NURS 212 unit 1

Unit 1

nursing-patient relationship

nursing-patient relationship

caring, helping, professional relationship, promoting/restoring health & wellbeing

horizontal violence

anger / aggressive behavior between nurses, nurse-to-nurse hostility (also called bullying or lateral violence)

aphasia

no speaking

expressive aphasia

ppl mostly understand speech, but may have difficulty expressing themselves

dysphagia

difficulty swallowing (gulping)

what kinds of ppl should NOT be used as a pt’s interpreter?

a family member

• they may not accurately translate bc they insert their own opinions into what they believe is the right course of action for the pt

cliches that we should avoid saying to pts

“everything will be ok”

“don’t worry”

“tomorrow will be better”

what kinds of qs should we avoid asking pts with aphasia?

open-ended qs

(stick to yes / nos)

SBAR - S

situation

• “Hi im the nurse I’m calling abt ___.”

• give VS

• I am concerned bc _____

SBAR - B

background:

• How could I forget my background at MOS?????

• pt’s Mental status

• pt’s O2

• pt’s Skin

SBAR - A

assessment

• i think the problem is _____

SBAR - R

recommendation

• i recommend that the pt gets _____

• do u need any tests?

• **remember, read orders back to Dr to verify

rapport

a positive relation that fosters cooperation, communication, or trust

• ppl are “in sync” w each other

Communication

The process of exchanging information, and generating and transmitting meanings b/ 2+ ppl

source / encoder

person or group who begins the communication process

message

communication product from the source

• speech, interview, conversation, chart, gesture, nursing note

4 components of communication process

1. source / encoder

2. message

3. channel

4. receiver / decoder

channel

the medium the source sends the message

• auditory, visual, kinesthetic

kinesthetic

touch

receiver / decoder

interprets the message sent, & chooses a response

verbal communication

exchange of info using words, including both spoken & written (even electronic)

nonverbal communication

transmission of info w/o using words

10 examples of nonverbal communication

1. Touch

2. Eye contact

3. Facial expressions

4. Posture

5. Gait (walking)

6. Gestures

7. Physical appearance

8. Mode of dress / grooming

9. Sounds (not words: crying, sighing, coughing)

10. Silence

4 levels of communication

intrapersonal

interpersonal

small group

Organizational

intrapersonal communication

Self-talk, “I’m gonna do VS”, reflection

interpersonal communication

between 2 ppl, w/ a goal of exchanging messages

• doctors, patients, families

small group communication

between the nurse & 2+ ppl (3ppl total)

• purpose of achieving a goal

• ex- staff meetings, teaching sessions

organizational communication

Between groups or people w/in an organization

• Purpose of achieving a goal

• ex- reviewing policies in a hospital

intimate zone

w/in 0-18 inches of pt

personal zone

18in - 4ft from pt

social zone

4-12 ft from pt

public zone

12-25 ft from pt

therapeutic relationship

 between ppl providing & receiving human needs

• Patient-centered

• Dynamic, both pt & nurse participate in the care

• Time-limited goal

• Help pt, not do all the work for them. both pt & nurse have their own responsibilities

nurse-patient relationship

• caring, therapeutic

• nurse is career and patient is person being cared for

• focus is promoting or restoring health and well-being

phase 2 of therapeutic relationship

working

• longest phase

• the nurse & pt work together to meet pt’s physical and psychosocial needs

• interactions are purposeful and designed to ensure achievement of established goals

• Provide assistance with ADLs

• teaching and counselor roles as a nurse

phase 1 of therapeutic relationship

orientation

• begins during data-gathering

• intros (nurse & pts names)

• Roles of each person in the relationship are clearly defined

• goals and the means of achieving them are set

• pt is given any welcoming info /resources to decrease anxiety

• develop trust

phase 3 of therapeutic relationship

termination

• the conclusion of the relationship

• could be at change of shift, pt discharge, nurse takes vacay or leaves employer

• goals of the therapeutic relationship are examined with the pt

assertive behavior

the ability to stand up for yourself and others using open, honest, and direct communication; focus is on issue not the person

aggressive behavior

• never do this!

asserting one’s rights in a negative manner that violates the rights of others; verbal or physical

open-ended qs

allow pt a wide range of responses; allows expression of what they understand to be true; encourages more descriptive info

• Ex: “What did your health care provider tell you about your need for this hospitalization?” “Tell me about…”

closed qs

provides the receiver with limited responses, often yes or no response

• ex. “Are you having pain?” “What medication do you take?”

• ex. “You said you are taking BP meds, did you take them today?” “You said you were having pain today, correct?”

• Validated what the nurse heard or observed

Validating qs

prevents possible misconceptions if the pt was unclear

• ex- Patient-”I have never taken medication before.” nurse-”Is this the first health problem you experienced?”

Clarifying qs

sequencing qs

places events in chronologic order to investigate a possible cause-effect relationship

• ex- “Your pain began after you lifted the heavy box?”

reflective qs

repeating what the pt said OR asking them abt their feelings; encourages them to elaborate on their thoughts and feelings

• Ex- when patient states they have been sad nurse replies “You have been feeling sad?”

probing qs

violate the client’s privacy & are inappropriate even in a focused interview.

• occurs when the nurse persistently attempts to obtain information even after the client indicates an unwillingness to discuss the topic

directing qs

used to control the aim of the convo

• guiding pt back when they get distracted talking abt something else

emesis

vomiting

I & O

input & output

• liquids into & out of the body (drinks, IVs, urine, stool, blood, emesis [vomit])

Incivility

bullying, anger, aggression, hostility

hypotension

BP is lower than 90/60 mmHg

ADLs

Activities of Daily Living

• Get into/out of bed or chair

• Using toilet

• Bathing or Showering.

