ATI - Health Assessment Final Exam ?

Eye Charts

1. Snellen

- Stand 20 ft away

2. Rosenbaum

- Stand 14 inches away

SAFTEY IS BIG ON THIS ATI!

Factors that affect the patient's ability to protect themselves

- Age

- Mobility

- Cognitive and sensory awareness

- Emotional state

- Ability to communicate

- Lifestyle

- Safety Awareness

Fall Risk

- Decreased visual acuity

- Generalized weakness

- Urinary frequency

- Gait and balance problems (Cerebral palsy, MS, Parkinsons)

- Cognitive dysfunction

- Medication side effects

Seizure precautions

- Have oxygen, suction, oral airway at bedside

- Padded side rails

- Saline locked IV for immediate access (High risk patients)

- Rapid intervention to maintain airway patency.

- Clutter free environment

- Make sure everyone (family too) knows that if pt. has a seizure, to not put anything in their mouth during seizure. *Only thing that would go in mouth during seizure is airway for status epilepticus.

- During seizure do not restrain pt. Lower pt. to floor or bed and protect pt. head. Remove nearby furniture. Put patient on side with head flexed slightly forward if possible and loosen his clothing.

How would you help prevent falls for a patient with orthostatic hypotension?

- Avoid getting up to quickly

- Sit on the side of the bed for a few seconds prior to standing

- Stand at the side of the bed a few seconds prior to walking

Seclusion and Restraints

- When everything else fails (orientation to environment, family member, sitter, diversional activities, electronic devices) is when you use restraints.

- Provider must prescribe after seeing the patient face to face

Provider prescription for restraints must include what?

- Reason for restraints

- Type of restraints

- Location of restraints

- How long to use restraints

- Type of behavior that warrants restraints

- Prescription only last 4 hours for an adult. Providers may renew these prescriptions with a maximum of 24 consecutive hours.

Restraints in an emergency situation

- When there is an immediate risk to the patient or others, nurses may place restraints on patient.

- The nurse must then obtain a prescription from the provider ASAP, usually within 1 hour.

Nursing Responsibilities for patients in restraints

- Explain the need for restraints to pt. and family. They are for safety and are temporary.

- Ask pt. or guardian to sign consent form.

- Assess skin integrity and provide skin care according to hospital protocol, usually Q2.

- Offer fluid and food.

- Provide means for hygiene and elimination.

- Monitor Vitals

- Offer range of motion exercises of extremities.

- Pad bony prominences to prevent skin breakdown.

- Use quick release knot to tie the restraints to the bed frame where they will not tighten when raising or lowering the bed.

- Fit 2 fingers b/w restraints and patient.

- Remove or replace restraints frequently to ensure good circulation to the area and allow for full range of motion to the limbs.

- Never leave pt. alone without restraints.

Fire Response - RACE

R - Rescue and protect patients close to fire by moving them to a safer location. Let patients who can walk, walk.

A - Alarm Activate alarm

C - Contain the fire by closing doors and windows and turning off any sources of oxygen and electrical devices. Vent. pts. who are on life support with a BVM.

E - Extinguish fire

How to use fire extinguisher - PASS

P - Pull the pin

A - Aim at base of fire

S - Squeeze handle

S - Sweep extinguisher from side to side.

State licensing boards

Ensure that health care providers and agencies comply with state regulations.

The Joint Commission

Sets quality standards for accreditation of health care facilities.

Medicare

For patients older than 65 or those with permanent disabilities.

Medicaid

For patients who have low income.

Preventative health care

Educates and equips patients to reduce and control risk factors for disease.

Examples

- Programs that promote immunizations

- Stress management

- Occupational health programs

- Seat belt use

Primary Health care

Emphasizes health promotion and includes prenatal and well-baby care, family planning, nutrition counseling, disease control.

Sustained partnership between patient and provider.

Directed toward promoting health and preventing development of disease process or injury

Examples

- Office/clinic visits

- Community health centers

- Scheduled school or work-centered screenings (vision, hearing, obesity)

- Immunizations

- Smoking cessation

- Diet

Secondary Healthcare

The diagnosis and treatment of acute illness and injury.

Focus on screening for early detection of disease with prompt treatment of any found.

