Chapter 1-7, 8-12, 13-14

Nursing process

Assessment

Diagnosis

Planning

Implementation

Evaluation

Assessment

step 1 of nursing process; collecting subjective and objective data

Diagnosis

second step of nursing process; analyzing data to make a professional nursing judgement (nursing diagnosis, collaborative problem, or referral)

Planning

step 3 of nursing process; determining outcome criteria and developing a plan

Implementation

step 4 of nursing process; carrying out the plan

Evaluation

step 5 of nursing process; assessing whether the plan worked/was effective and revising the plans as needed

Holistic nursing assessment

Collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment

Physical medical assessment

Focuses primarily on the client's physiologic development status

Initial Comprehensive Assessment

complete assessment upon admission of patient into the facility; patient is totally new; gather all subjective and objective data we can about the patient to establish baseline info about patient; AKA admission assessment

Ongoing assessment

partial assessment, mini overview as a follow up to initial assessment for comparison; focuses on body systems; "are they getting better/worse?"

Focused assessment

problem oriented assessment; specific concern

Emergency assessment

rapid assessment that is performed immediately and promptly while implementing life saving measures; focus on ABCs

Character

Onset

Location

Duration

Severity

Pattern

Associated factors

COLDSPA

Supine position

lying on the back

Prone position

lying on abdomen, facing downward (head may be turned to one side)

Sim's position

the patient is lying on the left side with the right knee and thigh drawn up with the left arm placed along the back; used for rectal exam

Lithotomy position

lying on back with legs raised and feet in stirrups; used for pelvic exam

Inspection

using the senses (vision, smell, hearing) to observe findings; begins the moment you see the client; bilateral assessments

Palpation

using parts of the hand to touch/feel for characteristics

Percussion

tapping on parts of the body

Auscultation

use of stethoscope to listen to sounds

Light palpation

Depress the skin about 1 cm or less

Moderate palpation

depress 1-2 cm

Deep palpation

depress 2.5 to 5 cm

Bimanual palpation

"sandwich" the body part

Dorsal

use this part of the hand to feel temperature

Ulnar/palmar

use this part of the hand to palpate vibrations, thrills, fremitus

Finger pads

use this part of the hand to palpate pulses, texture, size, shape, crepitus (popping sound)

Direct percussion

tapping directly on patient; ex: assessing sinuses

Blunt percussion

used to detect tenderness over organs by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface

Indirect percussion

striking finger in order to produce a sound (sound varies based on density of what's beneath your finger)

Resonance

normal lung (hollow sound)

Hyperresonance

lower-pitched, booming sound; ex: lung with COPD

Tympany

high-pitched, musical, drumlike percussion note heard when percussing over the stomach and intestine; ex: gastric bubble

Dullness

Thud like sound produced by dense tissue; ex: diaphragm, effusion, liver

Flatness

flat; heard over bones and muscle

Diaphragm

part of stethoscope for listening to high pitched sounds such as normal heart, breath, bowel sounds

Bell

part of stethoscope for listening to low pitched sounds such as abnormal heart sounds (ex: murmurs) or bruits (loud, blowing sounds from turbulent blood flow)

Situation background assessment recommendation

SBAR; standardized way of presenting information

Infant

basic trust vs mistrust Erikson's stages of psychosocial development

Toddler

Autonomy vs shame and doubt Erikson's stages of psychosocial development

Preschooler

initiative vs guilt Erikson's stages of psychosocial development

School ager

industry vs inferiority Erikson's stages of psychosocial development

Adolescent

identity vs role confusion Erikson's stages of psychosocial development

Young adult

intimacy vs isolation Erikson's stages of psychosocial development

Middle adult

generativity vs stagnation Erikson's stages of psychosocial development

Older adult

Ego Integrity vs. Despair Erikson's stages of psychosocial development

Alert

Awake and oriented; LOC

Lethargic

client opens eyes, answers questions, and falls back asleep

Stupor

client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep

Obtunded

Client opens eyes to loud voice, responds slowly with confusion and seems unaware of environment

