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67 Cards in this Set

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This is Karla's lecture right after test 1. we talked about the nursing process and purposes.4 steps were assessment, anaylsis,planning,Implementation, Evaluation. Now we are going to discuss ...
Nursing Process Observation.
Quick, what is the first thing the nursing process begins with each visit to a patient's room?
the process b/g w/ an assessment OR gathering AND analysis of information about the client's health status.
whats the next thing the nurse does?
makes clinical judgements about the client's response to health problems, defined as NURSING DIAGNOSIS. The nurse performs all planned interventions in an effort to improve their health.
you can compare steps of problem solving, the scientific method, and nursing process. In problem solving, you encounter a problem, in scientific method, its the problem, and in the nurse medical model, its ...
In problem solving you collect data, in scientific method, its collecting additional facts, in nursing process, its
still assessing
in problem solving there is carrying out the plan, in nursing process its...
in problem solving there is the evaluating plan in new situation, in nursing there is...

Doing an assessment isn't doing anybody any good if the communication of it isn't any good. How do we communicate the assessment correctly?
Document the care plan! This is how we communicate this information.
Our data collections should never contain interpretations
that is subjective information. Just ...
describe what you see. Don't put interpretations
What is the difference b/t observations and statements made?
observations are objective
statements by others are subjective
What can we learn by being observant in our assessment?
tell something by their color
tell an idea of age
tell if in pain, hydrated like sunken eyes
turgor of the skin
body lanuage ie emotonal stage
general nutritonal status
see perspiration
efforts to breathe
crying is a general observations
bruises, amputations,
see can see their clothes, gromming.
what is LOC
level of consiousness

how alert they are
don't confuse this w/ orentation, how awake or alert someone is.
Oxygen status
emotional status
we hit all these in general assessments.
Every time you have an intervention w/ a patient you are going to make assessments. like ...
color, etc
we will learn to do a head to toe assessments but we will document this we will put it in ...
a format that puts the data in system by system format.
If you put the information in a same order and stict to it, your less likely to miss something.
we will be doing a physical assessments in the hospital and document those assemssments in the ....
narrative fashion and instructor will give feedback on that.
when would be a good time to look at the patient's skin?
when we give a bath or shower.
when would be a great time to listen to their lungs?
when you get them up to go to the commode first thing in the morning.
why do we do an assessment early in the day, like first thing?
so we can establish a baseline and therefore be able to detect any changes during the day. we need that early physical assessment.
we need to get the patient ready for breakfast first, then what?
getting the physical assessment.
Karla mentions 4 techniques for Physical assessments. what are they?
palpation...use of hands
percussion...tapping body

