Exam 1 Therapeutic Applications

AIDET

A- Acknowledge, greet the patient and check ID band

I- Introduce, introduce self, who you are and how you are going to help them

D- Duration, how long you will be in there, as well as keep them updated

E- Explanation, explain procedures/processes/ what you are about to do

T- Thank you, thank the patient for allowing you tow work with them

Along with AIDET:

• wash hands

• identify patient as needed

• provide privacy

• infection control (PPE)

• leave patient safe and comfortable

SBAR

S- situation

B- background

A- assessment

R- recommendation

Used for report

General Survey

It is the physical appearance, body structure, mobility, and behavior of a patient when you walk in to a room to meet them.

Physical appearance- age, gender, LOC, skin color, facial features, overall appearance

Body structure- stature, nutrition, symmetry, posture, position, body build/contour, physical deformities

Mobility- gait, range of motion

Behavior- facial expression, mood and affect, speech pattern, dress, hygiene

Subjective vs objective:

subjective- what the patient tells you, (pain rating, nausea, anxiety, fatigue)

objective- what you observe, (appearance of patient, vital signs, lab results)

Sorting assessment data

Physical assessment techniques

Physical assessment technique - Inspection

• always comes FIRST

• begins when you first meet the patient with a general survey

• start assessment of each body system with inspection- compare right side to left side

Physical assessment technique - Palpation

texture, temperature, moisture, size, shape, degree of tenderness

Techniques:

• finder pads→ pulses, texture, size, consistency

• dorsa (back) of hand→ best for determining temperature because skin here is thinner than on palms

• palm of hand→ best for vibrations, fremitus

start with light pressure and increase only when needed

Physical assessment technique - Percussion

Tapping a persons skin with short, sharpp strokes to assess underlying structures

Uses it for:

• mapping location/size of organs

• signaling density or emptiness of structure

• detecting a superficial abnormal mass

• elicting deep tendon reflex using percussion hammer

Two methods:

- Direct→ directly “strike” the body with hand

- Indirect→ striking hand hits nurses own hand

Resonance- hollow, low pitched sound

Tympany- loud, high-pitched, drumlike

Dull- muffled thud, high-pitched

Flat- absolute dullness

Physical assessment technique - Auscultation

listening to sounds produced by body

• most body sounds are soft and must be channeled through a stethoscope

• stethoscope does not magnify sound, but it blocks out extraneous sounds

• once you can recognize normal sounds, you can distinguish the abnormal sounds and “extra” sounds

How to use the stethoscope

Diaphragm- high-pitched sounds

• breath- wheezes, crackles

• bowel sounds- “gurgling”

• normal heart- S1/S2

Bell- low-pitched sounds

• murmurs

• bruits

PQRSTU

P- provoke, palliative (what makes the pain better or worse?)

Q- quality (what does the pain feel like?)

R- radiate, region (does the pain move anywhere?)

S- severity (how would you rate your pain 0-10?)

T- timing, treatment (when did the pain start?, Tried any treatments?)

U- understanding (what do you think is watching the pain?)

Chronic vs Pain

Acute-

• short term

• self-limiting

• follows a predictable trajectory

• dissipates after injury heals

Chronic-

• continues for months or years

• does not stop when injury heals

• malignant vs nonmalignant

Fall Prevention

- result in minor to severe injuries

- reduce mobility and independence

- increase the risk of premature death

- patients who have underlying disease states are more susceptible to fall related injuries

