HAP Final Need to Knows

Nursing Process

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

Clinical Judgement Model

1. Recognize Cues

2. Analyze Cues/formulate hypothesis

3. Generate solutions

4. Take action

5. Evaluate outcomes

First Level Priorities

Airway

Breathing

Cardiac/Circulation Problems

Second Level Priorities

• Wounds

• Abnormal Lab values

• Abnormal Vital Signs

• Broken Bones

• Pain Management

Third Level Priorities

• Long standing condition

• Bruising

SBAR

Situation

Background

Assessment

Recommendation

Primary Prevention

Prevent someone from getting disease

• Diet and exercise

• Vaccinations

• Smoking cessation

Secondary Prevention

Early detection of disease by screening

• Mammogram

• Pregnancy test

• Pap smear

Tertiary Prevention

Rehabilitation of a patient to prevent complications or progressions of disease

• Chemo

• Physical therapy

• Insulin injections

Steps for making clinical judgement

1. Identify medical problems that require immediate referral

2. Identify client problems that require nursing care

3. Identify collaborative problems that require interdisciplinary care

4. Identify need for client teaching and heath promotion

Purpose of Health Assessment and Promotion

• Promote and protect health

• Prevent and detect illness early

• Advocate for individuals and families

Social Determinants of Health

• Economic Stability

• Education Access and Quality

• Health Care Access and Quality

• Neighborhood and Built Environment

• Social and Community Context

Phases of Interiew

1. Pre-interaction: review chart

2. Introductory: introduction to client, explain questions to be asked, assure confidentiality

3. Working: obtain all the data, reason for seeking care, PMH, family history, review of symptoms

4. Closing: summarize info and validate problems and goals

Comprehensive/Complete Health History

Complete database, typically in Primary care setting

• Individual in long term care facility

Focused Health History

What is happening at current moment, questions related to situation

• Patient in an outpatient clinic has cold and influenza-like symptoms

Emergency Health History

Rapid collection of data is obtained

ADLs

• Uses KATZ

  • Bathing

  • Dressing

  • Toileting

  • Transferring

  • Continence

  • Feeding

IADLs

More advanced skills

• Cooking

• Cleaning

• Transportation

• Laundry

• Managing finances

Cultural Competency First Step

Understand his or her own heritage and cultural values

How is culture learned

Learned through language acquisition and socialization

Spirituality

A personal effort to find meaning and purpose in life

Nursing Diagnosis

A concise statement of actual or potential health concerns or level of wellness

Lethargic (somnolent)

Very drowsy and sluggish, often with difficulty in waking

• Can be easily aroused but remains drowsy

Obtunded

less responsive, slow response to stimulation

Stupor

Near onconscious state, where the individual is almost unresponsive and requires vigorous stimulation to elicit a response.

How often is a patient assessed in the hospital

The patient will need a consistent, specialized examination every 8 hours that focuses on certain parameters

Medial Diagnosis

The cause of a disease

Ethnicity

Social group within a cultural and social system that shares common cultural and social heritage that includes: language, history, lifestyle, religion

General Survey Components

• Physical Appearance

• Body structure

• Mobility

• Behavior

Normal order of assessment

1. Inspection

2. Percussion

3. Palpation

4. Auscultation

Order of assessment for abdomen

1. Inspection

2. Auscultation

3. Percussion

4. Palpation

Palpation Techniques

Dorsal Hand: temperature

Palmar Hand: moisture

Finger tips: edema, masses

Flat Percussion

Bones

• Dull sound

Resonance

Adult lung

Hyperresonance

• Child lung or emphysematous lung

Dullness

Dense organs

• Liver, spleen, heart

• Or over abdominal mass

Tympany

Abdominal Areas (intestines and stomach)

Use the diaphragm to listen to…

High pitch sounds

Use the bell to listen to

Low pitch sounds

Heave

Visible or palpable lift of chest wall

Thrill

Palpable vibration felt over chest wall

Bruit

Swishing or whooshing sound heard with stethoscope over artery often due to narrowing or plaque build up

• Heard in patient who has athersclerosis

• occur with turbulent blood flow

Murmur

Abnormal heart sound caused by turbulent blood flow through heart valves

Normal Temperature

1. 96.4-99.1 F; 35.8-37.3 C

   1. Rectal temp is 1 degree F higher 

   2. Axillary temp is 1 degree F lower 

Normal Pulse

60-100bpm

• Count for 30 seconds, 1 minute if irregular

Respirations

12-20 bpm

• Do not mention you are taking respirations will mess up pt breathing  

• Count to 30 and multiply by 2 if regular, if irregular full min 

BP Range

120/80

Systolic BP

Maximum pressure during left ventricular contraction

Diastolic BP

Resting pressure or pressure that blood exerts constantly between each contraction (diastole)