No percussion assessments yet.
do you clean stethscopes b/t patients?
yes you do!
you need good light to do a physical assessment. so what?
ask them if I can turn on the lights so I can do a good assessment. You also cannot do an assessment thru the gown. You have to provide for privacy but have to see what your doing.
You need to see their skin and find landmarks to to know where you are. We are always looking for ...
symmetry in things like symmentry in pulses, are they the same on both sides. A pedial pulse is a PERIPHERAL PULSE. will tell us if the pulse is the same on both sides of the body. So are not going to count a pedial pulse, we're looking for symmentry!
Where would we go or get a rate? Radial or ...?
get the pulse rate at the radial. we will touch, see, smell, use our senses here.
so how to start:
enter the room
wash your hands
introduce yourself and what?
identify the patient. look at charts, their bands, or say? "Can you tell me your name?" Provide privacy, shut the door AND the curtain. Always knock b/f going in and tell them what I'm going to do in lay terms.
what have we missed so far?
always offer for them to empty their bladder. Patient comfort! Don't let the patient shiver! This affects their temperature. Another reason to only uncover on part of the body at a time.
don't just march in and turn off the tv, ask first to turn the tv down. you need a quiet enviroment. We also don't want interuptions, if any diagnostic tests will be coming into the room to interupt this. Clothing ...
have a gown on, OR try to catch them before getting their clothes on for the morning.
We need to take care of the patient physically and psycologically. what does this mean?
physically by going to the bathroom, getting comfortable
psycologically asking permission to get good light, to turn down tv, to get permission to do the assessment, to provide for their privacy. etc. Why its important to make them comfortable as possible is because 1/2 thru they may just want to blow it off!
Don't forget that the patient is a human so talk to them, why?
most students focus too much and forget about the fact the subject is a human b/c the instructor is there watching us do this. So talk to the patient some.
we need to be professional about this whole thing. how do you be professional?
Be open, receptive, answer any questions they might have, tell them about my findings,
As long as you remain professional, the patient will stay comfortable with you looking at their bodies, especially because of what?
their gender! your looking at their bodies! Its when I don't feel comfortable they pick up on that!
When you go into a patient's room and see something you don't know what it is what do you do?
find out about it. find out about it, be knowledgable about it. IVs? look at it! look at the solution and make sure it the correct bottle! Look at the tubing, the patient IV site, is it bruised? Bleeding? I have to look!!! ck the solution, the rate set at,is it correct?
the patient is on oxygen. and so many liters per minute, and prongs, etc. so what do you do?
go in and verify settings. is the prong on the patient? what is the flow rate at? follow the tube to the wall and check it all out!
what about a feeding tube? check the tube and rate. I won't be adjusting the rate or pump, just checking it. what about the nasal gastric tube?
that its working, its connected, what the drainage look like, how much is coming out? is it bloody, green? observing that.
what are SCGs?
Compression devices, goes on their legs. so, check if they are on! suppose they are off, they took them off!
CPM, continual Path of motion machine. know what it is and if its suppose to be there. what about a foley catherture?
look at the tubing, look at the urine, is it clear, obstructive? I don't and wont change any of it, just inspect it.
VS is part of the physical assessment, and touch is important, get the temp of their skin, if they are perspiring. what else?
see if the patient can follow commands or not.
What is hypopnia? Decreased ability to breath. So what?
So you have to sit up to breathe. Even to sleep, can't lay flat b/c gravity pushes on the lungs when laying down, so you sit up.
Landmarks, mid clavicalar line, both r and left mid clavicular line. what are the costal margins?
Where the ribs end. Think the V on both sides below the Xiphoid Process.
What is Costal Vertebral Angle? or CVA
historys of physicals
checking for costal vertebral tenderness, the kidneys are behind that is tapped looking for kidney tenderness.
Trachea sounds. is there a difference b/t in and out sounds?
no. they are the same.
The trachial sounds are only anterior! Remeber this. what about brachial?
expirations are longer than the inspirations.
we hear bronchovesicular sounds, etc. make sure you hear all the inspirations and expirations b/f ...
moving your stethescope. the bronchovisicsular sounds are breezy, pitch lower than broncial sounds, in and out are the same duration.
the trach and bracial sounds are high pitched loud and hollow. but the trach has a ...sound
a harsh sound.
the lower lung sounds are called the vesicular sounds. they are soft, breezy, and ...
inspiration is about 3 times longer than expiration.
so what is the landmark for the back broncial sounds?
Apexes at the C7 vertebra!
Where are the 2 back bronchovesicular sounds picked up?
at the lateral limits
the medium scapular border. that means right at the edge of the scapulas. REMEMBER!
Where are the 2 Vesicular sounds picked up?
at the lung bases...10th spinous process. REMEMBER!
Where you going to pick up the anterior tracheal sounds?
2 to 4 cm above the inner 3rd of each clavicle.
Hea, the sterum is a long bone with 3 major parts. What are they top to bottom?
there is a place at the very top called the suprasternal notch.
Manubrium of the sternum
Manubriosternal angle (angle of Louie)
Body of Sterum
Xiphoid Process
Costal Angle
Where you going to pick up the Bronchial sounds? What landmark?
over the manubrium...POSTERLY...b/t C7 & T3
Bronchovesicular is picked up anteriorly...over the what?
Over the 1st and 2nd intercostal spaces. Posteriorly just to the right & left of the T3 & T5 vertebrae.
Do vesicular sounds sound like bronchial sounds?
no. bronchial sounds are loud, high pitched, and hollow. like when someone blows thru a pipe. Bronivesvucular are lower sounding. Vesicular sounds are low pitched. and breezy.
What is a trick to listening to vesicular breathing?
don't try and get them over the scapula. So, you have to know where the scapula is! So the listening areas are like BIG Jays in Reverse to each other!
the plural rub is
the grading sound of inflammed plural walls of the lung walls, the plural cavity.
Styder is a child who has the crup. a forced crowing sound. What is any abnormal breast sounds called?
adventitious sounds! The nurse auscultates for normal breath sounds and abnormal lung sounds or adventitious sounds.pp.720
what does auscultated mean?
to listen, to listen, to listen to
crackle? Does it clear with coughing! Did it clear with a cough? What do you do if you hear crackling?
Document that you heard crackling. Pneumonia has a solid sound.
Wheezes, crackles, Plurral rub, Stidor are all adventitious sounds.
What causes this sound?
air going thru moisture
air going thru narrow airways
inflammed linings
KNOW THE HANDOUT ON HEART SOUNDS. Assessing Normal Heart Sounds.
Remember: listen to S1 and S2. what is actually happening ...What is the systole sound?
the closing of the atrioventricular (tricuspid & mitral) valves produce the S1 sound- the lub of lub/dub.
Where is the best place to hear S1 sound? To auscultate for S1?
4th intercostall space near left sternal border & 5th intercostal space near midclavicular line
What is the S2 sound?
the dub of lub/dub...occurs at the END of systole when the semilunar (aorta & pulmonic) valves close.
Where is it best to hear the S2 sound, to ascultate the S2 sound?
at the right or left sternal border at the 2nd intercostal space. If they have Tachycardia, anything weird, papate for a pulse like at the carodid during ascultation, you'll hear S2 immediately after feeling the pulse!
How long do you count a difficult or atrial heart rate for?
one full minute.
pp 723 The apical impulse is what?
point of maximal impulse (PMI). Look, its just right by an inch of the left tit.
When the patient has a pulse deficit, what is going on?
the radial pulse is slower than the apical pulse b/c ineffective contractions fail to send pulse waves to the periphery. So, it takes 2 people to get these and coordinate this together.
what would cause a pulse deficit?
the heart was beating irregularly, not have a full contraction, not a full wave. So, you count apical and radial and subtract and that would be the deficit pulse.