caring facilitates a nurse's ability to know a client, allowing the nurse to recognize a client's problems and to find and implement individualized solutions.
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• Discuss the potential implications when nurses’ perceptions of caring differ from the clients’ perception of caring.
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The study of clients’ perceptions is important because health care is placing greater emphasis on client satisfaction. What clients experience in their interactions with institutional services and health care professionals, and what they think of that experience, determines how clients use the health care system and how they can benefi t from it When clients sense that health care providers are sensitive, sympathetic, compassionate, and interested in them as people,they usually become active partners in the plan of care
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• Describe ways to express caring through presence and touch.
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Touch is relational and helps create a connectin between the nurse and the client. Touch is best used when ther is a caring connection between nurse and client.
Presence involves a person to person encounter that conveys closeness and a sense of caring. presence involves "being there" and 'being with" a client, including communication and understanding |
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• Describe aspects of critical thinking that are important to the communication process.
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Critical thinking helps the nurse overcome perceptual biasis, or human tendencies that interfere with accurately perceinging and interpreting messages from others. People often assume that others think, feel, act, react, and behave as they would in similar circumstances. They tend to distort or ignore information that goes against their expectations, preceptions, or stereotypes. By thinking critically about personal communication havits, you will learn to control these tendencies and become more effective in interpersonal relationships
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• Describe the fi ve levels of communication and their uses in nursing.
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Intrapersonal- occurs within an individual
Interpersonal- one to one interaction between the nurse and the other person Transpersonal- interaction that occurs withing a person's spiritual domain Small-group- interaction tha occurs with a small number of persons Public- interaction with an audience |
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• Identify signifi cant features and therapeutic outcomes of nurse-client helping relationships.
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Preinteraction phase-before meeting the client
Orientation phase-when the nurse and client meet and get to know one another Working phase-when the nurse and client work together to solve problems and accomplish goals Termination phase-during the ending of the relationship Creating a therapeutic environment depens on your ability to communicate, to comfort, and to help clients meet their needs. In a therapeutic relationship, nurses often encourage clients to share personal stories. Therapeutic interactions increase feeling of personal control by helping the person feel secure, informed, and valued. |
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Explain the various forms of communication.
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Verbal communication- uses spoken or writtren words. denotative and Connotative meaning, Pacing, Intonation, Clarity and Brevity, Timing and Relevance.
Nonverbal communication-includes all of the five senses and everthing that does not involve the spoken or written word. Researches have estimated that approximately 7% of meaning is transmitted by words, 38% is transmitted by vocal cues, and 55% is transmitted by body cues. Personal apperance, Posture and Gait, Facial Expression, Eye Contact, Gestures, Sounds, Territoriality and Personal Space. Symbolic communication- Art and music are utilized to enhance understanding and promote healing. The verbal and nonverbal symbolism used by others to convey meaning. Metacommunication-refers to all factors (verbal and nonverbal) that influence communication. |
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• Describe qualities, behaviors, and communication techniques that affect professional communication.
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Courtesy- say hello and goodby to clients, know on doors before enteringk, and use self-introduction, also states his or her purpose, addresses people by name and says pleas and thank you to team members.
Use of Names Trustworthiness- relying on someone without doubt or question, means helping others without hesitation. Autonomy and Responsibility- the ability to be self-directed and independent in accomplishing goals and advocation for others. Assertiveness-conveys a sense of self-assurance while also communication respect for the other person. advantages of assertiveness include: • It is more likely you will get what you want when you ask for it.• People respect clear, open, honest communication.• You stand up for your own rights and experience self-respect.• You avoid the invitation of aggression.• You are more independent.• You become a decision maker.• You feel more peaceful and comfortable with yourself. |
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• Describe multidisciplinary communication within the health care team.
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Client record-a confidential, permanent legal documentation of information relevant to a clients health care.
Reports-are oral written or audiotaped exchanges of information. Consultations-one professional caregiver gives formal advise about the care of a client to another caregiver. Referrals-an arrangement for services by another care provider |
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• Identify purposes of a health care record.