• Getting Dressed.

• Personal hygiene.

• Eating.

• Walking / Climbing Stairs

what could a nurse do for someone who is hyperventilating?

raise HOB, check pulse oximeter and VS, apply O2

Tidal volume (VT)

Total amount of air inhaled and exhaled with one breath during normal breathing

vital capacity (VC)

Maximum amount of air exhaled after maximum inspiration

forced vital capacity (FVC)

Maximum amount of air that can be forcefully exhaled after a maximal inspiration

forced expiratory volume (FEV)

The volume of air exhaled at a specific time interval

• ex- in the 1st, 2nd, and 3rd secs after a full inspiration (timed vital capacities)

total lung capacity (TLC)

The volume of air contained within the lungs at maximum inspiration

residual volume (RV)

The volume of air left in the lungs at maximal expiration

peak expiratory flow rate

The maximum flow attained during the forced vital capacity (FVC)

nasal cannula O2 flow rate

1-6 L/ min

simple O2 mask flow rate

5-8 L / min

nonrebreather mask flow rate

10-15 L / min

Venturi mask flow rate

4-6 L / min

why should we Never put high O2 on a pt w/ chronic lung issues?

bc their lungs cannot efficiently expel the CO2

orthostatic hypotension

a common form of low BP, resulting from an inadequate physiologic response to postural (positional) changes

• occurs when a person rises to an erect position (supine to sitting, supine to standing, or sitting to standing)

classical orthostatic hypotension

a decrease in systolic bp of ≥20 mmHg

or

a decrease in diastolic bp of ≥10 mmHg

(w/ in 3 mins of standing or upright tilt)

some symptoms of orthostatic hypotension

dizziness, confusion, lightheadedness, blurred vision, weakness, fatigue, nausea, tachycardia, palpitations, headache

• the presence of symptoms is not necessary for the diagnosis

palor

pale appearance

syncope

loss of consciousness caused by low BP

initial orthostatic hypotension

a transient decrease in systolic BP of ≥40 mm Hg

and/or

a transient decrease in diastolic BP of ≥20 mm Hg

(within 15 secs of standing)

orthostatic hypotension broken down into parts

movement after being at rest resulting in low blood pressure

BP cuff size for infants & children

Cuff bladder length should encircle 80–100% of arm

BP cuff small adult size

12 × 22cm bladder

22–26cm arm circumference

BP cuff adult size

16 × 30cm bladder

27–34cm arm circumference

BP cuff large adult size

16 × 36cm bladder

35–44cm arm circumference

BP cuff adult thigh

16 × 42cm bladder

45–52cm leg circumference

what if the BP cuff is too big?

it could give a false low BP reading

what if the BP cuff is too tight?

it could give a false high BP reading

correct measurements of a BP cuff should have ______

bladder length = 75% to 100% of pt’s arm circumference

&

bladder width = 37% to 50% of pt’s arm circumference

• length-to-width ratio of 2:1

what are Korotkoff sounds

BP sounds!

• the series of sounds that correspond to changes in blood flow through an artery as pressure is released

phase I of Korotkoff sounds

the first appearance of faint but clear tapping sounds that gradually increase in intensity

• the first tapping sound is the systolic pressure!

phase II of Korotkoff sounds

muffled or swishing sounds

phases III and IV of Korotkoff sounds

louder, distinct muffled sounds

phase V of Korotkoff sounds

The last sound heard before loss of all sounds

• diastolic pressure!

anemia

low blood count

oxygenation

the process of providing cells life-sustaining oxygen

pulse oximetry (pulse ox)

noninvasive technique that measures the O2 saturation (SaO2) of arterial blood

what kind of pts may have inaccurate pulse ox results

pts with dark skin

cardiopulmonary system

respiratory and cardiovascular systems

upper airway is composed of ______

nose, pharynx, larynx, and epiglottis

functions of upper airway

warm, filter, and humidify inspired air

lower airway (the tracheobronchial tree) is composed of _____

trachea, R and L main stem bronchi, segmental bronchi, and terminal bronchioles

functions of lower airway

conduction of air, mucociliary clearance, and production of pulmonary surfactant

factors affecting cardiopulmonary function

• Health status

• Developmental considerations (heart issues, anatomical deformities, etc)

• Meds side effects

• Lifestyle considerations (living situations)

diffusion in respiration

the movement of O2 and CO2 between the air (in the alveoli) and the blood (in the capillaries), moving from an area of higher to lower concentration

perfusion

Oxygenated blood passes thru the body’s tissues

• When moving a body part, more blood & O2 flows to that area

things to do before taking pt’s pulse ox

hand hygiene, look at pt’s ID, check pt’s history, if extremities are cold, no fake nails or nail polish

auscultatory gap

BP sounds may temporarily disappear, especially in hypertensive ppl

• may cover a range of as much as 40 mm Hg

• failing to recognize this gap may cause serious errors of BP measurements

interpreting the assessment for orthostatic hypotension

(After recording the measurements for each position)

• *A decrease in systolic BP of ≥20 mm Hg or a decrease in diastolic BP of ≥10 mm Hg within 3 minutes of standing, when compared with BP from the sitting/ supine position

• In pts with hypertension, a drop of systolic BP of at least 30 mm Hg is more appropriate