NUR 126 Week 1

Explain what the NLN (National League for Nursing) competencies are.

They ensure that nursing graduates have the necessary skills, knowledge, and attitude to deliver high quality care. They guide nursing education programs.

Explain the purpose of the NLN competencies.

They ensure consistency and standardization in nursing education across the country. They provide benchmarks for measuring progress through the program and support students in developing a professional identity. Ultimately, they benefit students, nursing programs, and patients.

Describe the main component parts of the NLN competencies: human flourishing, nursing judgment, professional identity, spirit of inquiries.

Human Flourishing: supports patient, family, and community wellbeing. (Physical, emotional, social, and spiritual overall health)

Nursing Judgment: supports critical decision making that’s evidence based and uses ethical reasoning.

Professional Identity: helps build a sense of one’s self as a nurse and to value the professional behavior and standards of nursing.

Spirit of Inquiry: fosters curiosity that continues learning and questioning the status quo to improve patient care.

Describe how the component parts of the NLN competencies relate to the MCC nursing curriculum.

They provide standardization for evaluating the effectiveness of the nursing program.

Identify the NLN competencies for the NUR 126A student.

Human flourishing: treat patients with respect. Understand patients have physical, emotional, social, and spiritual needs. Use therapeutic communication. Recognize that cultural differences exist and understand basic patient rights.

Nursing judgment: apply the five steps of the nursing process. Collect basic patient data. Identify when something doesn’t seem right. Perform skills according to protocol. Ask for help when you need guidance from instructors or nurses. Understanding which patient needs come first.

Professional identity: Dress appropriately in clinical uniform. Arrive on time and prepared. Know fundamental ethical principles. Understand and maintain HIPAA requirements. Take responsibility for your learning and actions. Work collaboratively with classmates and healthcare team. Use appropriate language and tone.

Spirit of inquiry: seek to understand the why behind actions. Research unfamiliar terms, medications, and conditions. Know how to find reliable nursing information. Accept feedback and use it to improve. Read textbook and understand key concepts. Understand the evidence behind procedures.

Describe the NLN competencies that relate to professional identity for the NUR 126A student.

Display integrity, accountability, responsibility, and commitment to patients as a nurse and member of the interdisciplinary healthcare team.

Identify the elements of the chain of infection (infection process cycle).

Infectious agent: The microorganism causing the infection.

Reservoir: The environment where the infectious agent lives and multiplies.

Portal of exit: The way the infectious agent leaves the reservoir.

Mode of transmission: how the infectious agent is transported from the reservoir to the susceptible host.

Portal of entry: The route through which the infectious agent enters the susceptible host.

Host: The organism that the infectious agent can infect.

Explain how the infection process cycle can be disrupted.

Identify examples of the following:

a. Infectious agent

b. Reservoir

c. Portal of exit:

d. Mode of transmission

e. Portal of Entry

f. Host

Identify examples of the following:

a. Infectious agent: bacteria, viruses, fungi, or parasites.

b. Reservoir: person, animal, water, soil, objects.

c. Portal of exit: bodily fluids

d. Mode of transmission: Direct or indirect contact, droplets, airborne, vehicles (nonliving), vector (living).

e. Portal of entry: mucus membranes, nose, respiratory tract, GI tract, skin breaks.

f. Host: person or organism. Susceptibility factors include age, vaccination status, health, medical conditions.

Differentiate between medical and surgical asepsis.

Medical Asepsis: (Clean technique) seems to reduce the number of microorganisms and prevent their spread.

Surgical Asepsis: (sterile technique) creates and maintains a sterile field.

Identify the type of asepsis we use in isolation and hand hygiene.

Medical asepsis

Differentiate between airborne, droplet, and contact isolation. Identify infection control barriers needed to prevent transmission of infection in each isolation environment.

Review information on the CDC.gov website for specific information on standard precautions, including:

a. Respiratory hygiene/cough etiquette

b. Hand hygiene

c. Personal protective equipment

a. Respiratory hygiene/cough etiquette: Cover your mouth and nose with a tissue when you cough or sneeze or do it into your upper sleeve. Wash with soap and water or clean with alcohol-based hand sanitizer afterwards. Wear a mask to protect others.

b. Hand hygiene

c. Personal protective equipment

Identify the purposes of a physical examination.

