NURS 3410 - Exam 1

the nursing process

central to your ability to provide timely and appropriate care to your patients

steps of the nursing process

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

assessment

the gathering and analysis of information about the patient's health status

diagnosis

making clinical judgements from the assessment to identify the patient's response to health problems in the form of nursing diagnoses

planning

includes setting goals and expected outcomes for your care and selecting interventions (nursing and collaborative) individualized to each of the patient's nursing diagnoses

implementation

performing the planned interventions

evaluation

evaluating the patient's response and determine whether the interventions were effective

critical thinking in assessment of clients

1. knowledge base

2. environment

3. experience

4. standards

5. attitudes

knowledge base

basic nursing and science; nursing and healthcare theory (health promotion); patient data (assessment findings)

environment

time pressure (nurses are always short on time), setting (where you perform assessment), task complexity (physical condition, numerous procedures), interruptions (phone calls, other providers walking in, family talking to you)

standards

ANA scope of practice, clinical practice guidelines, intellectual, professional (standards of care, ethical standards)

attitudes

perseverance, curiosity, confidence, discipline, responsibility, intellectual, professional

developing the nurse-client relationship for data collection

- client (interview, observation, physical examination) - BEST source of info

- family and significant others (obtain clients agreement first)

- health care team

- medical records

- scientific literature

source of data: client

- BEST source of information

- establish nurse-client therapeutic relationship, mobilizes hope for client and allows client to use support for fears, illness, pain, and anxiety

- show interest in client's healthcare problems that help you collect a relevant database

- rounding is vital opportunity to build trust with clients to help gain more info

source of data: family and significant others

- primary source of information for infants, children, and patients who are critically ill, mentally handicapped, or have cognitive impairment

- supply info about client's current health status and can tell when a the status has changed

sources of data: health care team

- frequent communication with other health care team members

- change-of-shift report, bedside rounds, client hand-off

- every member of team is a source of information for identifying and verifying essential information about the client

source of data: medical records

- source for client's medical history, laboratory and diagnostic test results, current physical findings, and primary health care providers treatment plan

- valuable tool for checking the consistency and similarities of data with your personal observations

sources of data: scientific literature

- review nursing, medical, and pharmacological literature about a client's illness completes a client's assessment database

- increases your knowledge about patient's diagnosed problems, expected symptoms, treatment, prognosis, and established standards of therapeutic practice

sources of data: personal experiences

- your clinical experiences as you observe other client's behaviors and physical signs and symptoms

- track trends and recognize clinical changes

- learn types of questions to ask and choose questions that will give most useful info

types of assessment

- client-centered interview during nursing health history

- physical examination

- periodic assessments you make during rounding or administering care

cue

information you obtain through senses

inference

your judgement or interpretation of the cues

comprehensive assessment

- moves from general to specific (asking questions focusing on the basis of patient responses and physical signs

- problem oriented (asking follow-up questions to expand assessment and understand full nature of the problem)

- continuously think about what data is telling you and decide if more data is needed

subjective client cues

- often reflect physiological changes (explore further through objective review of body systems)

- client's verbal descriptions of their health problems

- include clients' feelings, perceptions, and self-reported problems

- report from family

- shift/handoff report

objective client cues

- observations or measurements of client's health status

- physical assessment

- medical record/HER

- lab tests

- inspecting condition of surgical incision/wound, describing observed behavior, vital signs

effective communication

- foundation for creating nurse-client relationships

- trust building

- presence

- rounding

interview techniques

- three phases: orientation, working, termination

- open ended questions (narrative response) - to begin interview, intro into new set of questions and whenever the client introduces a new topic

- closed ended questions (1-2 words) - "yes/no" "right/left"

orientation phase

includes personal introduction and purpose of interview

working phase

- nurse focuses on the purpose of the interaction and demonstrates active, engaged listening

- open/closed ended questions are relevant

- health history and review of systems

termination phase

- summarize key findings

- validates information provided

- opportunity for client to share additional relevant information

- discuss next steps

- thank client for seeking care

observation of client behavior

- direct you to gather additional objective info to form accurate conclusions about the clients condition

- important observation includes a client's level of function: physical, developmental, psychological, and social aspects of everyday living

- does data obtained by observation match what client communicates verbally?

cultural considerations

- cultural competence - involves self-awareness, reflective practice, and knowledge of a client's core cultural background

