SG QUIZ 1 FUNDS

Prof Mark ;Based on Class 1 Class 2

Be able to define & explain Health

Health is complete physical, mental and social well-being and not merely the absence of disease or injury; the overall condition of one’s body and mind

Be able to define and explain the concept of illness

illness

• Abnormal process in which any aspect of a person’s functioning is diminished or impaired compared with his previous conditioned

Be able to define and explain the concept of Health Promotion

Activities that help persons maintain or enhance their present level of health and reduce their risk of developing certain diseases

Be able to define and explain the concept of illness prevention

Health education programs or activities directed toward protecting patients from threats or potential threats to health and minimizing risk factors

What are risk factors? What are some examples?

Internal or external variable that makes a person or group more vulnerable to illness or an unhealthy event

• Genetic and physiological factors

• Age

• Environment

• Lifestyle

What is patient safety and why is it important?

Avoidance and prevention of patient injuries or adverse events resulting from processes of healthcare delivery

• Important because nurses should NEVER cause harm to patient

What is the purpose of an environmental safety survey? What are some of the elements contained in doing an environmental safety? When should nurse conduct one?

• To identify and intervene with hazards that may cause harm to patient

• Entering and Before leaving patient room

What is the purpose of an environmental safety survey? What are some of the elements contained in doing an environmental safety? When should nurse conduct one?

• Side rails UP (2 minimum, 3 max unless restraint order for 4 SRs)

• Bed in LOWEST position

• Bed wheels in LOCKED position

• Call light within reach

• Adequate lighting

• Personal items within reach

• Floor clear of clutter/cords

• Mobility aids within reach

• Patient in position of comfort

• Fall precautions identifiers (wrist bands, room signs)

• Oxygen therapy equipment or other lines working and connected

• Ambu bags are nearby

What is the difference between subjective and objective data? What are some examples?

Subjective: Patient reports SYMPTOMS. Cannot be measured

• Pain

• Fatigue

• Nausea

• Dizziness

Objective: Observable and measurable SIGNS

• Vital Signs

• Sweating

• Rash

• Fever

What are the 4 assessment techniques and in what order should we perform them?

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

Define each assessment technique and when you would use each one. Are there any special considerations? (INPSECTION)

“Concentrated Watching”

Involves Looking, Listening, Smelling to distinguish expected findings from unexpected findings

• Identify degree of distress

• Look before you touch

• Provide comfortable, private conditions

• Provide adequate lighting and exposure

• Inspect each area of size, shape, color, symmetry, position, abnormalities

Symmetry on opposite sides of body

Define each assessment technique and when you would use each one. Are there any special considerations? (PALPATION)

• Use touch to gather information

• Use different parts of hands to detect different characteristics

• Used to assess skin, organs, glands, blood vessels, thorax

• Hands should be warm, fingernails short, technique is slow, gentle and systematic

• Palpate tender areas last

• Start with light palpation; end with deep palpation

Define each assessment technique and when you would use each one. Are there any special considerations? (AUSCULTATION)

• Listening to sounds produced by the body, such as lungs, heart, blood vessels, and abdomen

• Equipment: Stethoscope and Ear

• Sound characteristics

  • Frequency

  • Loudness amplitude

  • Quality

  • Duration

What are the special considerations while assessing patients with cultural differences? How about with older adults?

Consider

• Health beliefs

• Use of alternative therapies

• Nutrition habits

• Relationships with family

• Comfort with physical closeness

What are the special considerations while assessing patients with cultural differences? How about with older adults?

• Sensory and physical limitations may affect ability to respond quickly

  • Be patient; adjust pace of assessment data gathering to accomodate

• Signs and symptoms tend to be subtle

• Observe for signs of fatigue, sighing, grimacing, irritability, leaning against objects for support, drooping head and shoulders

• Allow pauses or rest periods as needed

What are the different levels of communication and what are some examples of when you would use each type?

• Intrapersonal

• Interpersonal

• Small group

• Public

• Electronic

What are the phases of the nurse-patient relationship?

Preinteraction

• Occurs before meeting the patien

Orientation

• Nurse & patient meet and get ton know each other

Working

• When the nurse and the patient work together to solve problems accomplish goals

Termination

• Occurs at the end of a relationship

When does therapeutic communication occur? What are examples? How/when would you use each one?

During working phase

Example: Active listening SOLER

S: Sit facing the patient

O: Open position

L: Lean toward the patient

E: Eye contact

R: Relax

Example: Empathy

Example: Touch

Example: Silence

What are the elements of professional communication and what are some examples of each element?