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Communication-means by which client needs and progress, individual therapies, client education, and discharge planning are conveyed to others in the health care team.
Legal documentation-one of the best defenses for legal claims. Financial billing-to determine the accurate and timely reimbursement. Education-learning the nature of an illness and the individual client's responses. Research-gathering of statistical data of clinical disorders, complications, therapies, recover, and deaths. Auditing-objective, ongoing reviews to determine the degree to which quality improvement standars are met |
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• Discuss legal guidelines for documentation.
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Factual- contains descriptive objective information about what the nurse sees, hears and smells.
Accurate-the use of exact measurements; use of an institutions accepted abbreviations, symbols and system of mesures. Complete- containing appropriate and essential information Current-Timely entries are essential in the clients ongoing care. Organized-communicate information in a logical order. |
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• Identify ways to maintain confi dentiality of records and reports.
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Federal and state regulations, state statues, standards of care, and accrediting agencies set nursing documentation standards. The American Nurses Association’s (ANA’s) standard of nursing documentation states that “documentation must be systematic, continuous, accessible, communicated, recorded and readily avail-able to all members of the health care team.” It is expected that all nurses will maintain the client’s record in accordance with the standard of care and the institution’s policy and practice.
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• Identify ways to reduce data entry errors.
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In advanced systems, CPOE has built-in reminders and alerts that help the client’s health care provider to select the most appropriate medication or diagnostic test. There are major initia-tives from the Institute of Medicine to improve the quality of care and reduce medication errors. Many believe CPOE is the answer. CPOE allows direct entry of orders to eliminate issues related to illegible handwriting and transcription errors. In addition, a CPOE system speeds the implementation of ordered diagnostic tests and treatments, which improves staff productivity and saves money
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Identify ranges of acceptable VS values for an adult
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Temp: 36 - 38 C (96.8 - 100.4 F)
Avg oral/tymp: 37 C (98.6 F) Avg rectal: 37.5 C (99.5 F) Avg axillary: 36.5 C (97.7) Pulse: 60 - 100 beats per min Resp: 12 - 20 breaths per min BP: Avg: <120/80 Pulse Press: 30 - 50 mm Hg |
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Accurately assess palpated systolic pressure
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Palpating the Systolic Blood Pressure
Delegation Considerations: The skill of palpation of blood pressure may not be delegated. Equipment: Sphygmomanometer. 1. Perform hand hygiene. 2. Apply blood pressure (BP) cuff to the extremity selected for measurement. 3. Continually palpate the pulse of the brachial, radial, or popliteal artery with fingertips of one hand. 4. Inflate BP cuff 30 mm Hg above the point at which you no longer can palpate the pulse. 5. Slowly release valve and deflate cuff , allowing manometer needle mercury to fall 2 mm Hg per second. 6. Note point on manometer when pulse is again palpable; this is the systolic blood pressure. 7. Deflate cuff rapidly and completely. Remove cuff from client extremity unless you need to repeat the measurement. 8. Perform hand hygiene. Record pressure as systolic/palpated |
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Accurately assess oral and axillary temps
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There are several sites for measuring core and surface body temp. Obtain intermittent temp measurements from the routinely used sites of the mouth, rectum, typmanic membrane, temporal artery, and axilla. Temp varies depending on site used.