- any aged person can be at risk

Hester Davis Fall Risk Assessment

Age-

• <20 = 0 points

• 20-40 = 1

• 41-60 = 2

• >60 = 3

Last known fall-

• no falls = 0

• within the last year = 1

• within the last 6 months = 2

• within the last month = 3

• during the current hospitalization = 4

Mobility-

• no limitations = 0

• dizziness or generalized weakness = 1

• immobilized or requires assist of 1 = 2

• use of assistive device or requires 1 or more = 3

• hemiplegic, paraplegia, or quadriplegic = 4

Medications-

• no meds = 0

• cardiovascular or CNS meds = 1

• cardiovascular and CNS meds = 2

• diuretics = 3

• chemotherapy in the last month = 4

Mental Status/LOC/Awareness-

• awake, alert, oriented to date, place, and person = 0

• oriented to person and place = 1

• lethargic or oriented to person only = 2

• memory loss or confusion and requires redirecting = 3

• unresponsive or noncompliance with instructions = 4

Toileting needs-

• no needs = 0

• use of catheters or diversion devices = 1

• use of assistive device = 2

• incontinence = 3

• diarrhea, frequency, or urgency = 4

Volume/Electrolyte status-

• no problems = 0

• NPO >24hrs = 1

• use of IV fluids or tube feeds = 2

• nausea/vomiting = 3

• low blood sugar or electrolyte imbalances = 4

Communication/Sensory-

• no deficits = 0

• visual (glasses) or hearing deficit = 1

• non-english pt, unable to speak, slurred speech = 2

• neuropathy = 3

• blindness or recent visual change = 4

Behavior-

• appropriate behavior = 0

• depression or anxiety = 1

• behavioral noncompliance = 2

• ethanol or substance abuse = 3

• impulsiveness = 4

  A score >7 indicates a high fall risk
  

Med administration (7 rights)

Right patient

Right drug

Right dose

Right route

Right time

Right reason/indication

Right documentation

Med administration safety

• Routes of administration

  • enteral

  • topical

  • inhalation

  • irrigation

  • parenteral

Controlled substances

• l - high abuse potential, no accepted medical use (heroin, marijuana)

• ll - high abuse potential, may lead to severe dependence, must have written prescription (opium, morphine, codeine, oxycodone)

• lll - less abuse potential, may lead to MOD or LOW dependence (limited quantities of opioids)

• lV - less abuse potential, may lead to limited dependence (valium)

• V - low abuse potential, may lead to limited dependence (cough syrups)

Narcotics in acute care:

- kept in secure locked area

- nurse administering NARC signs it out

- NARCOTICS are counted every shift by 2 nurses

- verifying amount every time

• wasting of NARCOTICS

- must be witnessed by TWO licensed care providers RN or LPN

- document the amount of narcotic wasted

Basic pharmacokinetics

• Know; generic name, trade name, drug classification

- never administer an unfamiliar medication

- utilize your critical thinking to assess the medication properties in relationship to your patients individual condition

- is this safe to administer

Types of medication action:

• Therapeutic effect→ expected or predicted physiological response

• Side effect→ unavoidable secondary effect

• Adverse effect→ unintended, undesirable, often unpredictable

• Toxic effect→ accumulation of medication in the bloodstream

• Idiosyncratic reaction→ over-reaction or under-reaction or different reaction from normal

• Allergic reaction→ unpredictable response to a medication

Medication dose responses:

• Onset: time it takes for a medication to produce a response

• Peak: time at which a medication reaches its highest effective concentration

• Trough: minimum blood serum concentration before next scheduled dose

• Duration: time medication takes to produce greatest result

• Plateau: point at which blood serum concentration os reached and maintained

• Biological half-life: time for serum medication concentration to be halved

Insulin administration

Standard precautions/handwashing

Standard precautions- all patients

Handwashing- single most effective method of preventing transmission of microorganisms from one patient to another

• hand sanitizer/handwashing with soap

Isolation precautions

Types of Isolation Precautions

1) standard precautions- all patients

2) droplet precautions-

• influenza, rubella, mumps, pneumonia

• gloves and mask when entering room

• limit transports and visitors

3) airborne precautions-

• negative pressure room with frequent air exchange

• respiratory or fitted mask when entering room

• only transport patient out of room if absolutely necessary(place mask on patient)

• borne precautions (TB, chicken pox, SARS)

4) contact precautions-

• gloves and gown when entering

Atelectasis

partial or complete collapse of the lung that can cause SOB, etc

Respiratory interventions

Hypoventilation

Alveolar ventilation inadequate to meet the body’s oxygen demand or to eliminate sufficient carbon dioxide

Hyperventilation

Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism

Hypoxia

inadequate tissue oxygenation at the cellular level

Hypoxemia

low level of oxygen in the blood

Lung sounds

Pathophysiology of wheezes and crackles

Crackles-

• Fine→ discontinuous, popping, intermittent explosive sounds (sudden opening of airways [alveoli]) shorter duration than course crackles

• Course→ intermittent bubbling sound, inspiration/expiration or both, caused by fluid

Wheezes-

• high pitched, whistling/squeaking sounds

• can be heard on expiration or during both inspiration and expiration

• caused from narrowed airways in the lungs

Chest tube management/ patient safety

If the patient has the following:

-pneumothorax (air in chest cavity)

-hemothorax (blood in chest cavity)

-pleural effusion (fluid in chest cavity)

-empyema (pus in chest cavity)

-post-operative care (thoracic surgeries)

A nurse checks:

• tidaling→ this is normal, the ball rises and falls with breathing

• bubbling in the water-seal chamber

  • this may be abnormal, signifies and air leak

  • this is normal finding with pneumothorax

• chest tube is upright, below the level of the chest, and secure

Cardiac base vs apex of heart

Cardiac cycle

S1 and S2 sounds

Cardiac assessment subjective vs objective

Signs of heart failure, dyspnea, nocturia, orthopnea

cardiac, respiratory, peripheral vascular, mental status, nutrition, fluid balance/kidneys

Orthopnea→ how many pillows do you use when sleeping or lying down?

