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195 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Personal Hygiene - Factors influencing Hygiene
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Physical condition
Developmental Status Knowledge Level Culture Socioeconomic Status Social & Religious Practices Body Image Personal Preferences |
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Purposes of Hygiene
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Promotes Cleanliness
Provides comfort, relaxation Improves self-image Stimulates Circulation Allows for assessment |
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Critical thinking & Hygiene
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-nurse uses knowledge to give care that provides comfort
-Curiosity & humility-use to assess more fully & to learn client's preferences in care |
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Questions: what are two critical thinking attributes used in hygiene care for a patient?
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curiosity & humility
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Comprehensive Assessment
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-nurse should examine all skin areas for integrity or breakdown
-nurse can talk to pt about problems or concerns |
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While performing a comprehensive assessment during hygiene what are two opportunities the nurse has?
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to examine
to communicate |
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Types of Baths
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complete
partial assist tub shower |
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What should be the water temp. when giving a bedbath?
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105-115
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Oral Care
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EXTREMELY IMPORTANT
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What is Sordes?
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crust or pcs of food and bacteria on the teeth, and about the lips
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What is a nosocomial infection?
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inborn hospital infection, pay particular attention to cathaters.
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What is the most important task when shaving a patient?
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chart nicks
wear gloves |
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When would you not use an electric razor?
when would you not use a blade razor? |
around oxygen
pt on anticoagulant pt that is a hemophiliac |
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Functions of skin:
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protection
regulation of temp sensation prod. of vitamin D secretes Sebum |
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Normal skin appearance"
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variation in pigment
good turgor, smooth, soft flexible no evidence of cyanosis, jaundice or pallor warm to touch intact, no abrasions or excoriations normal lesions defined by age of individual |
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List ways to id and describe a lesion:
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asymmetry
border color diameter type shape, arrangement, distribution |
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Who is at risk for skin impairment?
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poor nutritional status
immobility altered or limited hydration secretions or excretions on skin mechanical devices altered venous circulation |
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When making a bed what are the 3 conditions you should afford your patient?
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Privacy
Safety Comfort |
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What is the first step in the Nursing Process?
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assessment or gathering and analysis of information about the client's health status
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How is the nursing process used?
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to identify, diagnose & treat human responses to health & illness
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What are the 5 steps of the nursing process?
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assessment
nursing diagnosis planning implementation evaluation |
adpie
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First item you need to know in assessment (nursing process)?
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what are the pts norms
Subjective/objective what the pt tells you what you can see or measure |
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Types of data needed in the nursing process:
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subjective/objective
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Methods of data collection:
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interview
pt or family members |
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Nursing Process & critical thinking- what are the attributes of Critical thinking needed for the Nursing Process
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Knowledge
Experience Standards Attitudes |
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What are 3 types of Diagnoses?
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Actual-characteristics-human responses
Risk- human responses Wellness- education etc-human responses |
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What are the components of the Nursing Diagnosis?
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1.Diagnostic label-diagnosis
2.Related factors-statement & etiology 3.Definition-describes the human response-actual vs risk 4.Risk factors-all that increase vulnerability of pt 5.Support of diagnostic statement- assessment data |
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What are the attributes of concept mapping?
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1.more integral than care plans
2.incorporates critical thinking 3.developes associative thoughts, links together lines of reasoning 4.more emcompassing picture of pt limitations of nursing diagnosis 5.better understanding of what the diagnosis should communicate 6.imprecise language may "mislabel" a client |
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What are four attibutes of Planning Nursing Care?
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1. establish priorities
2. establish goals & expected outcomes 3.interventions 4.implementation |
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Questions to ask yourself when planning nursing care
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What is going to happen? What do you suspect is going to happen?
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What are nursing interventions and implementations?
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any treatment, based on knowledge & judgement, that a nurse performs to enhance client outcomes-includes direct & indirect care, continous process, ever-adaptive
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How do you use critical thinking in nursing care?
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foundation to decision making process
guides care, direction of diagnosis & use of ongoing data collection supports incorporation of knowledge to delegate, monitor and evaluate care of clients |
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What is the Evaluation Process in nursing care?
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one of the most critical phases, ongoing, uses objective and subjective data, determines the effectiveness of nursing care & includes 5 elements
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id
evaluate interpet |
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Five elements of effectiveness in nursing care:
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-id criteria & standards
-evaluate data to determine if standards are met -interpreting & summarizing findings -documenting findings & clinical judgements -modifying or terminating, continuing or revising care plan |
IEIDM
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Identifying criteria & standards:
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-nurse evaluates care by knowing what to look for
-goals & expected outcomes must be clealy defined so that the nurse has objective criteria -goals should be established based on standards of care -expected outcomes should be goal-oriented & measurable |
id
evaluate interpet document modify |
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-Evaluative Data
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collected using developed assessment skills & tech.