Basic preparation steps: 1) Assess for any s/s of temp alterations or factors that may affect temp. 2) Determine any previous activity that interferes with accuracy of temp measure. NOTE: When taking oral temp; wait 20 - 30 min before measuring temp if pt has ingested hot / cold food/drink or has smoked. 3) Determine app site and device for pt 4) Instruct pt of route temp is being taken and ensure pt is positioned properly and still 5) Perform hand hygiene 6) Assist pt in assuming comfortable position that provides easy appropriate access for site. 7) Obtain temp reading Oral temp: (electronic thermometer) a) Apply clean gloves (opt.) b) Remove thermometer from charging unit. Place new clean disposable plastic cover on probe by sliding probe into cover until clicks in place c) Ask pt to open wide and then gently place therm. under tongue in posterior sublingual pocket lateral to ctr of lower jaw. Ask pt to hold in place with lips closed. d) Once audible signal indicates completion and temp reading appears on screen remove from under pt's tongue. e) Release cover into nearest trash can. f) Return probe to unit and replace on the charger. g) Discard gloves appropriately and perform hand hygiene. h) Document findings Axillary Temp a) Draw curtain around bed or close door to ensure privacy and assist pt to a supine or sitting position. Remove clothing from area. b) apply gloves (opt.) and prepare thermometer with probe cover c) raise arm away from torso; inspect for skin lesions and excessive prespiration. Clean and dry if necessary. Insert thermometer probe in center of axilla, lower arm over probe, and place arm across pts chest d) hold in place until audible sound signal occurs and temperature is displayed on screen e) discard probe cover and replace probe to unit. f) assist client to return to comfortable position replacing clothing/blankets. e) perform hand hygiene g) document findings |
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Explain the physiology of normal regulation of pulse rate.
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The pulse is the palpable bounding of blood flow noted at various points on the body. Electrical impulses originating from the SA node travel through the heart muscle to stimulate cardiac contraction. Approx 60 - 70 mL of blood enters the aorta with each ventricular contraction (stroke volume). With each stroke volume ejection, the walls of the aorta distend, creating a pulse wave that travels rapidly toward the distal ends of the arteries. When the pulse wave reaches the peripheral artery, you can feel it by palpating the artery lightly against underlying bone or muscle. The pulse is the palpable bounding of the flow in the peripheral artery. The number of pulsing sensations in 1 min is the PR.
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Identify when to take the VS.
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VS are an important part of the assessment database. You include VS in a complete physical assessment or obtain them individually to assess a pts condition. Establishing a database of VS during a routine physical examination serves as a baseline for future assessments. The client's needs and condition determine when, where, how, and by whom VS are measured.
Box 32-2;pg 504 When to take VS: -on admission to health care facility -when assessing the pt during a home care visit -in a hospital on a routine schedule according to hospital policy -before and after surgery or procedure -before, during, and after a transmission of blood products -before, during, and after the admin of med or therapies that affect CV, resp, or temp control functions -when the pts general condition changes (i.e. los of consciousness or increased intensity of pain) -before and after nursing interventions influencing a VS (i.e. ambulation or rom exercises) -when the pt reports nonspecific Sx of physical distress (e.g. feeling funny or different) |
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Accurately record and report VS measurements
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BP: Recording and Reporting
• Inform client of value and need for periodic reassessment of blood pressure. • Record blood pressure in nurses’ notes or vital sign flow sheet. Measurement of blood pressure after administration of specific therapies needs to be documented in narrative form in nurses’ notes. • Report abnormal findings to nurse in charge or health care provider. PR: Recording and Reporting • Record pulse rate with assessment site in nurses’ notes or vital signs flow sheet. Document pulse rate after administration of specific therapies in narrative form in nurses’ notes. • Report abnormal findings to nurse in charge or health care provider. Body Temp: Recording and Reporting • Record temperature in nurses’ notes or vital sign fl ow sheet. Document measurement of temperature after administration of specific therapies in narrative form in nurses’ notes. • Report abnormal findings to nurse in charge or health care provider. |
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Describe how unmet basic physiological needs of oxygen, nutrition, temp, and humidity threaten clients safety.
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A pts environment includes all of the many physical and psychological factors that influence or affect the life and survival of the patient. These include basic needs such as oxygen, temperature, nutrition and humidity. Safety in health care settings reduces incidence of illness and unjury, prevented extended length of Rx and/or hospitalization, improves or maintains a pts functional status and increases the pts sense of well being.
Low concentrations of oxygen can cause nausea, dizziness, H/A, and fatigue. High concentrations can cause death in 1 - 3 min of exposure. High levels of carbonmonoxide is a colorless, odorless poisoness gas that when inhaled prevents oxygen from reaching the tissues and can ultimately cause death. Foods that are inadequately stored and prepared can cause increased risk for infections and food poisoning. Exposure to extreme temps for prolonged periods can serious affect the overhealth and well being of a pt. Exposure to extreme cold can cause hypothermia while exposure to extreme heat can cause heatstroke or heat exhaustion. Relative humidity is the amount of water vapor in the air compared with the max amt of water vapor that can be contained in the same temp. |
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Describe assessment activities designed to identify clients physical, psychological, and cognitive status as it pertains to their safety status.
