NURS 210: Exam 1 - Chapters 1-10

chap 1-10 summary and key terms

What is the nursing process?

• Assessment = what data is collected

• Diagnosis = what is the problem?

• Planning = how to manage the problem?

• Implementation = putting the plan into the action

• Evaluation = did the plan work?

what does the joint commission require assessment of?

• physical

• self care

• environmental

• patient education

• discharge planning needs

What is HIPAA? What does it do?

how personal and identifiable information is protected

who follows HIPPA?

Health plans (HMOs, medicare, medicaid) and providers

what information is covered under HIPAA?

name, address, DOB, SSN, medical history, payment

What are the social determinants of health?

• neighborhood and built environment

• economic stability

• education

• social and community context

• health and health care

What must the nurse assess first when providing culturally competent health care to an Asian American patient?

The nurse's heritage-based cultural values, beliefs, attitudes, and practices

What is verbal communication?

words you speak, the tone used in conversation

What is nonverbal communication?

body language can be viewed negatively or positively physical appearance posture gestures eye contact voice touch facial expressions

What does SBAR stand for?

Situation Background Assessment Recommendation

what is the health history sequence?

1. Biographic data

2. Reason for seeking care

3. Present health or history of present illness

4. Past history

5. Family history

6. Review of systems

7. Functional assessment or activities of daily living (ADLs)

what is biographic data?

• name, address, age, birthdate, phone number

• gender

• race

• occupation

• primary language

Is a symptom subjective or objective?

subjective

past medical history examples?

• childhood illnesses

• accidents/injuries

• hospitalizations

• chronic illnesses

• operations

• immunizations

• allergies

What does OLDCART stand for?

Onset Location Duration Characteristics Aggravating factors Relieving factors Treatment

what are some aging changes for an older adult?

• address respectfully (do not use elder speak)

• pace (response time may be slower)

• physical limitations

• more information (they will have more history so may take longer)

• Therapeutic touch

when beginning an assessment what pneumonic do you use and what does it stand for?

A - acknowledge I - introduce D - duration E - explanation T - thank

What is palpation?

examination of the body using touch

what is percussion?

tapping the person's skin with short, sharp strokes to assess underlying structures

What is auscultation?

listening through a stethoscope

what is the diaphragm used for on a stethoscope?

listening to high pitched sounds

what is the bell used for on a stethoscope?

listening to low pitched sounds

what pneumonic do you use for general survey and what does it stand for?

A - appearance B - body structure M - mobility M - measurement

when assessing the patient using priorities what do you start with?

the first priority, Airway, breathing, circulation

what is aphasia?

impairment of language ability secondary to brain damage

what are some common concerns to look for in a patient?

• altered LOC (awake, sleep, coma)

• speech disorder

• mood and affect abnormalties

• anxiety disorders

• delirium, dementia, depression

• perception abnormalities

what is the mental status assessment pneumonic and what does it stand for?

ABCT appearance behavior cognition thought process

What is the Mini-Cog?

This consists of 3-item recall and Clock-Drawing Test (CDT)

• reliable, quick screen

• three item recall and clock drawing

• tests executive function

what are the types of intimate partner violence?

physical violence stalking sexual violence psychological violence/aggression

what are the types of older adult abuse and neglect ?

physical abuse sexual abuse psychological/emotional abuse neglect financial abuse

when are we mandatory reporters concerning abuse?

when an older adult or child is being abused

what are some barriers to treatment?

• poverty

• discrimination

• legal status

• lack of access to culturally appropriate care

What purpose do vital signs serve?

they reveal basic health condition and track changes

What is baseline? Why is it important?

baseline is the patients normal range of vitals, it is important because when doing vitals you want to know if there vitals are abnormal or if that is what they normally run

when do we obtain vitals?

• admission

• as ordered (routine)

• before/after certain medications

• before/during/after procedures

• when there is any sudden changes

Who is able to obtain vital signs?

delegation, this task can be delegated but it is the RN responsibility for knowing patient variations of "normal", baselines, and interventions

Where can temperature be measured?

-oral -axillary -rectal (most accurate) -tympanic

where is the most accurate temperature location?

rectal

what in the body maintains temperature?

the hypothalamus feedback system

what is temperature influenced by?

Diurnal cycle, menstruation, exercise, age, surgery, exposure to cold/hot, infection, and neurological diseases

where is the probe inserted during an oral temperature? why?

the sublingual pocket, it has rich blood supply from carotid arteries

when taking oral temperature if the patient has drank or ate how long should you wait before taking the temp?