-data collection should occur over a period of time to determine patterns of improvement or change -primary source of data is the client -secondary sources may include family, other caregivers -data must be pertinant, accurate |
Id
evaluate interpet document modify |
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Interperting & summarizing findings
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eval. is easier to perform over an extended period of time
-each outcome & its priority should be evaluated -failure to evaluate results in inadequate or inappropriate care decisions |
id
evaluate interpet document modify |
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Documentation is:
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-a key element to all nursing care
-if you did not write it-you did not do it -if you wrote it-you'd better have done it -accurate info must be present in a clien'ts chart to facilitate ongoing eval. decisions |
id
evaluate interpet document modify |
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Modifying or Terminating Plans of Care:
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Modification: when goals are not met-change in client's condition, error in nursing judgment or follow-up
-Termination- when expected outcomes are met-client has reached the goals and expected outcomes, communication of achievements to other health care personnel is crucial |
id
evaluate interpet document modify |
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Client Care Management
Nursing care delivery models * |
1.Functional nursing(task focused)
2.Team nursing (RN leads) 3. Total patient care (RN assumes responsibility for a caseload of clients over time) 4. Case Management-coordinates & links health care svcs. to clts and fam. while streamlining costs and maintaining quality |
FTTC
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Principles of Time Management
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1. goal setting
2.time analysis 3.priority setting 4. interruption control 5. evaluation |
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What are the 5 rights of delegation?
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right task
right circumstance right person right direction/communication right supervision |
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Quality Management
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Nursing practice:
must be defined incorporate prof. standards & care guidelines -specify outcomes |
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What is Self-Concept?
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how one thinks and feels about oneself
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What are the components of Self-Concept?
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Identity
Body Image Role Performance Self-Esteem |
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How are role performance behaviors developed?
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1.reinforcement-extinction
2.inhibition 3.substitution 4.imitation 5.identification |
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What are Self-concept stressors
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1.Identity Stressors
2.Self-concept Stressors 3.Role performance stressors 4.Self-esteem stressors |
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What are Identity stressors?
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-for adults, cultural and societal stressors are greater
-if adaptation doesn't occur, the person may experience disturbed personal identity |
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What are Body Image stressors?
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changes in appearance
loss of function in body parts significance of loss to the individual |
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What are role performance stressors?
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-Conflict
=Ambiguity -Strain -Overload |
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What are Self-esteem stressors?
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1. Chronic illness
2. Socioeconomic status 3. marital status |
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What are some effects on self-concept
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family
nurse-non-judgmental |
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Implementaton for Self-esteem
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health promotion-assist to dev. healthy lifestyle behaviors; measures that support coping and stress mgt
-Acute care: be aware of stressors and level of adaptation to changes in self concept -Restorative care-mostly done in home health care situations-where a trusting relationship can led to steps to aleve the stressors in the home env. that are leading to the situational low self-esteem-doing self-evaluation, setting goals |
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Evaluation of self concept
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client care
client expectations goal attainment |
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What is Critical Thinking?
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1.reasonable and reflective thinking that is focused on what to believe and do
2.Alexander & Giguere-is an intellectually disciplined process of conceptualizing, applying, analysing, synthesizing, and /or evaluating info 3.the nurse who is a good critical thinker faces problems without forming a quick, single solution 4. critical thinking is an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others |
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Critical Thinking in Nursing
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1. outcome is nursing judgment
2.all aspects are aggressively explored 3.all assumptions are open to question |
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Three levels in critical thinking
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1.Basic
2.Complex 3.Commitment |
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Components of critical thinking in nursing
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1.specific knowledge
2.clinical experience 3.critical thinking competencies 4.attitudes 5.standards |
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Attitudes for Critical thinking
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1.self confidence
2.independent thinking 3.fairness 4.responsibility and accountability 5.risk taking 6.Discipline 7.perseverance 8.creativity 9.curiosity 10.integrity 11. intellectual humility |
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Standards for critical thinking
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1.intellectual
2. professional |
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what are the 14 intellectual standards for critical thinking?
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1.clear
2.precise 3.specific 4.accurate 5.relevent 6.plausible 7.consistent 8.logical 9.deep 10. broad 11.complete 12. significant 13. adequate 14. fair |
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What are the professional standards OF critical thinking?