- cultural humility - requires you to recognize your own knowledge limitations and cultural perspective and thus be open to new perspectives

- show client's respect and understand their individual differences; do not impose own attitudes, biases and beliefs

nursing health history

- key component of comprehensive assessment

- covers all health dimensions: physical and developmental, intellectual, spiritual, social, and emotional

- data documentation: use clear, concise appropriate terminology, becomes baseline for care

- concept mapping: visually shows connections among client's many health problems

biographical data

- name

- address and phone number

- age and birthdate

- birthplace

- sex

- marital status

- race

- ethnic origin

- occupation: usual and present

reason for seeking care

- brief spontaneous statement in person's own words for describing reason for visit

symptom

subjective sensation person feels from disorder

source of history

- record who furnishes information, usually the person but may be relative/friend

- judge reliability of informant and how willing he/she is to communicate

- reliable person always gives same answers when questions are rephrased/repeated

- note any special circumstances such as use of interpreter

PQRST

- Provokes - precipitating and relieving factors

- Quality - what does is feel like? dull or sharp?

- Radiate - where is symptom located? is it in one place? does it go anywhere else?

- Severity - rate on scale 0-10?

- Time - when did it start? does it come and go? what time of day or what day of week does it occur?

past health history

- hospitalizations

- injuries

- surgeries

- impact on daily living

- meds

- allergies

- blood transfusion

- habits

- emotional status

- use of alcohol, tobacco, caffeine, recreational drugs

- patterns of coping, sleep, exercise, and nutrition

family history

- age and health or cause of death of relatives

- health of close family members

- family history (high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, TB

- family tree (genogram) to show this information clearly and concisely

psychosocial and spiritual health

- support system

- recent loss

- ways of coping: walking, reading, talking with friends

- beliefs about life

- source for guidance

- relationship with family (exercising their faith)

- rituals/religious practices to express spirituality

review of systems

- general overall health state

- skin

- hair

- head

- eyes

- ears

- nose/sinuses

- mouth/throat

- neck

- breast

- axilla

- respiratory system

- cardiovascular system

- peripheral vascular

- gastrointestinal

- urinary system

- male/female genital system

- musculoskeletal system

- neurologic system

- hematologic system

- endocrine system

the older adult functional assessment

- measures a person's self-care ability in areas of general physical health ADL's

- self-concept, self-esteem

- occupation

- activity and exercise

- sleep and rest

- nutrition and elimination

- interpersonal relationships and resources

- coping and stress management

- environment and home safety hazards

concept mapping

- organize assessment data

- placing all of the cues together into the clusters that form patterns leads you to the next step of the nursing process, nursing diagnosis

guidelines for measuring vital signs

- measuring vital signs is your responsibility

- assess equipment is working properly and provides accurate findings

- know client's usual range of vital signs

- control or minimize environmental factors that affect vital signs

- use an organized/systemic approach when taking vital signs

- on the basis of client's condition, collaborate with healthcare providers to decide frequency of vital signs assessment

- use vital sign measurements to determine indications for medication administration. know acceptable ranges before administering

- analyze the results of vital sign measurement on the basis of client's condition and past medical history

- verify and communicate change in vital signs

hand hygiene

- most important step to decrease microorganism transmission

- before and after physical contact with each client

- after inadvertent contact with blood, body fluids, secretions, and excretions

- after contact with any equipment contaminated with body fluids

- after removing gloves

Oral/tempanic temperature range

98.6°F, 37°C

rectal temperature range

99.5°F

axillary temperature range

97.7°F

how does temperature affect the elderly

the average core temperature ranges from 35-36.1°C (95-97°F) as a result of decreased immunity

for tympanic temps

- must be in contact with ear surface

- most comfortable

- least invasive

- more variability due to incorrect placement

for oral temps

- probes must be under tongue

- lips closed

- nothing to eat/drink prior to temperature

for axillary temps

- probes must be in contact with skin

- least accurate

- 1 degree less than oral

factors affecting temperature

- age (newborns need caps due to heat loss through head)

- exercise - increases temp

- hormones - low progesterone=low temp, with ovulation progesterone increases=temp increases

- menopause - 7 degree temperature increase during hot flash

- circadian rhythm - temp lowest during night, highest in early afternoon - early evening

- stress - increased stress, increased metabolism = increased temp

- physical activity

- illness

- food/fluid consumption

when do you take in infants temperature rectally

last

Fever (pyrexia)