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In the case of safety, the nurse integrates knowledge from nursing and other scientific disciplines, previous experiences in caring for pts who had an injury or were at risk, critical thinking attitudes such as perseverance and any standards of practice that are applicable. Assessment activities should include obtaining a pts Hx (i.e. information about level of wellness, cognitive abilities, physical impairments, etc), a complete assessment of pts environment (i.e. home or pt room), to include possible fall risks (clutter, placement of equiment), nutritional needs (i.e. potention food poisoning, etc).
Other activities include observing pt in mobility, interaction, and also being aware of potential risks within the hospital etc |
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Describe nursing interventions specific to clients age for reducing risk of falls, fires, poisonings, and electrical hazards.
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Nursing interventions directed at eliminating environmental threats include general preventative measures such as meeting basic needs, reducing physical hazards and reducing pathogen transmission. Basic needs include oxygen, nutrition, temperature, and humidity. The nurse can intervene by recommending period inspection of the furnace to ensure proper functioning; obtaining a humidifier to ensure proper humidity for the older pt who has or is prone to upper respiratory infections. the nurse should also teach basic techniques for hand hygiene, food prep and storage to minimize food poisoning or to arrange for meals on wheels for pts who are unable to prepare adequate food. The nurse should teach the pt and family regarding adequate lighting in the home as well as observing for potential fall risks. The nurse should also encourage the family to have fire alarms, extinquishers installed as well as ensuring emergency numbers are available and close to phone when needed.
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Describe the four categories of of risks in a health care setting
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Specifi c risks to a client’s safety within the health care environ-ment also include falls, client-inherent accidents, procedure-related accidents, and equipment-related accidents. The nurse assesses for these four potential problem areas and, considering the developmental level of the client, takes steps to prevent or minimize accidents.
The risk for falling is signifi cantly higher in older clients. In addition to age, a history of previous falls, gait disturbance, balance and mobility problems, postural hypotension, sensory impairment, urinary and bladder dysfunction, and certain medical diagnostic categories (e.g., cancer and cardiovascular, neurological, and cere-brovascular diseases) increase the risk. One of the more common factors precipitating a fall is a client’s attempt to get out of bed to toilet. Drug use and drug interactions are also implicated in falls. Hip fractures are among the most serious fall-related injuries. Client-inherent accidents are accidents (other than falls) where the client is the primary reason for the accident. Examples of client-inherent accidents are self-infl icted cuts, injuries, and burns; ingestion or injection of foreign substances; self-mutilation or fi re setting; and pinching fi ngers in drawers or doors. Procedure-related accidents occur during therapy. They include medication and fl uid admin-istration errors, improper application of external devices, and ac-cidents related to improper performance of procedures (e.g., Foley catheter insertion). Equipment-related acci-dents result from the malfunction, disrepair, or misuse of equip-ment or from an electrical hazard. To avoid rapid infusion of IV fl uids, all general use and client-controlled analgesic pumps need to have free-fl ow protection devices. To avoid accidents, do not operate monitoring or therapy equipment without instruction. |
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Discuss common misconceptions about pain
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The following statements are false:
• Drug abusers and alcoholics overreact to discomforts. • Clients with minor illnesses have less pain than those with severe physical alteration. • Administering analgesics regularly will lead to drug addiction. • The amount of tissue damage in an injury accurately indi-cates pain intensity. • Health care personnel are the best authorities on the natureof a client’s pain. • Psychogenic pain is not real. • Chronic pain is psychological. • Clients should expect to have pain in a hospital. • Clients who cannot speak do not feel pain. |
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Describe guidelines for selecting and individualizing pain interventions
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The planning step required you to synthesize information from multiple resources. Critical thinking ensures that the pts plan of care integrates all that you know about the pt as well as critical thinking elements. Professional stds of care regarding pain management are available as well as use of concept mapss. The concept map assists you in relating how the nursing diagnoses are interrelated with each other and linked to the pts med diagnoses. Identifying these relationships assists you in developing a holistic and client centered plan of care.