Examples

- Care in hospital settings (inpatient & ER)

- Diagnostic Centers

- Emergent Care Centers

- Screenings

- Well visits

- Pap Smears

Tertiary Healthcare

AKA acute care, involves the provision of specialized and highly technical care.

Begins after the illness is diagnosed.

Examples

- ICU

- Oncology

- Burn Centers

- PT

- Rehab

- Medication

Ethics

The study of conduct and character

Code of Ethics

A guide for the expectations and standards of a profession

Ethical Principles

Standards of what is right or wrong with regard to important social values and norms

Are for individuals, groups of individuals, and societies

Bioethics

Applies ethics to health and life

Includes dilemmas such as:

- Stem cell research

- Organ Transplant

- Gender reassignment

Values

Personal beliefs about ideas that determine standards that shape behavior.

Morals

Personal values and beliefs about behavior and decision making.

Basic Principles of Ethics

- Advocacy: Support patient

- Responsibility: respect patient and follow through on promises

- Accountability: Ability to answer for ones own actions

- Confidentiality: Protection of privacy

Ethical Dilemma

Problems that involve more than one choice and stem from differences in the values and beliefs of the decision makes.

A problem is an ethical dilemma when...

1. A review of scientific data is not enough to solve it

2. It involves conflict between two moral imperatives

3. The answer will have a profound effect on the situation and the client.

Example

A doctor gives a nurse an order to give a pt meds. The pt does not want the meds, the doctor says give to her anyway.

Ethical decision making

A process that has a balance between science and morality.

Ethics Committees

Address unusual or complex ethical issues

Example

- If you meet challenges at work go to the EC.

Autonomy

Patient's right to make their own medical decision, even when it might not be in their best interest.

Beneficence

Action that promotes good for others without any self-interest

Fidelity

Fulfillment of promises

Justice

Fairness in care delivery and use of resources

Nonmaleficence

Commitment to do no harm

Veracity

Commitment to tell the truth

Civil law Aka Private law

Protects individual rights

Tort law relates to nursing

Types of torts

1. Unintentional Torts

A. Negligence - A nurse fails to implement safety measures for a client who has fall risk.

B. Malpractice - Unintentional. Give wrong med and patient dies.

2. Quasi-intentional torts

C. Break HIPPA

D. Defamation of character

3. Intentional Torts

A. Assault - One person makes another person fearful. Then nurse says "Be quiet or I will hit you"

B. Battery - Wrongful/intentional physical contact - The patient is still loud and you hit her.

C. False imprisonment - holding patient against their will

State Laws

Each state has enacted statutes that define the parameters of nursing practice and give the authority to regulate the practice of nursing to its state board of nursing.

Boards have the right to ...

- Adopt rules and regulations that assist nursing practice.

- Issue and revoke nursing license.

- Set standards for nursing programs and further delineate the scope of practice for, RNs, PNs, and advanced practice nurses.

Nurses role in informed consent

Witness the clients signature on the informed consent form and ensure that the provider has obtained the IC responsibly.

Nurses base practice on established standards of care or legal guidelines such as

1. The Nurse Practice Act of each state.

2. Published standards of nursing practice from professional organizations.

- ANA (American Nurses

Association)

- AACN (The American Association

of critical care nurses)

3. Health care facilities policies and procedures. They establish detailed information about how the nurse should provide care/respond while performing patient care.

Advance Directives

Communicates a patient's wishes regarding end-of-life care should the patient be unable to do so.

3 Types

1. Living Will - legal document that expresses the patients wishes regarding medical treatment in the even that the patient can't make those decisions.

2. Durable Power of Attorney for Health care - A document patients sign to have a proxy make the decisions for them if they are unable to.

3. Provider's Orders - Pt. gets CPR unless DNR or AND.

Elements of Documentation

1. Factual

A. Subjective Data - Symptoms -

Direct quotes - not measurable.

Should be supported by objective

data.

B. Objective Data - Measurable.

What the nurse sees, hears, smells.

Labs

2. Accurate and Concise

3. Complete and Current - Don't pre chart

4. Organized

Flow charts

Show trends in vital signs, blood glucose levels, pain level, and other frequent assessments.

Narrative Documentation

Records information as a sequence of events in a story-like manner

Charting by Exception

Standard forms that identify norms and allows selective documentation of deviations from those norms.

