Nursing Competency Skills and Application midterm

What is the general survey?

The first impression of the whole patient, made from the moment you meet them and before you touch them

General survey: appearance

Apparent age vs stated age, sex, level of consciousness, skin color, signs of distress, hygiene and grooming, dress

General survey: body structure

Stature, nutritional status (build), symmetry, posture, position

General survey: mobility

Gait, range of motion, involuntary movements, use of assistive devices

General survey: behavior

Mood and affect, facial expression, speech (clarity, rate, volume), orientation, eye contact, cooperation.

AIDET: A

Acknowledge: greet the patient by name, make eye contact, smile.

AIDET: I

Introduce: your name, role, and experience or training

AIDET: D

Duration: how long the test, procedure or visit will take.

AIDET: E

Explanation: what you are going to do and why, and what to expect. Ask if they have questions.

AIDET: T

Thank you: thank the patient and family, and ask if they need anything else.

PQRST: P

Provocation / Palliation: what brings it on, what makes it better or worse.

PQRST: Q

Quality: what it feels like (sharp, dull, burning, throbbing, cramping).

PQRST: R

Region / Radiation: where it is, and whether it spreads anywhere.

PQRST: S

Severity: rate it on a 0 to 10 scale (or a faces scale).

PQRST: T

Timing: when it started, how long it lasts, constant or intermittent.

Acute pain

Sudden onset, identifiable cause, lasts less than about 3 to 6 months, resolves as the body heals. Often raises HR, RR and BP, with sweating and pallor

Chronic pain

Lasts longer than 3 to 6 months or beyond expected healing. Vital signs are often normal because the body adapts. Look for fatigue, depression, withdrawal, poor sleep

Cutaneous pain

Skin and subcutaneous tissue. Sharp or burning, well localized (paper cut, minor burn)

Somatic pain

Bone, joint, muscle, connective tissue. Dull, aching or throbbing, fairly well localized (fracture, sprain)

Visceral pain

Internal organs. Poorly localized, cramping or gnawing, may be referred (appendicitis, gallstones)

Referred pain

Felt away from where it starts (heart attack felt in the left arm or jaw)

Neuropathic pain

Nerve damage. Burning, shooting, tingling, electric

Phantom pain

Pain felt in a body part that has been removed

What makes up a complete set of vital signs?

Temperature, pulse (heart rate), respirations, blood pressure, and SpO2. Pain is often added as the 5th vital sign

normal adult temperature

About 36.5 to 37.5 °C (97.7 to 99.5 °F)

normal adult heart rate

60 to 100 beats per minute

normal adult respiratory rate

12 to 20 breaths per minute

normal adult blood pressure

Below 120/80 mmHg

normal spO2

95% to 100%.

Fever: effect on other vitals

HR goes up, RR goes up. BP may fall from vasodilation and sweating.

Exercise: effect on vitals

Temperature, HR, RR and BP all go up

Caffeine or nicotine: effect

HR and BP go up

Acute pain: effect

HR, RR and BP go up

Anxiety or psychological distress: effect

HR, RR and BP go up (sympathetic response)

Dehydration or blood loss: effect

HR goes up, BP goes down

Medications: examples

Beta blockers lower HR and BP. Opioids can lower RR.

Other things that change vitals

Age, sleep, time of day, body position, illness, and the environment.

What is a never event?

A serious, largely preventable error that should never happen in a healthcare setting

• wrong-site surgery, wrong patient, retained surgical item, a medication error that causes death, a stage 3 or 4 pressure injury acquired in the facility

How do we prevent never events?

Two patient identifiers, time-outs and checklists, barcode scanning, hand hygiene, clear communication and handoffs, following policy, and reporting errors and near misses

Who is at risk for falls?

Older adults, history of falls, weakness or poor gait and balance, confusion or dementia, sedating or many medications, urgency or incontinence, poor vision, postoperative patients, dizziness or low BP when standing

Fall prevention strategies

Bed low and locked, call light in reach, nonskid footwear, bed or chair alarm, hourly rounding, assist with toileting, clear pathways, good lighting, fall-risk band, assist with walking

Usual order of assessment for any body system

Inspection, palpation, percussion, auscultation

The one exception for order of assessment

the abdomen

order of assessment for the abdomen

Inspection, auscultation, percussion, palpation. Palpating first can change bowel sounds

What is clinical judgment?

The nurse's observed outcome of clinical reasoning: the decision about what a patient needs and the action taken, based on assessment data and the patient's response

Tanner's model: the 4 phases

1. Noticing, 2. Interpreting, 3. Responding, 4. Reflecting

Tanner's model: Noticing

Gathering data and recognizing what is expected vs unexpected

Tanner's model: interpreting

Making sense of the data, prioritizing what matters most

Tanner's model: responding

Deciding on and carrying out nursing actions

Tanner's model: reflecting

Evaluating the outcome and what you learned (reflection-in-action and on-action)

What are standard precautions?

The basic infection control practices used with every patient, every time, whether or not infection is suspected. They apply to blood, all body fluids except sweat, non-intact skin, and mucous membranes

What is included in standard precautions?

Hand hygiene, PPE based on the task, respiratory hygiene and cough etiquette, safe injection practices and sharps safety, cleaning and disinfecting equipment and the environment, safe linen and waste handling, and patient placement.

What PPE is used for standard precautions?

Gloves, gown, mask, and eye protection or face shield, chosen by the exposure you expect. You do not need all of them every time

Best way for nurses to stop the spread of infection

hand hygiene!

When do you perform hand hygiene?