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1. ethical criteria for nursing judgments
2.scientific and practice-based criteria used for evaluation 3.criteria for professional responsibility |
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What are the professional standards FOR critical thinking?
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1.sound ethical standards
2.scientifically based and practice-based criteria 3.professional organizations, practices, policies and procedures |
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What are three aspects of critical thinking?
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1. reflection
2.language 3.intuition |
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Reflection in critical thinking is?
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process of purposefully thinking back or recalling a situation to discover its purpose or meaning
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Language in critical thinking is?
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the ability to use language is closely associated with the ability to think meaningfully
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Intuition in critical thinking is?
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the direct understanding of particulars in a situation w/out conscious deliberation
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Evidence of critical thinking in nursing
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1. problem solving
2.scientific method 3.nursing process 4.diagnostic reasoning and inferences 5.intuition' 6.decision making |
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Critical thinking flow chart
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1.identified need/problem
2.goal/outcomes 3.Knowledge/experience/Competencies required 4.questions that need to be answered 5.where to find the answers 6.answer or no answers/bad answers 7.action or further investigation 8. evaluation |
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synthesis: Critical thinking is:
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1. reasoning process used by individuals to reflect on & analyze thoughts, actions, and knowledge
2. ongoing with information being analyzed from many sources 3. is synthesized with the nursing process to allow students to become competent professionals |
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Development of critical thinking skills
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1.taught or developed
2. what kinds of activities can enhance critical thinking skills 3.indicators that critical thinking is developing 4.models of critical thinking |
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Nursing considerations for lab & diag. studies
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1. reason for the lab or study
2.specific preps or post-care for the pt 3.specialized collection or equipment |
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What are some laboratory studies?
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1. Chemistries
2.Hematology 3.Bacteriology or Microbiology 4. Blood bank 5. Pathology |
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What are some of the Hematology studies?
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1.coagulation
2.blood cell counts, maturity 3.CBS,WBC,PT,PTT,INR, Iron levels, Folic acid, Vitamin B12 etc |
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What are some of the Bacteriology or Microbiology studies?
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1. cultures on samples of blood & other body fluids
2.testing for sensitivity of organisms to antibiotics and other treatments 3. discovery of problem bacteria, fungi, ova and parasites through culturing |
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What are the studies done in a blood bank?
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1. types and crossmatches of blood and other bl. products for compatibility
2.maintains storage 3. maintains and controls bl. product distribution |
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What are Pathology studies?
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1.tissues are examined for cellular characteristics
2. tissue samples may be tested to substantiate a diagnosis, differentiate btw types of cells or after death to id. an abnormality |
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What labs tell us:
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1. nurse must read and understand a pts lab results
2.should direct the nurse to give or hold meds, to monitor a pt or call the physician, to make a decision to act in one direction or another |
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Critical thinking and lab values
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1.KNOWING the relevence of the number and steps to take or what to monitor
2.Understanding the diff. btw an abrupt drop or rise in a lab value versus a chronic condition 3. Are the values skewed by an underlying condition or problem (ex: right equip) |
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Critical thinking application and lab values
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1.during med. admin-(use labs)
2.to establish need for isolation 3.to validate therapeutic responses 4.to formulate a diagnois |
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What are dianostic procedures?
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Indirect visualizations (view on screen)
Direct visualizations(view w/a scope) |
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Critical thinking and diagnostic studies
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1.holding certain meds prior to and/or after certain procedures
2.recognizing expected and untoward side effects of procedures 3.always ask clients about Otc and herbal preps. |
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Enviromental safety-individual risk factors
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1.lifestyle
2.impaired mobility 3.sensory or communication impairment 4.lack of safety awareness 5.impaired vision |
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Client safety in the hospital
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1.must be assessed by the nurse & corrected
2.risk for falls -use the fall assessment tool 3.risk for med. errors can be prevented-7 rights of med admin |
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What are the 7 rights of med administration?