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Discuss nursing implications for administering analgesics
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Know the Client’s Previous Response to Analgesics
Determine whether the client has allergies. Know whether client is at risk for using NSAIDs or opoids. Identify previous doses and routes of analgesic administration to avoid under treatment. Determine whether client obtained relief. Ask whether a nonopioid was as effective as an opioid. Select Proper Medications When More than One Is Ordered Use nonopioid analgesics or opioid combination drugs for mild to moderate pain. You can give opioids with nonopioids. In older adults, avoid combinations of opioids. Fentanyl patches, morphine, or hydromorphone are the opioids of choice for long-term management of severe pain. Intravenous medications act more quickly and can relieve severe, acute pain within 1 hour, whereas oral medication may take as long as 2 hours to relieve pain. Know to avoid intramuscular analgesics, especially in older adults. Use an opioid with a nonopioid analgesic for severe pain because such combinations treat pain peripherally and centrally. For chronic pain, give sustained-release oral formulations around-the-clock (ATC). Know the Accurate Dosage Recall that 4 g is considered the maximum 24-hour dose for acetaminophen and acetylsalicylic acid (ASA); 3200 mg for ibuprofen Adjust doses, as appropriate, for children and older clients. Large doses of opioids are acceptable in opioid-tolerant clients, but not opioid-naive clients. When titrating opioids, it is important to titrate to effect or to uncontrollable side effects. Assess the Right Time and Interval for Administration Administer analgesics as soon as pain occurs and before it increases in severity. An ATC administration schedule is usually best. Give analgesics before pain-producing procedures or activities. Know the average duration of action for a drug and the time of administration so that the peak effect occurs when the pain is most intense. Use extended-release opioid formulations to treat chronic pain. |
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Describe the components of pain assessment
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• Determine the client’s perspective of pain including history of pain; its meaning; and physical, emotional, and social effects
• Measure objectively the characteristics of the client’s pain • Review potential factors affecting the client’s pain • Identify medical comorbidities (e.g., diabetes, cancer, etc.) Knowledge needed • Physiology of pain • Factors that potentially increase or decrease responses to pain • Pathophysiology of conditions causing pain • Awareness of biases affecting pain assessment and treatment • Cultural variations in how pain is expressed • Knowledge of nonverbal communication Experience needed • Caring for clients with acute, chronic, and cancer pain • Caring for clients who experienced pain as a result of a health care therapy • Personal experience with pain Attitude needed • Persevere in exploring causes and possible solutions for chronic pain • Display confidence when assessing pain to relieve the client’s anxiety • Display integrity and fairness to prevent prejudice from affecting assessment Standards to know • Refer to AHRQ guidelines for acute pain management • Refer to clinical guidelines of APS and ASPMN • Apply intellectual standards (e.g., clarity, specificity, accuracy, and completeness) when gathering assessment • Apply relevance when letting the client explore the pain experience |
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Describe applications for use of nonpharmacological pain interventions
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Nonpharmacological interventions include cognitive-behavioral and physical approaches. The goals of cognitive-behavioral interventions are to change clients’ percep-tions of pain, to alter pain behavior, and to provide clients with a greater sense of control. Distraction, prayer, relaxation, guided imagery, music, and biofeedback are examples. Physical ap-proaches have the goal of providing pain relief, correcting physi-cal dysfunction, altering physiological responses, and reducing fears associated with pain-related immobility. Chiropractic ther-apy and acupuncture/acupressure therapy are examples.