Dyspnea→

Nocturia→ do you awaken at night with an urgent need to void? how long has this been occurring?

Cyanosis/pallor→ have you ever noticed your facial skin turn blue or ashen?

Peripheral vascular, the P’s, grading pulses, edema

Describe the location of each area where you can assess a pulse on someone

Edema, pitting edema score +1 to +4

Preventing post op complications, pneumonia, UTI, VTE (blood clots)

Sitting up in bed

Walking as soon as possible

Review common post op complications Doc

Types of exudate (whats going on and whats bad/concerning)

How to assess all cranial nerves

12 pairs

CN I Olfactory- sensory: smell

• smell something

CN II Optic- sensory: visual acuity and peripheral fields

• count fingers or movement in all quandrants and periphery in each type

CN III Oculomotor- motor: controls eye movements and pupillary muscles, (PERRLA- pupils are equal, round, reactive to light, and accommodating)

• move eyes in all directions except outward and down and in

CN IV Trochlear- motor: controls superior oblique muscle of the eye, eye moves in and down and out

CN V Trigeminal- sensory: upper, mid and lower face (including cornea, inside mouth and nose), motor: controls masseter muscle (chewing)

• 3 branches, sensation to face

• ability to chew

CN VII Facial- sensory: taste with anterior 2/3 of tongue (sweet, salty, some sour), motor: facial expressions

• moves face, make facial expression

CN VI Abducens- motor: abduction movements of eye (CN III, IV, & VI motor function can be tested all at once with this test)

• give the side eye

CN VIII Acoustic- sensory: able to hear and balance

• snap in both ears

CN IX Glossopharyngeal- sensory: taste to posterior 3rd of tongue (bitter), motor: controls swallowing

• swallow

CN X Vagus- sensory: gag reflex, motor: enervates the gut, heart, and larynx

• gag reflex?

CN XI Spinal accessory- motor: enervates sternocleidomastoid and trapezius muscles

• push on shoulders, have them push up

CN XII Hypoglossal- motor: enervates the muscles of the tongue

• stick out tongue

What is vasovagal response?

Vagus nerve is overstimulated- results in bradycardia, vasodilation- vasovagal syncope (fainting) can happen with straining during constipation

Normal vs abnormal findings of cranial nerves

size, shape, and symmetry

light reflex

brain injury

• unilateral dilated, nonreactive pupil is ominous

• from increasing intracranial pressure

The role of the lobes/areas of the brain

4 Lobes:

• Frontal(front)→ concerns with personality, behavior, emotions, and intellectual function

  • Broca’s area(towards front)→ understands language but cannot express themself verbally

• Parietal(middle)→ receives and processes sensations from the body- touch/pain/temp/shapes

• Occipital(back)→ processes info related to vision, influences ability to read

• Temporal(bottom)→ regulates hearing, taste and smell, participates in language and learning

  • Wernicke’s area(middle)→ speech comes out but may not make any sense, incomprehensible

Glasgow coma scale

Tool to assess LOC

A change in LOC can be subtle and can start with confusion

• Eye opening

  • spontaneously = 4

  • to speech = 3

  • to pain = 2

  • none = 1

• Verbal response

  • oriented = 5

  • confused = 4

  • inappropriate = 3

  • incomprehensible = 2

  • none = 1

• Motor response

  • obeys commands = 6

  • localises to pain = 5

  • withdraws from pain = 4

  • flexion to pain = 3

  • extension to pain = 2

  • none = 1

Maximum score 15

Abnormal posturing while doing painful stimuli, what do they look like

Decorticate- abnormal posturing where a person is stiff with bent arms, clenched fists, and legs held out straight

Decerebrate- involuntary body position that’s a sign of severe brain damage or major disruptions in brain function

When is it appropriate to do a full neuro assessment vs a focused neuro assessment

Complete neuro assessment: q4h

• people of concerns with: headache, weakness, loss of coordination, and show signs of neurologic dysfunction

1) Mental status and LOC

2) Cranial nerves

3) Motor system

4) Sensory system

5) Reflexes

Focused neuro assessment:

1) LOC

2) Motor function

3) Pupillary response

4) Vital signs