• Appearance, demeanor, and behavior

• Use of names

• Autonomy and responsibility

• Courtesy

• Trustworthiness

• Assertiveness

What are the different forms of communication barriers? How would you provide effective communication to patients with different forms of communication barriers?

Skipped

What is the difference between colonization, infection, and infectious diseases? What are risk factors for infection? How do you decrease the risk of infection?

Colonization

• Presence and growth of microorganisms within a host but without tissue invasion or damage

Infection

• The invasion of susceptible host by pathogens or microorganisms, resulting in disease

Infectious Disease

• Communicable & transmissible

What is the difference between colonization, infection, and infectious diseases? What are risk factors for infection? How do you decrease the risk of infection?

• Age

• Lifestyle

• Occupation

• Nutritional Status

• Travel History

• Stress

• Procedures

• Disease

What are healthcare-associated infectious and who is at risk?

• Infections associated with healthcare delivery in any health care facility

• Patient with higher risk w/ HAIs

  • Multiple illnessses

  • Older adults

  • Poorly nourished

  • Compromised immune system

Explain the chain of infection

skipped

What is medical asepsis and be able to provide examples

Asepsis:

• Absence of pathogenic (disease-producing) microorganisms

Medical Asepsis

• Clean technique

• Procedures used to reduce the number and transmission of disease causing microorganisms after they leave the body, but doesn’t necessarily eliminate them

What is the difference between Universal and Standard precaution?

Universal Precautioin

• Prevent transmission of bloodborne pathogens and bodily fluids

• Bloodborne pathogens

  • Hepatitis B (HBV)

  • Hepatitis C (HCV)

  • Human immunodeficiency Virus (HIV)

• Bodily Fluids

  • Applies to: Semen, Vaginal Secretions, Saliva, Bodily fluids contaminated with blood

  • Does NOT apply to: Sputum, feces, sweat, emesis, urine, nasal secretions

What is the difference between Universal and Standard precaution?

Prevent and control infection and its spread to all persons

Based on that these may contain transmissible infectious agents

• Blood

• Body fluids

• Secretions

• Excretions (except sweat)

• Non-intact skin

• Mucous membranes

What are the key elements of Standard Precaution? When would you use each element of standard precaution?

• Hand hygiene

• Use of PPE (Gloves, gown, mask, googles, face shield)

• Safe injection practices

• Equipment handling

• Respiratory hygiene/cough etiquette

What is the proper technique/procedure and indications for using hand hygiene, alcohol-based hand sanitizer, and PPE. How do you decide when to use each?

Putting On:

1. Hand Hygiene

2. Gown

3. Mask or respirator

4. Goggles or face shield

5. Gloves

Removing:

1. Hand hygiene

2. Gloves

3. Hand hygiene

4. Goggles/Face Shield

5. Hand Hygiene

6. Gown

7. Hand Hygiene

8. Mask/Respirator

9. Hand Hygiene

What is the proper technique/procedure and indications for using hand hygiene, alcohol-based hand sanitizer, and PPE. How do you decide when to use each? (GLOVES)

Gloves: Potential Contact with

• Blood (during phlebotomy

• Body fluids

• Secretions

• Excretions (except sweat)

• Mucous membranes

• Non-intact skin

• Contaminated items or surfaces

What is the proper technique/procedure and indications for using hand hygiene, alcohol-based hand sanitizer, and PPE. How do you decide when to use each? (ISOLATION GOWN)

Isolation Gown: During procedures or activities where contact with blood or bodily fluids is anticipated

What is the proper technique/procedure and indications for using hand hygiene, alcohol-based hand sanitizer, and PPE. How do you decide when to use each? (Mask/Respirator)

• To protect the nose and mouth

• Wear a face mask when there is potential contact with RESPIRATORY secretions and sprays of blood or body fluids

• May be in combination with goggles or face shield to protect the eyes in addition to the nose and mouth

What is the proper technique/procedure and indications for using hand hygiene, alcohol-based hand sanitizer, and PPE. How do you decide when to use each? (Goggles)

Goggles

• Wear eye protection for potential for splash or spray of blood, respiratory secretions or other body fluids

What is the difference between contact, droplet, airborne and protective environment precautions? When would you use each type of isolation? What PPE would you use for each one? How are they different than standard precautions?

Contact precautions: Direct patient or environmental contact

Droplet precautions: Respiratory tract transmission over short distances

Airborne precaution: remains in the air, infective over time and distance

Protective environment:": limited patient population

Why is hygiene important? What role do nurses play?