Relaxation is mental and physical freedom from tension or stress that provides individuals a sense of self-control. You are able to use relaxation techniques at any phase of health or illness. Physiological and behavioral changes associ-ated with relaxation include the following: decreased pulse, blood pressure, and respirations; heightened global awareness; decreased oxygen consumption; a sense of peace; and decreased muscle ten-sion and metabolic rate. Relaxation techniques include medita-tion, yoga, Zen, guided imagery, and progressive relaxation exer-cises The reticular activating system inhibits painful stimuli if a person receives suffi cient or excessive sensory input. With suffi cient sensory stimuli, a person is able to ignore or be-come unaware of pain. Persons who are bored or in isolation have only their pain to think about and thus perceive it more acutely. Distraction directs a client’s attention to something other than pain and thus reduces the awareness of pain. Cutaneous stimulation of the skin can also help relieve pain. A massage, warm bath, ice bag, and transcutaneous electrical nerve stimulation (TENS) stimulate the skin to reduce pain perception |
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Who regulates medical records?
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Licensing statues, accrediting organizations, state laws, federal laws, and case laws regulate the content of the MR. For example, JC mandates that hospital documents be recorded in a timely manner and that the MR be readily accessible to appropriate personnel
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Looking for red flags in the record
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Red Flags include:
-lack of Rx -delayed, substandard, or inappropriate Rx -lack of pt teaching or discharge instructions -charting inconsistencies(lapse in times) -references to an incident report -pt abandonment -battles between providers (ie physicians) -lack of informed consent -late entries that aren't documented as such or appear to be self serving -fraudulent or improper alterations in the MR -destruction of or missing MR - |
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Do's of charting
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-Base documentation on objective assessment findings
-document at the time of or as close to as possible -be aware of shortcomings that in documenting that could allow an atty to raise questions in the quality of care given -while keeping personal opinions out, document factually and objectively regarding pts behavior including failure to adhere to treatment plan or refusal of treatment. -document thoroughly and accurately -follow your facility's policy |
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Don'ts of charting
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-leave gaps in time, space or other areas leaving a "mystery" as to care provided
-use "bias" in documentation (i.e. obnoxious, beligerent, hostile, or rude) as these suggest level of care may have been compromised. -document that an "incident report" was done. document facts and circumstances surrounding the incident -deviate from hospital policy |
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Eye catching flaws in the record
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-pgs w/out any pt id, such as pts stamp in one of the corners
-notes written w/the wrong date or w/times that don't correlate w/the remainder of the chart -long narrations that don't seem to be sequential -an entry written over a previous entry to correct or change it -changes in slant, uniformity, or pressure of hand writing or changes in ink or pen on the same entry -any erasure or obliterations -itemized billings for medical expenses that are inconsistent with test, meds, or equipment referenced in the chart, which could indicate that the pt was given the wrong med, test or Rx, or didn't receive an item for which he was billed |
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Explain the physiology of normal regulation of respiration
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Breathing is generally a passive process. Normally a person thinks little about it. The respiratory center in the brain stem regulates the involuntary control of respirations. Adults normally breath in a smooth uninterrupted pattern, 12 - 20 x per min.
The body regulated ventilation using levels of CO2, O2, and pH in the arterial blood. The more imprtant factor in the control of ventilation is the level of CO2. An elevation in this level causes the respiratory control system in the brain to increase the rate and depth of breathing. Although breathing is normally passive, muscular work is involved in moving the lungs and chest wall. Inspiration is an active process. During inspiration the respiratory center sends impulses along the phrenic nerve, causing the diaphragm to contract. Abdominal organs move downward and forward, increasing the lenght of the chest cavity to move air into the lungs. The diaphragm moves approximately 1cm (4/10 in), and the ribs retract upward from the body's midline approx 1.2 - 2.5 cm (1/2 to 1 in). During the normal, relaxed breath, a person inhales 500 mL of air. This is referred to as tidal volume. |
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Explain the physiology of normal regulation of blood pressure
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Blood pressure reflects the interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity.