- heat loss mechanisms are unable to keep pace with excessive heat production

- pyrogens elevate body temp, acting as antigens, triggering immune system responses, hypothalamus raises set point and body conserves heat which causes chills, fevers, and feels cold resolves when the new set point a higher temperature is achieved

- next phase of plateau, the chills subside and person feels warm and dry - if the new set point is "overshot" or the pyrogens are removed, the third phase of a febrile episode occurs which causes the hypothalamus set point to drop and initiates heat-loss responses, skin feels warm and flush, diaphoresis assist in evaporative heat loss. when fever breaks the client becomes afebrile

- during a fever metabolism increases and ocygen consumption rises

a fever is not usually harmful if it stays below what in ADULTS

39°C (102.2°F)

a fever is not usually harmful if it stays below what in CHILDREN

40°C (104°F)

hyperthermia

elevated body temperature resulting from body's inability to promote heat loss or reduce heat production, resulting from an overload of the thermoregulatory mechanisms of the body

malignant hyperthermia

hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs

heatstroke

(defined as a body temperature of 40° C [104° F] or more)

- depresses hypothalamic function, and occurs from prolonged exposure to the sun or high environmental temperatures

- commonly seen in people who spend time outside (athletes, construction workers)

- signs and symptoms - giddiness, confusion, delirium, excessive thirst, nausea, muscle cramps, visual disturbances, elevated body temp, increased HR, lower BP, hot and dry skin

heat exhaustion

- occurs when profuse diaphoresis results in water and electrolyte loss

- first aid includes transporting him/her to cooler environment and restoring fluid and electrolyte balance

hypothermia

frostbite

- occurs when body is exposed to subnormal temperatures

- ice crystals form inside the cell and permanent circulatory and tissue damage occurs

for rectal temps

- insert probe 1-1.5 inches

- 1 degree higher than oral

pulse

- palpable bounding of blood flow noted at various points on the body

- indicator of circulatory status

pulse rate

number of pulsing sensation in 1 minute

cardiac output

- heart rate x stroke volume

- volume of blood pumped by the heart during 1 minute

when factors are unable to alter stroke volume what happens?

- a change in HR results in a change in cardiac output, which affects BP

- as HR increases without a change in stroke volume, BP decreases

- as HR slows, filling time is increased and BP increased

what group of people may have a pulse lower than 60

athletes

bradycardia

pulse less than 60 bpm

tachycardia

pulse greater than 100 bpm

how long do we count a pulse for children and where do we do it?

a full minute; apical pulse

acceptable pulse range for newborn

110-160

acceptable pulse range for infant (1 month - 1 year)

90 - 160

acceptable pulse range for toddler (1-3 years)

80-140

acceptable pulse range for preschooler

70-120

acceptable pulse range for school-age (6-12 years)

60-110

acceptable pulse range for adolescent

50-100

acceptable pulse range for adult

60-100

what is the bell in a stethoscope used for

low pitched sounds like heart murmurs

what is the diaphragm of a stethoscope used for

high pitched sounds like breath and bowel sounds

what is needed if you cannot feel a pulse

doppler

character of the pulse

rate, rhythm, strength, equality

pulse deficit

the difference between the rate of an apical pulse and the rate of a radial pulse

dysrhythmia

- abnormal rhythm

- threatens the ability of the heart to provide adequate cardiac output

- identified by palpating an interruption in successive pulse waves or auscultating an interruption between heart sounds

strength of pulse is documented as

0: absent

1: barely palpable

2: diminished

3: normal

4: full/strong

respiratory rates

- breaths per minute

- count for 30 seconds then double if REGULAR

- if irregular count full minute

acceptable respiratory rate for newborn

30-60 breaths/min

acceptable respiratory rate for infant

25-60

acceptable respiratory rate for toddler

25-30

acceptable respiratory rate for preschooler

20-25

acceptable respiratory rate for adolescent

16-20

acceptable respiratory rate for adult

12-20

bradypnea

RR < 12

tachypnea

rate is regular but rapid >20

hyperpnea

labored, increased depth and rate >20

oxygen saturation

- 95-100% expected range for healthy lungs

- measures the percent of hemoglobin that is bound with oxygen in the arteries

blood pressure

- force exerted on the walls of an artery by pulsing blood under pressure from the heart

- systolic/diastolic