Role of nurses

• Healthy people can maintain their hygiene

• Ill, physically or emotionally challenged people often require assistance with hygiene

• Preserve patient independence

• Ensure privacy and comfort

What are the factors that influence hygiene

Personal preferences

Factors influencing hygiene practices

• Social practices

• Personal preferences

• Body image

• Socioeconomic status

• Health beliefs and motivation

• Cultural variables

• Physical condition

Patient care should be individualized

What is the process of bathing a patient comfortably

• Provide privacy

• Maintain warmth

• Promote independence

• Anticipate needs

What are vital signs and when you should measure vital signs?

• Blood pressure

• Temperature

• Oxygen saturatioin

• Respiration rate

• Pulse

• Pain

What are vital signs and when you should measure vital signs?

• On admission

• Hospital routine schedule

• Before, during and after medication and treatments or procedures

• Before, during and after nursing interventions

• When a patient’s general physical condition changes

• When a patient reports nonspecific symptoms of physical distress

What is body temperature? What are the different sites for taking body temperature measurements?

Heat produced - Heat Loss = Body temperature

Sites:

• Oral

• Axillary

• Rectal

• Tympanic (Ear)

• Temporal

What are the normal ranges for adults and older adults for temperature? When should/should not each site be used?

Average oral 37 C (98.6)

Average Rectal/tympanic 37.5 C (99.5)

Average axillary 36.6 (97.6)

Average older adult

35-36.1 C (95-97)

What are the normal ranges for adults and older adults for temperature? When should/should not each site be used? (ORAL)

Oral

• 🟢 Most common for cooperative, conscious adults

• 🔴 Do NOT use immediately after the patient has consumed hot or cold liquids/food — wait 30 minutes (directly tested in the Quick Quiz)

• 🔴 Not appropriate for patients who cannot hold thermometer in mouth (unconscious, confused, oral surgery, mouth-breathers, very young children)

What are the normal ranges for adults and older adults for temperature? When should/should not each site be used? (RECTAL)

Rectal

• 🟢 More accurate core temperature; useful when oral is not possible

• 🟢 Often used for infants and young children

• 🔴 Contraindicated in rectal surgery, rectal disorders, diarrhea, or when patient cannot tolerate positioning

What are the normal ranges for adults and older adults for temperature? When should/should not each site be used? (AXILLARY)

• 🟢 Safest, non-invasive; appropriate when other sites cannot be used

• 🟢 Good for newborns/infants

• 🔴 Least accurate — considered the least reliable site; readings run lower than core temperature

What are the normal ranges for adults and older adults for temperature? When should/should not each site be used? (TYMPANIC)

• 🟢 Fast and convenient; useful in children and adults

• 🔴 May be inaccurate with excessive earwax or ear infections

• 🔴 Improper positioning of the probe can lead to inaccurate readings

What are the normal ranges for adults and older adults for temperature? When should/should not each site be used? (TEMPORAL ARTERY)

• 🟢 Non-invasive, quick, and well-tolerated; good for all ages including children

• 🟢 Increasingly preferred in clinical settings

• 🔴 May be affected by perspiration or improper scanning technique

What are some of the factors influencing body temperature?

• Age

• Exercise

• Hormonal level

• Circadian Rhythm

• Environment

• Temperature altrerations

What do pulse measurements measure? What are some factors that influence pulse/heart rate? What are acceptable pulse rates for adults? What is bradycardia & tachycardia?

Number of pulsing sensations in 1 minute

Factors

• Exercise

• Temperature

• Emotions

• Medications

• Postural changes

• Pulmonary conditions

• Hemorrhage

60 - 100 bpm (Eucardia)

Tachycardia > 100 bpm

Bradycardia < 60 bpm

When to be concerned P > 120, P< 50, pt specific

Where are pulse locations?

• Carotid

• Brachial

• Radial

• Femoral

• Popliteal

• Post Tibial

• Dorsalis Pedis

What elements are contained in a pulse assessment and what are the characteristics of each element?

Technique: Palpation

Rate (beats/min)

Rhythm (Regular or Irregular)

Strength/Amplitude (force) (3+, 2+, 1+, 0)

Equality** (even, same on all peripheries)

You notice that a patient has an irregular pulse. The best action you should take includes:
A. Reading the history & physical

B. Assessing the apical pulse rate for 1 full minute

C. Auscultating for strength and depth of pulse

D. Asking whether the patient feels any palpitations or faintness of breath

B. Assessing the apical pulse rate for 1 full minute

What do respirations measure? Difference between ventilation, diffusion and perfusion?

Breaths per minute

Ventilation: The movement of gases in and out of the lungs

Diffusion: movement of oxygen and carbon dioxide between alveoli and RBCs

Perfusion: Distribution of RBCs to and from pulmonary capillaries

What are some factors that influence respirations?