Establishes a baseline for comparison.

Identify as medical conditions or concerns.

Tracks changes in the patient’s condition.

Offers opportunities for patient education and health promotion.

Discuss cultural sensitivity in relationship to physical examination.

Awareness of cultural variations in health beliefs, practices, and body language is crucial. Respecting cultural differences enhances patient comfort, trust, and cooperation.

List and define each of the following techniques of physical assessment:

a. Inspection

b. Palpation

c. Percussion

d. Auscultation

Inspection: Visual examination of the patient’s body and behavior.

Palpation: using touch to examine the body. (Texture, temperature, moisture, lumps, tenderness)

Percussion: Tapping the body with the fingers or an instrument to produce sound waves.

Auscultation: listening to the body with a stethoscope. (Heart, lungs, GI)

Describe the preparation for physical assessment. Include infection control, environment, equipment, physical and psychological preparation.

Infection control: Hand hygiene, gloves

Environment: keep quiet for auscultating. Well lit. Kept private.

Equipment: keep clean,

Physical/psychological preparation: Make sure the patient is comfortable and explain the purpose of the examination.

Describe the various positioning used for examination. Give rationale for each and also limitations.

Supine: Flat on back. Examine abdomen, chest, extremities.

Limitations: Difficulty breathing, back pain, pregnancy discomfort.

Prone: Flat on stomach. Examine back, spine.

Limitations: Difficulty breathing, obesity discomfort, abdominal pain, pregnancy.

Lateral: On side. Examine heart, chest, lungs.

Limitations: shoulder injuries, balance issues.

Fowler’s: sitting upright with HOB elevated. For patients with respiratory or cardiovascular issues and for examining the head, neck, and chest.

Limitations: pressure sores, hypotension, spinal injuries.

Lithotomy: On back with legs held up In stirrups. Child birth, pelvic exams

Limitations: Uncomfortable for back and hips and invasive for patients.

Discuss assessment of the various age groups and cultures and how the nurse can show sensitivity to needs.

Infants: Be calm and gentle. Perform less invasive assessment first like auscultation. Use pediatric sized equipment. Check for rash or birth marks. Evaluate reflexes.

Elderly: Speak clearly and slowly. Be patient with them. Check their ability and functioning. Evaluate all medications for side effects.

Cultural Sensitivity: Use language interpreters.

Describe how the physical examination is organized. Why?

Starts with a general survey, which includes their appearance, movement, and behavior. Then vital signs. Then a focus assessment of a particular system or part.

Consistency helps notice changes over time and maintains a comprehensive assessment.

List the recommendations nurses should follow to keep the physical assessment organized.

Use a checklist, follow the same order, document promptly and accurately, communicate effectively with the patient.

List of the components of the general survey and compose a general survey using your own personal information.

Appearance: overall appearance, grooming, and hygiene.

Behavior: level of consciousness, mood, and affect.

Body structure: posture, build, and nutritional status.

Mobility: gate and range of motion.

Survey example: the patient is a well-groomed, alert, and oriented nursing student in their early 30s. They present with a healthy build and normal posture. The patient’s mood is calm and their speech is clear and coherent. No visible distress or abnormalities are noted.

Define respirations

Describe 3 areas of respiration that are included in your assessment.

Respiratory rate: 12-20 breaths per minute

Ventilatory depth: deep, normal, shallow

Ventilatory rhythm: regular/irregular

Identify the normal range for respirations in adults.

12-20 per minute, deep/regular

Identify the factors influencing respirations.

Define bradypnea, tachypnea, hyperpnea, apnea, eupnea, hyperventilation, and hypoventilation.

Bradypnea: Less than 12 breaths per minute

Tachypnea: Greater than 20 breaths per minute

Apnea: respirations cease for several seconds

Hyperventilation: increased rate and depth

Hypoventilation: abnormally low rate and depressed depth

Review pulmonary anatomy and physiology.

Explain the measurements that should be included with respiration assessment.