Problem-oriented medical records

Organized by problem or diagnosis and consist of a database, problem list, care plan, and progress notes.

Examples - SOAP, PIE, DAR

The nursing process is

- Dynamic

- Continuous

- Patient-Centered

- Problem solving

- Decision making framework

Nursing Process

A - Assessment/Data Collection

D - Diagnosis

P - Planning

I - Implementation

E - Evaluation

Assessment

The systematic collection of information about clients present health status to identify needs and additional data to collect based on findings.

Subjective (what pt tells nurse-symptoms) date collected during history.

Objective data during (signs) during physical examination

Diagnosis/Analysis/Data Collection

Use critical thinking skills (a diagnostic reasoning process) to identify pt health status or problems, interpret or monitor the collected database, reach an appropraite nursing judgement about health status and coping mechanisms, and provide direction for nursing care.

Planning

Establish priorities and optimal outcomes of care they can readily measure and evaluate.

Use guidelines such as Maslow hierarchy to figure out what is priority.

End product of planning step is NCP (Nursing Care Plan)

Implementation

Nurses base the care they provide on assessment data, analysis, and plan of care developed in the previous steps.

Step where nursing action takes place

Evaluation

Nurse evaluates patients response to nursing interventions and form a clinical judgement about the extent to which patients have met the goals and outcomes.

Continuous, Modify or Stop

A critical thinker.....

1. Prioritizes

2. Explores various courses of action

3. Keeps ethics in mind

4. Determines appropriate outcomes

When does discharge planning start?

Upon patient admission

Chain of infection

Causative agent

- Bacteria, virus, fungus, prion, parasite

Reservoir

- Human, animal, food, organic matter on inanimate surfaces, water, soil, insects

Portal of exit - means for leaving host

- Respiratory tract - Droplet, airbone

- TB

- GI - Hep. A, Shigella

- Skin - Herpes, Varicella

- Blood - HIV

Mode of Transmission

- Contact

- Droplet - sneezing, coughing, talking

- Airborne

- Vector - through insects - lyme disease

Portal of Entry

- Entry to the host

- Might be same as portal of exit

Susceptible host

- Compromised defense mechanisms (Immunocompromised, breaks in skin), no sleep, ect, leave host more susceptible to infections.

Stages of infection

Incubation

- Interval between pathogen entering the body and presentation of symptoms

Prodromal Stage

- Interval from onset on general symptoms to more distinct symptoms.

- Pathogen is multiplying

Illness Stage

- Symptoms specific tot eh infection occur..

Convalescence

-mAcute symptoms disappear. Total recovery could take days to months.

Airborne precautions require

- Private room

- Particulate Respirator (N-95) mask for caregivers and visitors

- Negative pressure airflow

- Full face (eyes, nose, mouth) if splashing is a possibility

Droplet precautions require

- Private Room

- Mask

Contact precautions require

- Private room

- Gown

- Gloves

In a primary survey and/or an emergency situation use ABCDE

A - Airway - Establish a patent airway and protect the cervical spine

B - Breathing - After achieving patent airway, assess for presence and effectiveness of breathing

C - Circulation - After ensuring adequate ventilation, assess circulation (Check pulse)

D - Disability - Perform a quick assessment to determine the client LOC.

E - Exposure - Quick physical assessment to determine the patients exposure to adverse elements such as heat or cold.

*Always complete this before first aid

Sprains - RICE

R - Refrain from weight bearing

I - Ice

C - Compression dressing (to decrease swelling)

E - Elevate

Heat stroke - symptoms and treatment

Symptoms

- Hot

- Dry skin

- Hypotension

- Tachypnea

- Tachycardia

- Anxiety, Confusion

*The patient DOES NOT sweat

Treatment

- Remove pt. clothes

- Place ice packs over major arteries (axillae, chest, groin, neck)

- Immerse pt. in a cold-water bath

- Wet body then fan with rapid movement of air

- Do not allow pt. to shiver, if shiver, cover with a sheet

Bed and Patient Positions

Semi-Fowler's - 15 to 45 degrees

Fowler's - 45 to 60 degrees

High Fowler's - 60 to 90 degrees

Supine - On back

Prone - On stomach

Orthopneic - Pt. sits in the bed or at bedside with a pillow on over bed table, which is across patients lap. He rest his arms on the over bed table to allow for chest expansion.