Korotkoff sounds

What we listen to during auscultation

Ranges of BP

Elevated: 120-129/less than 80

Stage 1: 130-139/80-89

Stage 2: >140/>90

Hypertensive Crisis: Systolic over 180/Diastolic over 120

Position of patient for BP

• Legs uncrossed

• Arm at heart level

Phases of BP

1. Phase I: start of faint, clear tapping that intensifies. (systolic)

2. Phase II: Muffled swishing; when and auscultatory gap often occurs

3. Phase III: return of distinct, crisp sounds indicating return of arterial blood flow

4. Phase IV: muffle, less distinct sounds with a blowing quality

5. Phase V: the last sound heard before continuous silence (diastole)

Normal O2

95%-99%

• Less than 92% is abnormal

• Keep in mind if patient is COPD (88-92 is normal range)

Falsely High BP

1. Person is anxious, just exercised, angry

2. Arm below heart level

3. Supporting own arm

4. Legs not positioned correctly

5. Too small cuff

6. Too loose of cuff

7. Deflate too slowly, reinflate too soon

Where is popliteal artery felt

Behind the knee

Where is dorsalis pedis artery

Lateral to the extensor tendon of the big toe

Where is the posterior tibial artery found

In the groove behind the medial malleolus

Falsely Low BP

1. Arm above heart level

2. Too large cuff size

3. Not finding occlusion pressure first

4. Deflate cuff to quickly

Normal bowel sounds

• High pitched

• Gurgling

• Irregular sounds

Where are normal abdominal aortic pulsations seen

Between xiphoid process and umbilicus

Spinal Column Count

Cervical: 7

Thoracic: 12

Lumbar: 5

Sacral: 5

Cox: 4

Protuberant abdomen

Bulging and stretched in appearance.

Arteriosclerosis

Thickening and loss of elasticity of the arterial walls

Pain Signs in Children

• Increased HR

• Hypertension

• Pallor

• Sweating

• Decreased O sat

Rapid Response Values

1. Temp less than 35C/ 95F or greater than 39.5C/103.1F 

2. Pulse less than 55 or greater than 120 

3. Resp less than 10 or greater than 32 breaths per minute

4. Ox stat less than 92 

5. Systolic BP less than 90 or greater than 170

Functions of Skin

• Protection

• Sensation

• Temperature regulation

• Production of vitamin d

• Excretion/absorption

Pallor

Paleness (check face, hands)

• Anemia, shock, arterial insufficiency

Cyanosis

Central

• Face, lips, tongue conjunctiva

Peripheral

• Nail beds/hands

Erythema

Redess

• Hyperemia

• Polycythemia

• Venous stasis

Jaundice

Yellow skin tone from increased bilirubin, uremia

• Check face, sclera

Annular

Ring-like

• Tinea corpis (ring worm)

Confluent

Coming together

• Hives

Discrete

• Skin tags or acne

• Not clustered, on their own

Gyrate

Twisted, sprial like

Grouped

Cluster together

• Contact dermatitis, eczema

Target

Centered area with ring around it

• Tick bites

Zosteriform

Along a dermatome (nerve root)

• Shingles

Polycyclic

Circular lesions growing together

• Psoriasis

Macule

Flat, circumscribes area with color change that is less than 1cm

• Freckles

Patch

Flat, circumscribed, discolored

• Patch>1cm diameter

• Moles, birthmarks, vitiligo

Papule

• Raised, defined, circumscribed, any color

  • <1cm diametes

  • Wart, insect bite

Plaque

Raised, defined, any color

• Greater than 1cm in diameter

• Psoriasis

• Plateau like

Nodule

Nodule

• Solid, palpable

• Varies in size < 2cm

• Depth

• Uticaria, large raised moles

Tumor

A larger nodule

Wheal

Raised, flesh colored, or red edematous papules or plaques, vary in size and shape

• Basal cell carcinoma

Urticaria

Commonly called hives

• Accumulation of fluid in dermal later as a result of histamine release

Vesicle

Clear fluid filled elevated cavities

• Friction Blisters

• Less than 1cm

• Chicken pox

• Herpes

Bulla

Fluid filled cavity

• Greater than 1 cm

• After a burn (big blister)

Cyst

Distinct and walled-off

• Deep

• containing fluid or semisolid material,

• Cavity in dermis

Pustule

Purulent, fluid filled, raised of any size

• Pustular acne

Assessment of Skin Lesions

ABCDE

Asymmetry

Boarder

Color

Diameter > 6mm

Evolution/enlargement

Stage 1 Pressure Injury

Red, blanchable, epidermis is intact 

Stage 2 pressure injury

Loss of epidermis, break of skin, partial thickness 

• Dermis is exposed

• Blister

Stage 3 Pressure Injury

Full thickness skin loss

• Exposed subcutaneous tissue

Stage 4 Pressure Injury

• Full skin loss with exposed muscle, bone, tendon

Edema Grading

1. 1+ Pitting= mild, slight indentation (ex: from wearing socks)

2. 2+ Pitting= moderate, indentation subsides rapidly

3. 3+ Pitting: deep, indentation remains for short time, legs look swollen

4. 4+ Pitting: very deep, indentation remains for long time, leg is very swollen

What to inspect on nails

Contour

Color

Consistency

Clubbing

Curvature of nail is 180 degrees or more, spongy

• Signifies lung diseases (hypoxemia)

• Results from chronic low blood-oxygen levels

What does nail clubbing indicate

Hypoxemia