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right diagnosis
right med right dose right person right route right time right documentation |
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Restraints- when client is at risk
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since the nurse should do all that is possible to prevent falls then restraints may need to be used
only when pt is at risk from wandering or in a agitated or disruptive state should be removed asap -nurse should use extreme caution, frequent assessments and close monitoring |
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Alternatives to restraints
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1.orient the client as often as necessary
2.encourage families to stay/or trained sitters 3.assign these pts to rooms close to nurses' station 4.use relaxation techniques 5.provide scheduled toileting to alleviate pts ambulation w/out assistance |
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Restraint application
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1.delegated to trained assistive person
2.communicate w/pt about the reasons 3.physician's order is necessary 4.assess and docu. pts responses at least every two 2 hrs 5.tie w/quick release knots -assess pulse and skin every 2 hrs or more 6.notate the use in chart & during report |
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Institutional environmental risk are:
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1.falls
2.client-inherent accidents 3.procedure-related accidents 4.equip. related accidents |
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Some nursing diagnoses pertaining to safety
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1.impaired memory/disturbed thought processes
2.risk for poisoning 3.disturbed sleep pattern 4.impaired physical mobility 5.risk for injury 6.disturbed sensory perception 7.acute/chronic pain |
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Theory is?
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the domain and paradigm of nursing
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Domain is?
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a.view or perspective of the discipline
b.contains the subject,central concepts, values, & beliefs, phenomena of interest & central problems of the discipline |
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Paradigm is?
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model that explains the linkage of science, philosophy & theory accepted and applied by the discipline
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Nursing Paradigm is?
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directs the activity of the nursing profession
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What are the 4 linkages of the Nursing paradigm?
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1. person
2.health 3.environment/situation 4.nursing |
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theory
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set of concepts, definitions, relationships and assumptions that project a systematic view of phenomena
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Nursing theory
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a conceptualization of some aspect of nursing communicated for the purpose of describing, explaining, predicting and /or prescribing nursing care
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Components of a theory
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1. concepts
2.definitions 3.assumptions 4.phenomenon |
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Concepts of a theory?
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come from individual perceptual experience
-help to describe or label phenomena |
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Definitions of a theory
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convey the general meaning so it fits the theory
describes the activity necessary to measure (test) the constricts, relationships or variables within that theory |
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Assumptions of a theory
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-statements that describe concepts or connect two concepts that are factual
-taken for granted statements that determine the nature of the concepts, definitions, purpose, relationships and structure of the theory |
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Phenomenon of a theory
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a.an aspect of reality that can be consciously sensed or experienced
b.nursing theories focus on the phenomena of nursing and nursing care c.reflect the domain of nursing practice |
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Types of Theories
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1. Grand
2.Middle range |
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middle range theories are:
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1.limited scope, less abstract, address specific phenomena or concepts, reflect practice
2. Descriptive theories- a.1st level of theory development b. describe phenomena, speculate on why phenomena occur, describe consequences of phenomena 3. Prescriptive theories: address nursing interventions and predict the consequence of a specific nursing intervention |
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Theoretical models
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refers to global ideas about the individuals, groups, situations, or events of interest to a specific discipline from the view of the theorist
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Interdisciplinary theories
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1.Systems theory
2.Basic Human needs 3. Health-and-Wellness models 4.Stress & adaptation 5.Developmental theories 6. Psychosocial theories |
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Systems theory is
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a. input enters from the system
b. output is the end product of the system c.feedback is the process that returns output into the system d. systems may be open or closed e. nursing process-open system b/c influenced by environment f. chemical reaction-gets result |
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Basic Human Needs theory is
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a. useful for designating priorties of care
b. Maslow's Hierarchy of Needs c. levels id basic to complex needs to be met |
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Health and Wellness models
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designed to help health care professionals understand relationships btw the two concepts and clients attitudes toward health
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Stress & adaptation
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a. universal and dynamic
b. physiological and behavioral |
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Developmental theories
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a. orderly, predictive process beginning with conception and continuing through until death
b. many models available that describe and predict behavioral and development at phases of the life continum |
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Psychosocial theories
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a. physiological, psychological, sociocultural, developmental and spiritual