- pt. with COPD

Trendelenburg - Entire bed is tilted with the HOB lower than the foot of bed

- Facilitates postural drainage and venous return

Reverse Trendelenburg - Bed tilted with foot of bed lower than HOB

- Promotes gastric emptying and prevents esophageal reflux.

Modified Trendelenburg - Pt. is flat with legs above level of heart

- Helps prevent hypovolemia and facilitates venous return

3 Types of Prevention

1. Primary

- Addresses the needs of healthy patients to promote health and prevent disease with specific protections. It decreases the risk of exposure to disease

Examples

- Immunization programs

- Child car seat education

- Nutrition/Fitness Activities

2. Secondary

- Focuses on identifying illness, providing treatment, and conducting activities that help prevent a worsening health status.

Examples

- Early Detection = treatment of DM

3. Tertiary

- Aims to prevent the long-term consequences of chronic illness and to support optimal functioning

- Begins after and injury or illness

Examples

- Prevention of pressure ulcers after a spinal injury

- Promoting independence after TBI

- Rehabilitation center

- Referral to support groups

Cognitive learning

Requires intellectual behaviors and focuses on thinking. It involves knowledge, comprehension, application, analysis and using that analysis (new info) for a new outcome.

Affective learning

Involves feelings, beliefs and values. Hearing the instructors words, responding verbally and nonverbally ect.

Ex. Patient learns about the life changes necessary for managing DM and then discusses their feelings about having diabetes.

Psychomotor learning

Gaining skills

Ex. Patient demonstrates how to prepare insulin injection.

Erikson

Piaget

Therapeutic Communication

Helps develop rapport and trust.so patients feel comfortable telling their story.

Begin with purpose of interview, gather information them conclude by summarizing findings.

Active listening

Show patients that they have your undivided attention.

Open ended questions

Used to encourage patients to tell story in their own way.

Clarifying

Questioning patients about specific details in greater depth or direct them toward relevant part of their history.

Back channeling

Use active listening phrases such as "Go on" and "tell me more" to convey interest and to prompt disclosure of the entire story.

Probing

Ask more open ended questions such as "What else would you like to add to that?" to help obtain comprehensive information.

Close ended questions

Ask question that require yes or no answers such as "Do you have pain when you sleep?"

Summarizing

Validates the accuracy of the story

What order do you do physical in?

1. Inspect

2. Palpate

3. Percuss

4. Auscultate

**Only exception is abdomen, you inspect, auscultate, percuss and palpate as to not alter bs.

Percussion

The denser the tissue, the quieter the sound. It can help you locate organs or masses, find their edges and estimate their size.

1. Direct - Striking body to elicit sound

2. Indirect - Place your hand flat on the body, as the striking surface for sound production.

3. Fist - Helps identify tenderness over the kidneys, liver and gallbladder.

Pulse provides information about ___________

Circulatory status

Blood Pressure

Reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relaxation (diastole) of the heart.

SBP occurs during ventricular systole of the heart, when the ventricles force blood into the aorta and pulmonary artery and it represent the maximum amount of pressure exerted on the arteries when ejection occurs.

DBP occurs when ventricles relax and exert minimal pressure against arterial walls, and represents the min. amount of pressure exerted on the arteries.

Pulse - Physiologic Responses

ANS - Controls heart rate

PNS - Lowers heart rate

SNS - Raises heart rate (Fight or flight)

Factors leading to tachycardia (pulse over 100)

- Exercise

- Fever

- Meds - Epi, albuterol

- Acute pain

- Hyperthyroidism

- Hypoxemia

- Hypovolemia

- Shock

- Heart Failure

- Hemorrhage

What monitors carbon dioxide levels of the blood?

Chemoreceptors in the carotid arteries and aorta.

Rising carbon dioxide levels trigger the respiratory center of the brain to increase the respiratory rate. Increased respiratory rate = rids the body of excess carbon dioxide.

Ventilation

The exchange of oxygen and carbon dioxide in the lungs. Measure ventilation with respiratory rate, rhythm, and depth.