Respiratory rate: 12-20 breaths per minute

Ventilatory depth: deep, normal, shallow

Ventilatory rhythm: regular/irregular

Define arterial oxygen saturation and describe how it is measured.

The oxygen saturation of the blood. pulse oximeter detects the amount of oxygen bound to hemoglobin. (Percentage of oxygen saturated hemoglobin)

Less than 90% is a clinical emergency. 95-100% is normal.

Define pulse

Pulpable bounding of blood flow noted at various points on the body.

Explain four measurements that are included when assessing the radial pulse.

Identify the normal heart rate ranges for an adult.

60-100 bpm

Define bradycardia, tachycardia, dysrhythmia, and pulse deficit.

Bradycardia: slow heart rate below 60bpm

Tachycardia: fast heart rate above 100bpm

Dysrhythmia: irregular beats that are late, early, or missed.

Pulse deficit: inefficient contraction that fails to send a pulse. The difference between the apical pulse and the radial pulse rates.

Describe factors that can influence pulse rate.

If you detect an abnormal peripheral pulse, you should:

Assess the apical pulse rate for one full minute.

Define blood pressure. Describe systolic and diastolic parameters.

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

Systolic is the maximum peak pressure during contraction.

Diastolic is the minimal pressure during ventricular relaxation.

Define pulse pressure.

The difference between systolic and diastolic pressures.

Identify the factors that influence blood pressure and what is considered a normal blood pressure.

Less than 120/80mm/hg

Normal pulse pressure

30-50mm/hg

Explain concepts that have interrelationships that compose the blood pressure.

Define hypertension and hypotension. Compare the systolic and diastolic ranges of each.

Hypertension is more common. Caused by thickening of artery walls, loss of elasticity, family history, and risk factors like obesity and smoking.

Elevated: 120-129 and less than 80.

Stage 1: 130-139 or 80-89.

Stage 2: 140 and higher or 90 and higher.

Hypertension is caused by the dilation of arteries, loss of blood volume, decrease of blood flow to vital organs, and orthostatic/postural

Systolic below 90.

Describe common mistakes that can cause errors in blood pressure measurement.

Cuff too wide: false low reading

Cuff too narrow: false high reading

Cuff too loose: false high reading

Deflating too slowly: false high diastolic

Arm above heart line: false low reading

Arm below heart line: false high reading

Repeating assessments too quickly: false high reading

Define orthostatic/postural hypotension.

When a person rises from laying/sitting to standing and develops a drop in systolic pressure by at least 20 or a drop in diastolic pressure by at least 20 within three minutes. symptoms include lightheadedness, blurry vision, syncope, and weakness.

Define the Korotkoff sounds.

Four phases that correspond to the sounds of the heartbeat (Five, when including silence).

Phase one: sharp thump

Phase two: Blowing or whooshing sound

Phase three: crisp intense tapping

Phase four: softer blowing sound that fades

Phase five: silence

Explain the two Korotkoff sounds that are recorded for blood pressure.

Phase 1: systolic

Phase 5: diastolic

Determine when the nurse should assess an apical pulse instead of a radial pulse.

When dysrhythmias are noted.

Identify the average oral, tympanic, rectal, and auxiliary temperature for a healthy adult.

Oral: 96.8-100.4 (36-38)

Tympanic:

Rectal: 99.5 (37.5)

Auxiliary: 97.7 (36.5)

Identify an adult normal core temperature range.

37.5 (36-38)

Recognize the factors that influence body temperature.

Describe the five states to measure temperature, include the advantages and disadvantages of each.

Oral: compromised by food and drink.

Tympanic:

Auxiliary:

Temporal:

Rectal:

List four nursing diagnoses related to body temperature changes.

Hyperthermia: elevated body temperature.

Heatstroke: greater than 104F and up to 113F. Too much exposure to a hot environment.

Heat exhaustion: Too much sweating causes fluid and electrolyte imbalances.

Hypothermia: low body temperature.

Identify nursing interventions for hyperthermia.

Identify nursing interventions for hypothermia.

Given a situation, determine the best temperature taking method to use on a client.

When possible, use patient’s preferred site for taking temperatures. Food and drink ruin oral temps. Auxiliary temperatures are not recommended. Be consistent with the method.