Before and after patient contact, before clean or aseptic tasks, after contact with body fluids, after touching the patient's surroundings, and after removing gloves

Alcohol-based rub vs soap and water

Alcohol rub is fine for hands that are not visibly soiled. Use soap and water when hands are visibly dirty, after contact with a patient with C. difficile, and after using the restroom

Order to put PPE ON (don)

1. Hand hygiene

2. Gown

3. Mask or respirator

4. Goggles or face shield

5. Gloves (over the gown cuffs).

Order to take PPE OFF (doff)

1. Gloves

2. Goggles or face shield

3. Gown

4. Mask or respirator (last, after leaving the room)

5. hand hygiene

Doffing: key rules

Handle only the clean inside or the ties and straps. The outside is contaminated. Perform hand hygiene right after removal

Gloves: key point

Glove removal is first. Peel one glove off by the outside, hold it in the other gloved hand, then slide a clean finger under the second cuff and peel it off over the first

Steps of a full cardiac assessment

1. Hand hygiene, introduce yourself, identify the patient, explain

2. Health history and symptoms (chest pain, SOB, palpitations, dizziness, swelling)

3. General survey and vital signs

4. Inspect: skin color, JVD, chest, edema, nails

5. Palpate: carotid and peripheral pulses, apical impulse (PMI), capillary refill, edema

6. Auscultate the heart at each valve area

7. Document and report abnormal findings.

What do you check for when inspecting the neck?

Jugular vein distention (JVD), which can point to fluid overload or right-sided heart failure.

S1 ("lub")

Closure of the mitral and tricuspid valves (AV valves). Start of systole. Loudest at the apex.

S2 ("dub")

Closure of the aortic and pulmonic valves (semilunar valves). End of systole. Loudest at the base.

Aortic area

2nd intercostal space (ICS), right sternal border

Pulmonic area

2nd ICS, left sternal border

Erb's point

3rd ICS, left sternal border.

Tricuspid area

4th ICS, left sternal border (left lower sternal border)

Mitral (apical) area

5th ICS, left midclavicular line. This is also the PMI

Order of listening: cardiac assesment

Aortic, pulmonic, Erb's point, tricuspid, mitral

• Mnemonic: "ape to man"

• APETM

stethoscope diaphragm vs bell

Diaphragm: high-pitched sounds (S1, S2). Bell: low-pitched sounds (S3, S4)

S3

Extra sound early in diastole ("Ken-tuck-y"). Can mean heart failure or volume overload. Can be normal in children and athletes

S4

Extra sound late in diastole ("Ten-nes-see"). Stiff ventricle, often with hypertension or a past MI

Murmur

A swishing sound from turbulent blood flow

Pulses to assess

Carotid, brachial, radial, femoral, popliteal, posterior tibial (PT), dorsalis pedis (DP)

Radial pulse location

Thumb side of the wrist

Brachial pulse location

Inner elbow, medial to the biceps tendon

Femoral pulse location

Groin, midway between the pubic bone and the front hip bone.

Popliteal pulse location

Behind the knee. Deep, so press firmly.

Posterior tibial pulse location

Behind the inner ankle bone (medial malleolus).

Dorsalis pedis pulse location

Top of the foot, just lateral to the big toe tendon

What to include when charting a pulse

Site, rate, rhythm (regular or irregular), strength, and equality between sides. Note any missing pulse or use of Doppler

Pulse strength scale

• 0 absent

• 1+ weak or thready

• 2+ normal

• 3+ increased

• 4+ bounding

Carotid pulse safety

Palpate one side at a time. Never press both at once and never massage

Irregular pulse: what do you do differently?

Count for a full 60 seconds and take an apical pulse with a stethoscope. Report or compare apical vs radial if a pulse deficit is suspected

Instructions for an accurate BP

Rest 5 minutes first. No caffeine, smoking or exercise for 30 minutes before. Empty bladder. Sit with back supported, feet flat, legs uncrossed. Bare arm supported at heart level. No talking.

BP Cuff selection

Correct size for the arm (too small reads falsely high, too large reads falsely low). Place it snugly over bare skin about 1 inch above the bend of the elbow

BP: Arms to avoid

Arm with an IV, dialysis fistula, injury, or on the same side as a mastectomy

If you need to repeat the BP

Wait 1 to 2 minutes and fully deflate the cuff before re-inflating.

Peripheral artery disease (PAD): pain

Intermittent claudication: cramping pain with activity that goes away with rest. Severe PAD causes rest pain, often at night.

What does claudication indicate?

Inadequate blood flow (ischemia) to the muscle during exertion, which means arterial disease

PAD: skin and pulses

Pale, cool, shiny, thin skin, hair loss, thick nails, weak or absent pulses, pallor when raised and redness (rubor) when hanging down, little or no swelling

PAD: ulcers

On toes, heels or outer ankle. Deep, painful, pale or black base, little drainage

Venous insufficiency: pain

Aching, heavy, tired legs. Worse with standing, better with legs raised

Venous insufficiency: skin and pulses

Warm, swollen (edema), brownish skin color near the ankles, varicose veins, pulses present

Venous insufficiency: ulcers

Near the inner ankle. Shallow, irregular, wet with drainage, usually less painful

Preventing venous clots (DVT)

Early ambulation, leg exercises, compression stockings or SCDs, hydration, avoid crossing legs and long periods sitting or standing, anticoagulants as ordered

Preventing arterial disease and clots

Quit smoking, control BP, cholesterol and blood sugar, regular walking, healthy diet, careful foot care, avoid cold and tight clothing.

Leg position: arterial

keep legs level or hanging down, do not elevate

Leg position: Venous

elevate the legs