Diffusion

The exchange of oxygen and carbon dioxide between the alveoli and the RBC. Measure with pulse ox

Perfusion

The flow of RBC to and from the pulmonary capillaries (to alveoli where gas exchange happens)

What determines your BP?

- Cardiac Output

- Systemic (peripheral) Vascular Resistance (SVR)

Cardiac Output is determined by

- Heart Rate

- Contractility

- Blood Volume

- Venous Return

*Increase in any of these = Increase in CO and BP

*Decrease in any of these = Decrease in CO and BP

Systemic Vascular Resistance

Reflects the amount of constriction or dilation of the arteries, and diameter of blood vessels.

*Increase in SVR = Increase BP

*Decrease in SVR = Decrease BP

BP Classifications

Normal - 120/80 or less

Pre-HTN - 120-139/80-89

Stage 1 HTN - 140-159/90-99

Stage 2 HTN - Greater than 160/Greater than 100

Hypotension (systolic less than 90) can be a result of what?

- Fluid depletion

- HF

- Vasodilation

Health Assessment Steps

A

Delicious

P

I

E

Assessment-collecting subjective (symptoms, how the persons feels, ect) and objective (facts, temp, BP, what you see) data

Diagnosis - nursing diagnosis

problem + etiology + manifestations

Planning - Determine outcome criteria

Implementation - Interventions, carry out plan

Evaluation - Assess outcome criteria. Has it been met?

COLDSPA

C-Character - How does pain feel? Sharp? Dull?

O - Onset - When did pain start?

L - Location

D - Duration

S - Severity - 1-10

P - Pattern - what makes it better or worse?

A - Associated factors - Other symptoms it affect. Does it make it hard to sleep, walk, ADL?

Factors that contribute to BP

1. Cardiac output - The more blood the heart pumps, the greater the pressure in the blood vessels

Ex. BP increases during exercise.

2. Peripheral vascular resistance - Pt with circulatory disorders have higher BP

3. Circulating Blood Volume - Increase in BV=Increase in BP

-Sudden decrease in BP may indicate sudden blood loss, as with internal bleeding.

4. Viscosity - When blood becomes thicker, the pressure in blood vessel increases.

5. Elasticity of vessel walls - Increase in stiffness of vessel walls = increase in BP

Blood flow through heart

Right Side Mission - To get blood to lungs (pulmonary)

1. Blood enters superior and inferior vena cava. This blood is unoxygenated because it is coming from the body. It needs oxygen.

2. Goes to the R. atrium.

3. The tricuspid valve (Tri before you bi) opens for blood to shoot through to the R. Ventricle.

4. Blood then in R. ventricle goes to pulmonary valve and shoots out pulmonary artery.

Left Side Mission - To get blood to body bc it needs oxygenated blood.

5. Blood enters through pulmonary vein.

6. Blood is now in left atrium (A. always on top)

7. Blood crosses through the bicuspid valve

8. Blood now in L. ventricle.

9. L. ventricle contracts and shoots through aortic valve to body.

Cranial Nerves

1. Olfactory - one nose

2. Optic - two eyes

3. Oculomotor - test three things (1. Shine light 2. Move light towards pt Accommodation 3.

4. Trochlear

5. Trigeminal - try not ti bite my 5 caret ring

6. Abducens - 6 pack - need peripheral vision to look at 6 pack

7. facial - smile, frown

8. Acoustic - whisper into ear - Big 8 earrings

9. Glossopharyngeal - Fine-nine. A fine glossy hair makes me gag - testing gag reflex

10. Vagus - Vagus - X (10) rated. stick tongue out - Vegas = oh la la

11. Spinal Accessory - Raise shoulders. Stranger things = 11

12. Hypoglossal - pt sticks out tongue and moves it side to side

Cranial Nerves - sensory, motor or both

Some

Say

Marry

Money

But

My

Brother

Says

Big

Brains

Matter

Most

S=Sensory

M=Motor

B=Both

Rinne Test

Place a vibrating tuning fork firmly against the mastoid bone. Have the patient state when he can no longer hear the sound. Note the length of time that the patient heard the sound (Bone conduction)

Then move the tuning fork in front of the ear canal. When the patient can no longer hear, note that (air conduction)

*Air conduction should be longer than bone conduction (2:1)