CO: When volume increases in an enclosed space, such as a blood vessel, the pressure in that space rises. Thus, as cardiac output increases, more blood is pumped against arterial walls, causing the blood pressure to rise. Peri Resist: Blood circulates through a network of arteries, arterioles, capillaries, venules, and veins. Arteries and arterioles are surrounded by smooth muscle that contracts or relaxes to change the size of the lumen. The size of arteries and arterioles changes to adjust blood flow to the needs of local tissues. Normally, arteries and arteri-oles remain partially constricted to maintain a constant fl ow of blood. Peripheral vascular resistance is the resistance to blood fl ow determined by the tone of vascular musculature and diam-eter of blood vessels. The smaller the lumen of a vessel, the greater peripheral vascular resistance to blood fl ow. As resistance rises, arterial blood pressure rises. As vessels dilate and resistance falls, blood pressure drops. BV: Normally the blood volume re-mains constant. However, if volume increases, this exerts more pressure against arterial walls. For example, the rapid, uncon-trolled infusion of intravenous fl uids elevates blood pressure. When circulating blood volume falls, as in the case of hemorrhage or dehydration, blood pressure falls. Vis: viscosity of blood affects the ease with which blood flows through small vessels. The hematocrit, or percentage of red blood cells in the blood, determines blood viscosity. When the hematocrit rises and blood flow slows, arterial blood pressure increases. The heart contracts more forcefully to move the viscous blood through the circulatory system Elas: With reduced elasticity there is greater resistance to blood fl ow. As a result, when the left ventricle ejects its stroke volume, the vessels no longer yield to pressure. Instead, a given volume of blood is forced through the rigid arterial walls, and the systemic pressure rises. Systolic pressure is more signifi cantly elevated than diastolic pressure as a result of reduced arterial elasticity |
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What four elements must the plaintiff prove to prevail.
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-A duty to the plaintiff existed
-The standard of care was breached -The patient was injured -The injury was caused by the breach in the standard of care. |
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What should a patients medical record include
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It should provide a complete and accurate account of his condition and the care he received. It tells the story of his encounter with you and other professional caregivers.
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Define professional negligence.
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failure to provide the prevailing standard of care to a patien, which results in injury, damage, or loss of the patient.
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Who regulates medical records?
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Licensing statues, accrediting organizations, state laws, federal laws, and case laws regulate the content of the medical record. In particular, the Joint Commission on Accreditation of Healthcare Organizations mandates that hospital documents be recorded accurately on a timely basis and the medical record be readily accessibel to appropriate personnel.
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What flaws will catch the eye of the plantiffs attorney?
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pages without any patient identification
notes written with the wrong date or time long narrrations that dont seem to be sequential an entry written over a previous entry changes in slant, uniformity, or pressure of handwriting or changes in ink or pen on the same entry any erasure or obliterations itemized billings that are inconsistent with tests, medications, or equipment referenced in the chart pathology report or diagnostic test finding that dont correlate with physical assessment finding |
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How do you avoid documentation pitfalls.
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base your documentation on your objective assessment findings using your senses of sight, touch, hearing, and smell.
avoid gaps, bias,and diviation from policies and procedures. |
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Where do nurses go wrong?
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Failure to accurately assess and monitor the patient's condintion
Failure to notify the healt care provider of problems Failure to follow orders Contributing to medicaiton errors Failure to convey discharge instructions Failure to ensure patient safety Failure to follow policies and procedures Failure to properly delegate and supervise |
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What are the five rights of delegation?
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right task
right circumstances right person right communication right supervision |
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What circumstances alleges the nurse to failure to monitor the patient's condition?
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failure to properly monitor the patient's care, treatment, and condition
failure to monitor in a timely fashion failure to use the proper equipment to monitor the patient failure to document the monitoring. |
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Unexpected outcomes and nurse action: BP
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• Unable to obtain BP reading
• Determine that no immediate crisis is present by obtaining pulse and respiratory rate. • Assess for signs of decreased cardiac output; if present, notify nurse in charge or health care provider immediately. • Use alternative sites or procedures to obtain BP: auscultate BP in lower extremity, use a Doppler ultrasonic instrument, imple-ment palpation method to obtain systolic blood pressure. • Repeat BP measurement with sphygmomanometer. Electronic BP devices are less accurate in low blood fl ow conditions. • Blood pressure is not sufficient for adequate perfusion and oxygenation of tissues. • Compare BP value to baseline. A systolic reading of 90 mm Hg is an acceptable value for some clients. • Position client in supine position to enhance circulation and restrict activity if it is decreasing BP. • Assess for signs and symptoms of decreased CO; if present, notify nurse in charge or health care provider. • Increase rate of IV infusion, or administer vasoconstricting drugs if ordered. • Blood pressure is above acceptable range. • Repeat BP measurement in other arm, and compare fi ndings. Verify correct selection and placement of cuff . • Ask nurse colleague to repeat measurement in 1 to 2 minutes. |
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Unexpected outcomes and nurse action: PR
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• Radial pulse is weak and thready.