b. theories predict client responses to each of these domains |
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Scientific research and evidence-based practice in nursing
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Knowledge acquisition-hallmark of a mature discipline is development of multiple research methods designed to develop a knowledge base unique to the discipline
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Methods of knowledge acquisition
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a. tradition
b. information seeking c. experience d. problem solving e. critical thinking |
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The Scientific Method is:
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a. foundation of research
b. most reliable and objective c. used to understand, explain, predict or control d. produces empirical data (based on experience rather than scientific) |
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Nursing research:
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a. addresses issues that are important to the discipline of nursing
b. can focus on clinical nursing, nursing ed. client care, health care delivery or a comb. c. can use different methods to ascertain the information |
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Methodologies of Nursing research
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a.Quantitative:experimental, surveys, evaluation
b.Qualitative: interviews, several design structures c. mixed methods: combination of both |
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Ethical Issues in Nursing research
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a.rights of human subjects
b.informed consent c. anonymity d.confidentiality e. HIPPA f.IRB |
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HIPPA
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makes regulations to keep pt info confidential
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IRB
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Institutional Review Board-research board looking for problems
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Nursing Practice based on Research
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1. Research report-more expensive
2. Clinical article |
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Research report includes
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reported by primary or secondary source
a. abstract b.introduction 3.methods 4.results 5. discussion 6.reference list |
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Nursing research utilization
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a. improves the practice of nursing
b.raises the standards for the profession c. promotion & use increase the scientific knowledge base for nursing practice d. recipients of improvement are the consumers of nursing care |
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Nursing Health History
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building road map to pt
a. objective is to id patterns of health and illness, risk factors for physical and behavorial health problems, deviations from normal and help find solutions |
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Guidelines for Conducting a Health Assessment
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1. establish rapport
2.encourage honest communication 3.make eye contact 4.listen carefully 5.be aware of your own nonverbal communication 6.avoid technical terms-communicate in a way that is easily understood 7. consider educational & cultural background and any disabilities that the pt may have |
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Components of the Health History are:
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1. Biographical data-name, age, sex, race, marital status, ss.#, ed. occupation, religion, closest relative, physician, and med. record number
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Components of the Health History are:
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2,Chief Complaint- in the pts own words and in quotation marks
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Components of the Health History are:
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3. Present Health Concern-history of the present illness is the single most important factor
a.physical exam validates the info obtained b.diagnostic test often support rather than establish diagnosis c. gather relevant & essential data about the onset and duration of symptions d.record info. about the location, intensity, and quality of symptoms e.find out what action precipitates the symptom, makes them worse or provides relief |
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Components of the Health History are:
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4.Past History
a.prior hospitalization b.allergies c.if allergy note reactions and treatment d.id habits and lifestyles e.alcohol, tobacco, caffeine, OATC or routinely taken meds. *Noting the habit provides essential data f.assess patterns of sleep, exercise and nutrition g.general health status, immunization status h. last physical exam, CXR, EKG, eye exam, dental checkup, pap smear, mammogram, testicular and digital rectal exam i. previous illnesses are discussed |
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Components of the Health History are:
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5.Family History-
a.age, health status, or the age and cause of death of relatives b.1st order relatives (parents,siblings, spouse, children) c.second order relatives (grandparents, cousins) d.diseases: e. genogram or family tree is an easy way to record such data |
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Components of the Health History are:
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6.Environmental History
a.info about client's home env. and support systems b.includes function of utilities, layout of rooms, presence of barriers or risks to client safety c.ids exposure to pollutants, high crime areas and available resources |
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Components of the Health History are:
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6.Psychosocial History
a. reveals suport systems b.reveals info about how client deals w/stress c.reveals if pt has had recent losses that create a sense of grief |
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Components of the Health History are:
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7. Spiritual Environment
a.shaped by one's spirituality b.spiritual dimension is diff. to assess quickly c.review the client's belief about life, their source of guidance in acting on beliefs and the relationship they have w/ others in exercising their faith |
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Components of the Health History are:
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8.Review of Systems-
a.systematic method for collecting data on all body systems b.info provides a systematic description of the 11 functional health patterns and the pt perception, evaluation and explanation of particular problems c. info used to establish the database criteria against which any future changes are evaluated d.includes an overview of general health as well as symptoms related to ea body system e. it is not necessary to repeat previously obtained info |
