pp

Subjective data collection

information that vocally comes from the pt (history)

Objective data collection

information that the HCP observes thru percussion, auscultation, looking/ inspection, and palpation (physical exam)

Clinical reasoning models

- diagnostic reasoning
- nursing process
- critical thinking
- head-to-toe

Diagnostic reasoning

scientific method to analyze H data and draw conclusions to identify a diagnosis

Steps in diagnostic reasoning

1. attending to initially available cues
2. formulating diagnostic hypothesis
3. gathering data to the tentative hypothesis
4. eval. each hypothesis with new data collected to arrive at a final hypothesis

Nursing process steps

1. assessment
2. diagnosis
3. outcome ID
4. planning
5. implementation
6. eval.
(ADPIE)

Which clinical reasoning model is a "systemic approach"?

head-to-toe

Attending meaning

looking at initial available cues or information that pt gives

Formulating meaning

having a hunch that pt has something going on based on our gathered information

Assessment meaning

collecting data

Ways of collecting data during the assessment during the nursing process

- H history
- interview
- review of literature

Different parts of the nursing diagnosis in the nursing process

- interpreting data (identify clusters of cues to make inferences)
- validate inferences (thru subjective/ objective data)
- compare clusters of cues with definitions and characteristics
- document diagnosis

What is known as an "universal taxonomy" in nursing practice?

nursing diagnosis (what we can do as a nurse under nursing practice)

Actual nursing diagnosis is when...

the pt actually has something currently

Actual nursing diagnosis consists of what?

diagnostic label + contributing factors + as evidence by
(constipation related to inadequate fibre consumption as evidence by hard/ dry stools every 3-4 days with pain while defecating)

Risk diagnosis

clinical judgment that person/ grp is more vulnerable to develop due to risk factors

Risk diagnosis consists of what?

diagnostic label + contributing factors
(risk for impaired skin integrity related to immobility)

Wellness diagnosis

clinical judgment abt person/ fam./ community from a specific lvl of wellness to a higher lvl (pt might be "healthy" but wants to be in even better H)

Wellness diagnosis consists of what?

diagnostic label
(pt walks a lot and is in good "H" bc of that but wants to improve cardiovascular ctrl)

What starts a wellness diagnosis?

readiness to enhance by the pt

What does a nurse do during outcome identification?

- identify expected outcomes
- individualize care to the pt
- ensure outcomes are realistic and measurable
- include time-frame

What will a nurse do during the planning phase of the nursing process?

- establish priorities
- develop outcomes
- set time frame for outcomes
- identify outcomes
- document POC

In the nursing process, using the inhaler or taking pain medication before exercise would be arranged/ chalked out during which stage?

the planning stage

What will a nurse do during the implementation stage of the nursing process?

- review planned interventions
- schedule/ coordinate total HC and collaborate with team
- supervise care plan
- involve pt in POC
- refer pt for continuing care
- document care provided

When documentation is NOT done, what is assumed in the HC setting?

that when something is not documented, it is not done

What will a nurse do during the evaluation stage of the nursing process?

- refer to established outcomes
- compare actual vs. expected outcomes
- summarize results
- modify plan if needed
- document eval. in POC
- ask pt "ending" Q's

During the nursing process evaluation, why is the POC sometimes modified?

to ensure that the pt is actually being helped instead of being written off

What Q's would a nurse ask themselves just before finishing the evaluation stage of the nursing process?

- "is there a possible problem in a certain area?"
- "is the pt at risk?"
- "does the pt desire to improve their H?"

Critical thinking includes what?

- assumptions
- (looking at) inconsistencies
- (looking at) normal vs. abnormal findings
- clustering
- H promotion

Why should we, as nurses, be careful when using the language "normal" or "abnormal"?

normal or abnormal can mean very different thing in different ppl + saying someone is abnormal bc they don't fit a stereotype is rude

When is it okay to say "normal" or "abnormal" as a nurse?

when describing things like organ function or lab values

H promotion

the process of enabling ppl to increase ctrl over, and improve, their H

Methods of data collection

- interview
- nursing H history
- physical exam
- diagnostic/ lab data

Interviewing for data collection consists of what type of data?

subjective data from the pt to the examiner

Why does an interview consist of sending and receiving from both ends (pt + examiner)?

bc internal factors, mood, nonverbal communication, and verbal communication can aid/ obstruct the interview

The contract btwn pt and examiner consists if what?

- time/ place
- introduction/ explanation
- purpose/ expectations
- presence of others/ confidentiality
- costs

As a nurse, is always important to be truthful to your pt. If you do not know the answer to their Q, you are allowed to tell them that you don't know. However, what can this cause what btwn the pt and nurse?

distrust from pt to nurse

What are internal factors included in a nurse-pt interview?

- liking others
- empathy
- ability to listen
(be engaged - don't be preoccupied by thoughts)

What are external factors included in a nurse-pt interview?