Coma

client remains unresponsive to all stimuli; eyes stay closed

5 levels of consciousness

Alertness

Lethargy

Obtundation

Stupor

Coma

BMI

a measure of body weight relative to height; Weight in kg over (height in meters)^2

Normal BMI

BMI between 18.5-24.9

Underweight BMI

BMI less than 18.5

Overweight BMI

BMI between 25-29.9

Obese BMI

BMI over 30

Normal waist circumference

Females - less than 35 inches

Males- less than 40 inches

Waist to hip ratio

waist circumference / hip circumference; measures hips at widest point

Normal waist to hip ratio

Females - less than 0.8

Males - less than 0.9

Average temperature

98.6 F orally

Tympanic temperature

1\.4 degrees F higher than oral temp (0.4-0.5)

Axillary temperature

1 degree F lower than oral temp

Normal oral temperature

96-99.9 degrees F or 35.5-37.7 degrees C

Signs of fever

onset: chills, pallor, increased pulse and respiration

Flushed face

hot, dry skin

malaise

scant dark urine

anorexia

nausea/vomiting

hypo/hyperthermia

normal pulse

60-100 bpm

pulse amplitude

0 Absent, unable to palpate

\+1 Diminished, weaker than expected, easy to obliterate

\+2 Brisk, expected (normal), obliterate with moderate pressure

\+3 Bounding, unable to obliterate or requires firm pressure

Arrhythmia

Abnormal heart rhythm

Bradycardia

slow heart rate

less than 60 bpm

cause could be heart block, sitting/standing long time, etc

Tachycardia

fast heart rate

more than 100bpm

cause could be fever, stress, anxiety, exercise, hemorrhage, etc

Sinus arrhythmia

normal increase in heart rate that occurs during inspiration (deep breath in and heart speeds up, breath out and it slows back down)

normal in kids

normal respiratory rate

12-20 breaths per minute

faster in newborns (30-40)

oxygen saturation

AKA pulse ox; works by sending infrared light into capillaries to measure how much light is reflected off gases;

normal: 95-100%

inaccurate if cold extremities or nail polish

Dyspnea

difficult or labored breathing

Apnea

cessation of breathing

Bradypnea

slow breathing

Tachypnea

fast breathing

Orthopnea

breathing discomfort while lying flat

Hypoxia

low blood oxygen

cyanosis

bluish/gray color due to low O2 level

blood pressure

force of blood against the arterial walls

Systolic blood pressure

measurement of the pressure of blood in the arteries when the ventricles are contracted

normal is less than 120

\

Diastolic blood pressure

measurement of the pressure of the blood in the arteries when the ventricles are relaxed

normal is less than 80

Pulse pressure

systolic bp minus diastolic bp

normal is 30-50 mmHg

hypotension

low blood pressure

hypertension

high blood pressure

orthostatic hypotension

low blood pressure that occurs upon standing up; measure lying, sitting, and standing; important if client takes antihypertensives or has history of fainting or dizziness;

difference/change should be less than 20 mmHG

acute pain

usually associated wit a recent injury; short term

chronic pain

persistent; usually lasts 6 months or more; generally in slightly older people

cancer pain

may be caused by the cancer, its treatment, or its metastasis

intractable pain

high resistance to pain relief; no matter what you give them they are still in pain; often occurs in back pain patients (grinding of bones due to thinning vertebral discs)

Pain

the 5th vital sign

subjective - it’s whatever the patient says it is

protective mechanism

Perception

awareness of the characteristics of pain; hypothalamus and limbic system responsible for emotional aspect of pain perception while frontal cortex is responsible for the rational interpretation and response to pain; can be affected by emotional status (depression and anxiety)

Modulation

changes or inhibits the pain message relay in the spinal cord; descending pathways wither increase or inhibit pain transmission;

Physical abuse

restraint, pushing, slapping

Psychological abuse

insults, isolation, threats

Economic abuse

controlling money, exploitation

Sexual abuse

any sexual act without consent; forcing against will

Culture

the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making