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Components of the Health History are:
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9. Patient Profile
a.info is highly subjective and personal b.pt is encouraged to express feelings honestly c.begin w/general, open-ended quetions and move to direct specific questions d.past life events related to health e.education & occupation f.environment g.lifestyle h.presence of a physical or mental disability j.self-concept l.sexuality m. risk for abuse n.stress and coping response |
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Components of the Health History are:
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10. Cultural Considerations
a. care provider must take into account that other cultures have their own folklore and beliefs about the treatment of illnesses b.always respect other persons' beliefs, even if they conflict with yours |
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Components of the Health History are:
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11.Ethical/Legal use of history or physical exam data
a.pt has a right to know why the info is being sought and how it will be used b.important that they are aware that the decision to participate is voluntary c.written data should be stored in the pt's chart and made available only to those health professionals directly involved in the care of the pt |
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Components of the Health History are:
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12. Physical Examination
a.performed after the health history b.pt is asked to undress and drape apprp so that only the area to be examined is exposed c.procedures and sensations to expect are described to the pt b4 each part of the exam d.WASH hands, gloves e.an organized and systematic approach is key ophthalmoscope Otoscope Tuning fork Percussion hammer |
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Physical Assessment Techniques
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1.Inspection
2.Palpation 3.Percussion 4.Auscultation |
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Physical Assessment Techniques: Inspection
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1.deliberate, purposeful observations performed in a systematic manner
2.informed observation 3.visual, auditory & olfactory senses 4.adequate lighting 5.inspect ea area of body for size, color, shape, position & symmetry 6.look for rashes, scars, surgical scars, insect bites, sores, skin breakdown ets 7. a comparison of bilateral body parts is necessary for recognizing abnormal findings |
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Physical Assessment Techniques: Palpation
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1.uses sense of touch
2.used to gather info 3.dorsum of hand & fingers(used for gross measure of temp) 4.fingertips (nerve endings)(pulses, lymph nodes, & breasts) 5.palm of hand (vibs can be felt better with palm of hand)(especially the metacarpal joints-thrills) 6.what if you felt: warm and dry skin? hot skin? cold & clammy skin? 7. get into the habit when taking the BP to ask yourself-"what is the temperature of the skin?" 8. General guidelines for Palpation |
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Palpation
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gathers info about:
temp,turgor,texture, quality of pulses, edema, extent of tenderness, moisture,chest wall vibs, shunt thrills, abdomen softness or rigidity |
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General Guidelines for Palpation
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1.warm, comfortable,relaxed env
2.nurse's hands warm & fingernails short 3.any area of tenderness is palpated last 4.any expression of distress or pain should prompt the nurse to palpate lightly 5."Tickles" -use pt's hand to start palpation with 6.light & deep palpation 7.controlled by the amt of pressure applied 8.exert & release fingertips several times over an area 9. place hand parallel to the body surface that is to be palpated 10. move in a circular motion 11.light--1/2" 12. deep--about 1" |
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Deep Palpation
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***risk of possible internal injury***
1. do with caution 2.done after light pal. 3.used to detect abdominal masses 4.fingers are held at a greater angle to the body surface than light palpation |
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Percussion
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assesses the location, shape, size & density of tissue
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Four characteristics of sound
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intensity
pitch duration quality |
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Five percussion tones
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tympany
resonance hyperresonance dullness flatness |
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Percussion: Indirect method
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-place stationary finger over specific area
-keep palm & other fingers off the surface -apply light, uniform pressure -other hand--cock hand at wrist -use tip of striking finger -deliver blow btw knuckle & base of nail |
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Auscultation
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listening w/stethoscope
-used to listen over the lungs, heart, blood vessels, & abdominal viscera |
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Stethoscope
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a. diaphragm (firmly placed) to detect high-pitched sounds, such as normal heart tones & bowel sounds (S1,S2, friction rub, lung sounds, & abdominal sounds)
2. Bell (lightly placed) to detect low-pitched sounds, such as those produced by the heart & vascular system (S3, S4 & certain murmurs) |
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Bedside Head to Toe assessment
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1. general survey--general overview
2. what do you observe-inspection-informed observation 3.any immediate needs? a.observe for pain, dyspnea, anxiety b.general appearance-posture, skin color, facial expression, comfortable |
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Holistic care
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a.thorough data gathering, assess for anxiety, fear, affect and/or other emotional distresses
b. brief Neurological Exam: 1.orientation 2.response to verbal command 3.pupils 4.muscle strength |
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Starting an Assessment:
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I.orientation
II.response to Verbal command III. Consciousness IV. Level of consciousness V. Skin VI. hair & scalp VII. pupils VIII. nose & sinuses IX. Oral Mucous Membranes X. Vital signs XI. Chest XII. Heart XIII. Abdomen XIV Peripheral Vascular Assessment XV. Evaluate all XVI. Documentation |
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Assessment: Orientation
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1.direct questions-responses
2.assess for Oriented X 3 3.note speech content & patterns 4.doc. exact response-not "appears confused" |
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Assessment: Response to Verbal Commands
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1.does pt respond to verbal stimuli?