• Exercise

• Acute Pain

• Anxiety

• Smoking

• Body position

• Medications

• Neurological injury

• Hemoglobin function

What are acceptable respiratory rates for adults? What is tachypnea vs bradypnea?

12-20 breaths per minute (Eupnea)

Tachypnea > 20 per minute

Bradypnea <12 per minute

When to be concerned >24 breaths/minute, <10 breaths/minute, pt specific

What elements are contained in a respiratory rate assessment and what are the characteristics of each element? What is the technique to measure respiratory rates and when should the technique differ?

• Ventilation is assessed by determining respiratory rate, depth, and rhythm.

• Technique: Observation and palpation • Best to do without patient knowing

• Rate (numeric value)

• Depth (deep, full/normal/even, or shallow)

• Rhythm (regular or irregular)

• Effort (easy/relaxed or hard to breathe

What do blood pressure readings measure? What are the interrelationships to blood pressure? What can happen if any of these relationships change?

The force exerted on the walls of an artery by pulsating blood under pressure?

• Cardiac output

• Peripheral resistance

• Blood volume

• Viscosity

• Elasticity

An increase or decrease in any of these factors can affect blood pressure

What are some factors that influence blood pressure?

• Age

• Stress

• Ethnicity

• Gender

• Daily variation

• Medications

• Activity & weight

• Smoking

What is a normal BP reading for adults?

Less than 120/80

What are common errors in BP measurements?

• Use of a cuff of incorrect size

• Auscultatory Gap

What is the proper technique to measure a palpatory and auscultatory blood pressure?

Palpation & Auscultation

Inflate 30 mmHg above “normal” blood pressure

Avoids Auscultatory gap

When assessing the blood pressure of a frail older women, using an adult cuff of normal size will affect the reading and produce a value that is

A. Accurate

B. Indistinct

C. Falsely low

D. Falsely high

C. Falsely low

What are the different Korotkoff sounds? When do you measure systolic and diastolic blood pressure readings?

Phase 1: First tap sounds: Systolic BP

Phase 2

Phase 3

Phase 4

Phase 5: All sounds disappear, Diastolic BP

What is an auscultatory gap? How do we avoid measuring one? What happens if we don’t avoid one?

• Occurs between first & second Korotkoff sounds

• Underestimate SBP and overestimate DBP

• Avoid this by first palpating the systolic and inflating the cuff 30 mmHg ABOVE that number

When should/should not an electronic blood pressure device be used?

Advantages

• Useful

• Efficient

• No stethoscope needed

Not Appropriate

• Hypertension

• Hypotension

• Irregular heart rhythm

• Peripheral vascular obstruction

• Shivering

• Seizures

• Excessive tremors

• Inability to participate

What are some patient precautions to take when taking blood pressures? When should a different blood pressure site be used? Where are other sites that blood pressure can be taken instead?

ASSESS BEFORE YOU MESS

• Hemodialysis patients with shunts

• Patients who have had mastectomy or lymphectomy

• Patients with vascular accesss (e.g. Central Venous/PICC lines)

• Site Disruptions

  • Wounds

  • Irritations

  • Rashes

  • Swelling

  • Injury

What are some patient precautions to take when taking blood pressures? When should a different blood pressure site be used? Where are other sites that blood pressure can be taken instead?

• Choose different BP site from any contraindications of arms

• Brachial Artery

• Radial Artery

• Popliteal Artery

• Dorsalis Pedis Artery

• Posterior Tibial Artery

What does oxygen saturation measure?

Percent of hemoglobin that is bound with oxygen in the arteries (SaO2)

Evaluates diffusion and perfusion

What are factors that can affect accurate oxygen saturation levels? What are some examples to avoid them?

Anything that interferes with circulation/perfusion affects saturation

Interferes with light transmission

• Patient moving

• Nail polish

• Artificial nails

Interferes with arterial pulsation

• Hypothermia at assessment site

• Hypotension or low cardiac output

• Peripheral edema

• Disease and medication that restricts blood flow (Vasoconstriction)

A postoperative patient is breathing rapidly. You should immediately?

A. Call the physician

B. Count the respirations

C. Assess the oxygen saturation

D. Ask the patient if he feels uncomfortable

C. Assess the oxygen saturation

What is the expected normal ranges for SpO2? When is it a clinical emergency?

93 - 100%

Value less than 90% is a clinical emergency

Intervention: Sit the patient up, then retake it

What is Aphasia?

Injury to speech center in cerebral cortex

What is Dysarthria?

Weak, slowing moving or non moving muscles of the mouth

Hypotension is defined as a systolic blood pressure of less than < ___ mmHg

< 90 mmHG