Studied by 13 people
Unit 1
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
source / encoder
message
channel
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
Touch
Eye contact
Facial expressions
Posture
Gait (walking)
Gestures
Physical appearance
Mode of dress / grooming
Sounds (not words: crying, sighing, coughing)
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
Note 
Flashcard (23)