2.if no response to verbal commande, try: shout--sternal rub---pain |
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Assessment: Level of Consciousness
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1.Glasgow Coma Scale
2.level of consciousness a.awake and alert b.Lethargic c.Stuporous d.Comatose |
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Assessment: Skin
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1.color
2.temp 3.moisture 4.Nail color, capillary refill 5.Turgor 6.Edema 7. Texture 8. Any scars, rashes, insect bites 9. Redness or breakdown |
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Assessment: Skin con't
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a. check for edema-blanching, pitting
b. Petechiae-may indicate blood-clotting disorders, liver disease, or drug reactions Edema Scale 0=none +1-2mm=trace +2-4mm=moderate +3-6mm=deep +4-8mm=very deep |
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Assessment: type of skin lesions
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1.macule-fairly flat
2.papule-slightly raised, maybe inflammed 3.nodule-firm 4.-tumor-mass of cells benign or malignant 5.-wheal-raised, redened area 6.vesicle-fluid filled-clustered 7.pustule-pus filled 8. ulcer-missing tissue-1st or 2nd layer 9. atrophy-arterial insufficiency, holes deeper, smells bad, gangrene could form |
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Assessment: skin color
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cyanosis
1.central cyanosis: around lips & mouth-low arterial saturation 2.peripheral cyanosis: fingers, toes, & tip of nose--assoc. w/venous saturation |
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Assessment: hair & scalp
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1.itchy scalp, alopecia, excessive body hair
2.does the client wear a wig? 3. are there open sores, etc? |
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Assessment: pupils
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1.inspect size, shape, equality of pupils
2.partially darken room 3.instruct pt to stare straight ahead 4.test reaction of pupils to light (constriction & rate) sluggish brisk 5.approach penlight from side 6. PERRLA |
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Assessment: pupils-PERRLA
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pupils equal, round, reactive to light, accomadate
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Assessment: Glasgow Coma Scale
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1.three perameters
a. eye opening -1-4 b. motor response-1-6 c. verbal response 1-5 |
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Assessment: Nose & sinuses
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1. observe shape, size, skin, color & presence of deformity or inflammation
2.note any tenderness, masses or underlying deviations 3.assess patency of nares 4.inspect mucosa for color, lesions, discharge, swelling, and evidence of bleeding (use penlight) |
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Assessment: Oral Mucous Membranes
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1.normally pink, intact, & moist
2.should be free of swelling, lesion, cyanosis, bleeding gums 3.assess teeth for caries |
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Assessment: Vital Signs
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1. always part of head-to-toe
2.temperature 3.if nursing assistant takes temp, make sure you know what the reading is a. if pt feels hot or looks flushed-check the temp, even if not time to check the temp 4. Respirations 5. Blood pressure-may need to take in both arms 6. other concers a. after taking vital signs, ask yourself- Is this normal? b. if normal, chart the signs c. if abnormal, report the vital signs |
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Assessment: vital signs- respirations
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a. rate, depth, rhythm, character
b. normal rate-12-20 min c. symmetry of chest wall movement(may need history) d.any accessory muscles in use e. O2 in use f. cough, sputum character |
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Assessment: Chest- techniques used
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1. chest inspection
2. chest palpation 3.vocal fremitus 4.chest percussion 5.chest auscultation 6.4 types of sounds aucultated over lungs 7.normal breath sounds 8.abnormal breath sounds |
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Assessment: chest- techniques used: Inspection
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a. assess color, shape or contour, breathing patterns & muscle development
b. normally transverse diameter is greater than the anterior-posterior diameter |
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Assessment: chest- techniques used: Palpation
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a. used to detect areas of sensitivity, chest expansion during respirations & vibrations (fremitus)
c. palmer surface of hands used |
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Assessment: chest- techniques used: Vocal Fremitus
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a. vibs transmitted to the chest wall during speech
b.place ball of hand lightly on chest--instruct the patient to say "ninety-nine" c.dense tissue conducts sound better than air; therefore, pneumonia will increase intensity of vibs d. fremitus decreased in pneumothorax, asthma, empysema--due to trapped air e.normal: mild vib sensations; equal bilaterally |
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Assessment: chest- techniques used: Chest percussion
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a. used to determine lung position & size, to detect presence of air, liquids, or solids w/in the lungs
b. resonance-normal percussion tone for the lungs c.flat--over bony & well-developed muscle tissue d.Tympany--over the stomach e. Hyperresnance--over the emphysematous lung tissue (return of sound is absent) f. dullness-over fluid or a solid mass |
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Assessment: chest- techniques used: Chest Auscultation
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a. used to detect air flow w/in the respiratory tract
b.breath sounds normally clear c.vesicular over peripheral lung fields |
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Assessment: chest- techniques used: four types of sounds ausculated over lungs
