core exam 1

health assessment

systematic, critical thinking, patient's current and ongoing health status

systematic

do an assessment by systems - you want to preform from the head and work your way down

critical thinking

key to becoming a good nurse; use emotions

patient's current and ongoing health status

perform health history and current ongoing things (smoking, drinking, immunizations, family history); will lead us to ask more questions and think about more things

modifiable risk factors

smoking, drinking, diet, physical activity

non-modifiable risk factors

genetics, age, gender, race, birth defects

identify health promoting factors

sleep patterns, coping mechanisms, awareness of risk for heart disease, wearing sun screen

what should you look for when doing assessments?

physical, social, emotional, cultural, and environmental problems

physical problems

broken leg, cough, sob

social problems

not being able to communicate properly, social anxiety, tobacco use, financial issues

emotional problems

"have you had any recent life altering events?"

cultural problems

language barrier, diet preferences, spiritual/religious preferences

environmental problems

water, electricity, hazardous work environment, hurt on the job

types of assessments

initial (baseline), problem focused, emergency, ongoing reassessment

initial (baseline) assessment

performed within a specified time frame after admission to a healthcare agency

initial (baseline) assessment

establish a baseline for problem identification, reference, and future comparison

problem-focused assessment

ongoing process integrated with nursing care

problem-focused assessment

to determine the status of a specific problem identified in an earlier assessment

emergency assessment

during any physiologic or psychologic crisis

emergency assessment

to identify life threatening problems; to identify new or overlooked critical problems

ongoing reassessment

minutes to months after initial assessment

ongoing reassessment

to compare the patient's current status to baseline data previously obtained

initial assessment

everyone gets it

problem focused assessment

someone is complaining of sob - you only assess breathing

emergency assessment

sudden change in consciousness/condition; patient could be having a mental health crisis; focus on emergent issue

ongoing reassessment

ongoing with patient care

primary source of data

patient

secondary source of data

family members, other support people, previous healthcare professionals, electronic health care record, reports, labs, diagnostics, literature

subjective data

that the patient says, symptoms, when documenting it will be in quotations

objective data

can be seen and measures, signs, using your senses

methods of data collection

observing and interviewing

use your _____ to help observe patient data

senses

sight

facial expressions, discoloration

smell

fruity breath, infection, foul stool odor

fruity breath

diabetic ketoacidosis

touch

palpation of abdomen, pulse

hearing

wheezing/other breathing noises, bowel sounds

interviewing

be on patient's eye level, be in the right location, gather history and make a problem list

examining sequence

inspect, palpate, percuss, auscultate

abdomen examining sequence

inspect, auscultate, percuss, palpate

maslow's hierarchy of needs

physiological, safety, love/belonging, esteem, self-actualization

erickson's stages of development

important to organize and make sense of data

validate

allergies, vague statements, extreme abnormal findings

how to validate

double check data for accuracy, go back and clear up unclear statements, recheck vitals if they're extreme and abnormal

interpret

take information you have gathered and make a plan

how to interpret

is the data normal? is there any significance to the information? make a care plan

communication

ask open ended questions for information; closed ended questions for clarifying information

open ended questions

for information

closed ended questions

for clarifying information

documentation

tells a story, must be thorough and objective, never document personal judgement/opinion

guidelines for older adults

lifestyle, talking loud can be offensive, assistive devices, past surgeries, history, where they live, addressing pain, give them a restroom break

norms and ranges vary

across different lifespan groups

safety

freedom from danger, harm, or risk

nurses

middle man between physician and patient

neuro assessment safety

LOC, confusion, sensory perception deficit

physical assessment safety

vital sign changes, O2 stats, pain

functional changes assessment safety

respiratory distress, mobility, weakness

behavioral changes

mood, wandering, depression

joint commission

set guidelines/standards to accredit institutions

QSEN

set of competencies for maintaining and improving patient care

OSHA

guidelines for workplace safety

measures to enhance patient safety

PPE, housekeeping, disaster plans, staff safety trainings, incident reporting and root cause analysis, faulty equipment safety, effective communication

adverse event

results in harm to the patient

no-harm event

event that involves or reaches the patient, but does not cause harm

near miss

great catch; potential event or event that did not involve or reach the patient

sentinel event

event (not primary related to the natural course of the patient's illness or underlying condition) that reaches as a patient and results in death, permanent harm, or sever temporary harm

sentinel event

preventable/never should have happened

morphine

slow respirations- can cause respiratory distress

common safety concerns

falls, adverse drug events, healthcare associated infections (HAIs), seizures, restraints, wrong-site surgery, latex exposure

latex exposure

use powder free and latex free gloves, verify allergies/reactions often, hand hygiene

fall risk assessment

most important thing to prevent falls

fall priority action

fall risk assessment

fall risk assessment

fall risk ID/sign on door, patients gait;balance;LOC;mobility, medication that causes confusion/dizziness, clear floor, room exit safety measures, gait belts

adverse drug events

patient identification, verify allergies and reactions often, follow 6 rights of medicine administration

healthcare associated infections

hand hygiene, proper use of PPE, proper injection technique, disinfection, housekeeping, patient education

healthcare associated infections priority action

hand hygiene

seizure precautions priority action

protect patient's head

seizure precautions

pad side rails, remove items that can cause injury, loosen clothing, do not restrain, do nor place anything in pt mouth, place pt side lying, lower to floor, oxygen and suction readily available

restraints

physical, chemical, seclusion

physical restraints

ties, vests, mittens

physical restraints

don't tie restraint to moveable part of bed, tie under bed so restraints move with the patient

chemical restraints

sedative medication

seclusion restraints

confining patient to room involuntary (ex. locking a door from the outside)

when is it not appropriate to use restraints?

for convenience, as punishment, to prevent patient from leaving

wrong site surgery

sentinel event

wrong procedure

sentinel event

wrong patient

sentinel event

universal prevention protocols for wrong-site surgery

surgical site marking, surgical timeouts

code red

fire

RACE - R

rescue

rescue

evacuate patients in the immediate area- horizontally first, then vertically

RACE - A

alarm

alarm

activate alarm if not already sounding

RACE - C

contain

contain

close doors of patient; ensure fire doors have closed

RACE - E

extinguish or evacuate

extinguish or evacuate

extinguish only small;; fires (only if safe) using PASS; otherwise evacuate

PASS

Pull, Aim, Squeeze, Sweep

oxygen is

very flammable

you can turn off oxygen valve in room

not the main hospital one