15 minutes

when taking oral temperature if the patient has smoked or vaped how long should you wait before taking the temp?

2 minutes

what is considered the standard average temperature?

98.6

what is the normal resting heart rate for adults?

50-90 bpm

what is the normal force for a pulse?

2+

what are the normal respirations for an adult?

16-25

if the heart rate is irregular how long should you count?

60 seconds

What is normal blood pressure?

120/80 mmHg

what is the medical term for a resting heart rate less than 5 beats/min?

bradycardia

what affects BP readings?

age, race, sex, exercise, gender

What is the top number in blood pressure?

systolic

what is the medical term for low blood pressure?

hypotension

What is orthostatic hypotension?

A drop in blood pressure due to a sudden change of posture.

what is the clinically acceptable SpO2 value?

95% and above

where can you check a patients oxygen level?

ear lobe phalanges

What is the max pressure felt on the artery during LEFT ventricular contraction?

systolic pressure (think max pressure and systolic)

What is the resting pressure that blood exerts constantly during contraction?

diastolic

when listening for sounds in blood pressure what will you hear during the systolic period?

tapping

when listening for sounds in blood pressure what will you hear during the diastolic period?

silence

when recording orthostatic hypotension when do you record the patients blood pressure, how many times?

record BP first lying down, sitting up, and standing 3 times

when checking BP on thigh how should the patient lay?

in prone position

When doing a rectal temperature what are some points to remember?

use lube do not force in use only when you must and are indicated use when pt has had a stroke, shock, oral or facial injury

tympanic temperature characteristics?

• infrared emission on tympanic membrane

• gently place into ear canal

• pull pinna up and back

• tympanic may not be as accurate

what is pulse?

palpable flow felt in the periphery as a result of pressure wave generation from stroke volume

what is the rate of pulse?

number of beats per minute

what is the rhythm of pulse?

regular or irregular

what is the force of pulse and what are the different levels?

• stroke volume 3+ full/bounding 2+ normal 1+ weaky/thready 0 = absent

when would we use a doppler?

when we cannot palpate pulse

what should you do when recording respirations?

do not bring awareness to what you are doing

What is blood pressure?

force of blood against vessel walls

what does hypertension increase risk for?

heart disease, CVA, and heart failure

what can affect blood pressure?

time of day genetics exercise obesity emotions stress

what is ventricular contraction describe? systolic or diastolic

systolic

what does elastic recoil describe? systolic or diastolic

diastolic

what can cause an inaccurate blood pressure reading?

the size of the cuff and where it is placed

how should the patient be positioned when taking BP?

feet flat on the floor if sitting relaxed or laying

how long should the patient be in supine to check orthostatic blood pressure before sitting them up?

3 minutes

what do you do for the patient that is too weak or dizzy to stand and you need to check their orthostatic BP?

• assess BP supine and then sitting with legs dangling.

• Record pulse rate and rhythm, noting whether pulse is regular.

how does checking oxygen saturation work?

Light sensor detects and measures relative amount of light absorbed by unoxygenated hemoglobin

what are the normal ranges for oral temperature?

35.8 - 37.8 C 96.4 - 100.4 F

what are the normal ranges for rectal temperature?

• 0.4 - 0.6 C 0.7 - 1 F

what is the normal range for respirations?

16-25 breaths/min

what is the normal range for pulse?

50-90 bpm

what is the normal range for oxygen saturation?

95-100%

what is the term for abnormally high body temperature?

hyperthermia

what is the term for abnormally low body temperature?

hypothermia

what is a slow respiratory rate?

bradypnea

what is a fast respiratory rate?

tachypnea

what is the term that means to stop breathing?

apnea

What is a slow heart rate called?

bradycardia

What is a fast heart rate called?

tachycardia

what is an abnormal rhythm of the heart beat?

dysrhythmia

what is abnormally high blood pressure ?

hypertension

what is abnormally low blood pressure?

hypotension

what are some aging characteristics to do with vitals?

• Less likely to have fever, more likely to be hypothermic.

• irregular pulse

• stiff arteries, rigid arteries

• shallow respirations

• decreased vital capacity, decreased inspiratory reserve volume

• increased BP

• Sweat gland activity also diminished.

• Aorta and major arteries harden/stiffen which increases systolic pressure.

normal blood pressure ranges:

<120/<80 mmHg

~90-120/60-80 mmHg