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a. lung sounds
b. adventitous sounds c. voice sounds d. whispered sounds |
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Assessment: chest- techniques used: Normal Breath sounds
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a. vesicular
b. bronchovesicular c. Bronchial |
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Assessment: chest- techniques used: Abnormal breath sounds
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a. crackles (rales)
b. fine c. coarse d. wheezes e. rhonchi f. pleural friction rub |
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Assessment: Heart assessment-techniques used
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a. inspection
b. palpation c. auscultation |
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Assessment: heart inspection
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a. check for neck vein distention (NVD) @ 30-45 degree angle
b. check the precordium for visible pulsations c. generally no visible pulsation, except @ the PMI |
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Assessment: Heart palpation
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a. precordium palpated for the presence of pulsations
b. systematic manner--cardiac landmarks--aorta, pulmonic, tricuspid, & mitral areas c. gently palpate w/4 fingers held together d. normal findings: 1. no pulsation over the aortic & pulmonic areas, w/pulsation at the PMI e. abnormal findings 1. thrills 2. fine,palable, rushing vibs over the right or left 2nd intercostal space 3.lifts or heaves 4. a rise along the border of the sternum with ea heartbeat |
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Assessment: Heart Ausculation
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a. closure of the four heart valves
b. listen systemically c. client should breathe normally d. listen first w/ diaphragm, listen to apical pulse for 1 full min e. then, listen w/the bell (for low pitch sounds-where problems are) f. focus on overall rate & rhythm of the heart & the normal sounds (S1 & S2) |
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Assessment: Abnormal Heart sounds
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a. S3
b. S4 c. murmurs d. bruits e. pericardial friction rub apex of heart is where you will hear tri-cuspid valve |
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Assessment: Abdomen- techniques used
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a. inspection
b. ausculation c. percussion d. palpation e. nine regions f. assessment |
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Assessment: Abdomenal inspection
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a. inspect for shape, color, symmetry, pulsatons, masses
b.should be evenly rounded or symmetric, w/out visible peristalsis c. in thin people--an upper pulsation may normally be visible (epigastric region) |
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Assessment: Abdominal Ausculation
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a. used to assess bowel sounds & vascular sounds
b. systemic manner |
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Assessment: Abdominal Auscultation
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*used to assess bowel sounds & vascular sounds-4 quad.
2.systematic manner a. warm stethoscope b.note frequency & character of bowel sounds c. clicks and gurgles d. usually every 5-20 sec e. listen for 5 full min, b4 deciding bowel sounds are absent |
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Assessment: Abdominal Percussion
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a. used to identiy fluid, masses or air'
1. tympany-over air filled organgs 2.dullness-over liver, tumor, fluid 3. dullness--ovr full bladder 4. normally--predominatley tympany |
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Assessment: Abdominal Palpation
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a. pads of fingers are used to palpatate w.\/ a light, gentle, dipping motion
b. watch face for nonverbal signs of pain during palpation c.systematic manner 1. normal--soft, relaxed & free of tenderness |
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Assessment: Nine Regions
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a. right hypochondriac
b. left hypochondriac c. right lumbar d. left lumbar e. right inguinal f. left inguinal g. epigastric h. umbilical i hypogastric |
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Assessment: abdominal assessment questions
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a. good time to talk about last BM?
b. Any problems with urination? c. abnormal abdominal finding 1. distension 2.absent, hypoactive, or hyperactive bowel sounds 3. increased or decreased tympany/increased dullness 4. rigidity 5. spasm, pain |
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Assessment: Peripheral Vascular Assessment- techniques used
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a. inspect for color, edema, rashes, ulcers (esp on heels)
b. compare size of legs and feet |
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Assessment: Peripheral palpation
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a. used to assess temp, pulses, edema, capillary refill
b. use pads of the index & middle fingers to palpate for strength & quality |
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Assessment: Radial Pulse
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a. rate, rhythm, volume
b. compare radial pulses bilaterally c. normal rate--60-100 beats per min if have problem with this use apical pulse Pulse scale 0=absent +1=thready, weak +2=normal +3=increased +4=bounding |
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Assessment: Muscle strength
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1. test bilateral hand grips
2. MAE equally? 3. Active ROM of all extreemities? 4. Any numbness or tingling? 5. test muscle strength & ability to follow commands 6. Homan's sign- pain in the calf- may be deep vein thrombosis 7. dorsiflex the foot & note pain in calf, if positive then report it 8. assess both legs |
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Assessment: Evaluate all
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1. IV lines
2. tubes 3. dressings 4. incisions 5 equipment 6. nursing process |
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