• Assess both radial pulses, and compare findings. Local ob-struction to one extremity (e.g., clot, edema) decreases pe-ripheral blood flow. • Perform complete assessment of all pulses (see Chapter 33). • Observe for symptoms associated with decreased tissue perfusion, including pallor and cool skin temperature of tissue distal to the weak pulse. • Measure apical and radial pulse simultaneously to determine presence of pulse defi cit. • Apical pulse is greater than 100 beats per minute (tachycardia). • Identify related data, including fever, anxiety, pain, recent exercise, hypotension, decreased oxygenation, or dehydration. • Observe for signs and symptoms of inadequate cardiac output, including fatigue, chest pain, orthopnea, cyanosis, and dizziness • Apical pulse is less than 60 beats per minute (bradycardia). • Observe for factors that alter heart rate such as digoxin and antidysrhythmics: it is sometimes necessary to withhold prescribed medications until the health care provider is able to evaluate the need to adjust dosage. • Observe for signs and symptoms of inadequate cardiac output, including fatigue, chest pain, orthopnea, cyanosis, dizziness. |
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Unexpected outcomes and nurse action: Resp
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• Client has respiratory rate less than 12 (bradypnea) or above 20 (tachypnea) breaths per minute. Breathing pattern is irregular. Depth of respirations increase or decrease: client complains of feeling short of breath.
• Observe for related factors, including obstructed airway, ab-normal breath sounds, productive cough, restlessness, irritability, anxiety, confusion. • Assist client to supported sitting position (semi- or high-Fowler’s) unless contraindicated, which improves ventilation. • Provide oxygen as ordered. • Assess for environmental factors that influence client’s respiratory rate such as second hand smoke, poor ventilation, or gas fumes. |
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Unexpected outcomes and nurse action: Body Temp
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• Temperature 1° C above usual range
• Assess possible sites (e.g., central line catheter, wounds) for localized infection and for related data suggesting a systemic infection. • Follow interventions listed in Box 32-10, p. 520.(**Sep Flashcard) • Persistent fever • Notify health care provider, and administer antipyretic and antibiotics as ordered. • Temperature 1° C below usual range • Remove any drafts, wet clothing, or linen. • Apply extra blankets, and unless contraindicated offer warm liquids |
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BOX 32-10 Nursing Interventions for Clients With a Fever (pg 520)
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Interventions (Unless Contraindicated)
• Obtain blood cultures if ordered. Blood specimens are obtained to coincide with temperature spikes when the antigen-producing organism is most prevalent. • Minimize heat production: reduce the frequency of activities that increase oxygen demand, such as excessive turning and ambulation; allow rest periods; limit physical activity. • Maximize heat loss: reduce external covering on client’s body without causing shivering; keep clothing and bed linen dry. • Satisfy requirements for increased metabolic rate: provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells; provide measures to stimulate appe-tite, and off er well-balanced meals; provide fl uids (at least 3 L/day for a client with normal cardiac and renal function) to replace fl uids lost through insensible water loss and sweating. • Promote client comfort: encourage oral hygiene because oral mucous membranes dry easily from dehydration; control temperature of the environment without inducing shivering; apply damp cloth to client forehead. • Identify onset and duration of febrile episode phases: examine previous temperature measurements for trends. • Initiate health teaching as indicated. • Control environmental temperature to 21° to 27° C (70° to 80° F). |