- privacy
- stop/ decrease amt of interruptions
- comfortable environment
- dress nice
- note taking
- tape/ video recording

What are the challenges of note taking during a nurse-pt interview?

- impedes eye contact
- attention seeking and interrupts pt's narrative flow
- can be threatening

What is included in the physical environment during a nurse-pt interview?

- temp.
- lighting
- noise (IV noises, monitors)
- distracting equipment
- distance btwn examiner and pt (2 arms lengths or with covid 2 meters)
- equal status seating (eye-eye contact)

Techniques of communication during an interview

- open-ended Q's
- closed-ended Q's
- responses
- nonverbal skills
- closing the interview correctly

Open-ended questions

asks for narrative info
("tell me abt yourself/ abt your abdominal pain")

Closed-ended questions

asks for specific info (more answers + quicker than open-ended)
(yes/ no Q's)

What are the different types of responses that would assist the narrative during a nurse-pt interview?

- facilitation (head nodding)
- silence
- reflection (repeating pt answers)
- empathy
- clarification (confirming that you've understood the pt)
- interpretation ("this is what I heard. is that correct?")
- explanation (share info with pt)
- summary (summarize what you've heard to pt)

What are the 10 traps of interviewing?

1. providing false assurance
2. giving unwanted advice
3. using authority
4. avoidance language
5. distancing
6. jargon
7. leading/ biased Q's
8. talking too much
9. interrupting
10. "why" Q's

What are nonverbal skills an examiner must understand before having an interview with a pt?

- physical appearance
- posture
- gesture
- voice (don't talk too slow/ fast, don't talk too much, have a normal pitch of voice)
- touch
- facial expression

How should the examiner close an interview with a pt?

ask if there is anything that the pt would like to discuss or if they have any Q's

If a pt appears nourished and oriented x3 but refuses an interview, what should you not say in your documentation?

do not say "appears" - only tell the FACTS
("pt refused interview. pt states...")

What are the 4 main assessment techniques?

- palpation
- inspection
- percussion
- auscultation

Inspection meaning

visually looking at pt (secretly or in an assessment-related way)

What is done during a pt inspection?

- gait as pt walks into/ out of room
- comparing L + R side (symmetry)
- using otoscope (outer ear canal + eardrum) or ophthalmoscope (pupils/ eyes)
- using penlights or flashlights
- any strong odour
- skin colour
- posture
- movement

Palpation meaning

touching to figure out temp., bumps, lumps, and moisture

Light palpation

1-2 cm

Deep palpation

5-8 cm
(used for organs, abdomen, bariatric pt's - can cause harm)

Auscultation meaning

listening by using a stethoscope (typically)

Special considerations when using a stethoscope for auscultation

- hairy chest -> avoid friction
- clothing -> doesn't give accurate/ full results

Percussion meaning

assessing the density of the underlying structures

Indirect percussion

striking hand hits the stationary hand (more common than direct percussion)

Direct percussion

lightly tapping on sinus' (looking for pain response)

What are the percussion sounds?

- resonance
- hyperresonance
- tympany
- dullness
- flatness

Resonance percussion sound characteristics

location = part air part solid areas (ex. normal lung)
intensity = loud
pitch = low
length = long
quality = hollow

Hyperresonance percussion sound characteristics

location = mostly air area (ex. lung with emphysema, normal child lung)
intensity = very loud
pitch = low
length = long
quality = booming

Tympany percussion sound characteristics

location = air locations (ex. gastric bubble)
intensity = loud
pitch = high
length = moderate
quality = drum like

Dullness percussion sound characteristics

location = solid tissue areas (ex. diaphragm, pleural effusion)
intensity = medium
pitch = medium
length = moderate
quality = thud-like

Flatness percussion sound characteristics

location = very dense tissue areas (ex. muscle, bone, thigh)
intensity = soft
pitch = high
length = short
quality = flat

What are the different parts of the hands used for while percussing?

- fingertips = skin texture, swelling, pulse, lumps
- finger-thumb grasp = position/ shape/ consistency of organ
- hand/ finger dorsa = temp.
- finger bases/ hand ulnar surface of hand (side of palm) = vibration

Why is it important to pay attention to the pt's emotional state?

you don't want to be overly positive when the pt has gotten a cancer diagnosis - you will look insensitive and ignorant
(think of your "positive/ negative" impacts on the pt)

The general survey of a pt includes what?

- physical appearance
- body structure
- mobility
- behaviour

The physical appearance of a pt during a general survey can include what?

- age
- sex
- lvl of consciousness
- skin clr
- facial features

The body structure of a pt during a general survey can include what?

- stature
- nutrition
- symmetry
- posture
- position
- body build + contour

The mobility of a pt during a general survey can include what?

- gait
- ROM

The behaviour of a pt during a general survey can include what?

- facial expression
- speech
- hygiene
- mood/ affect
- dress

What is included in a vital signs check?

- temp.
- pulse
- respirations
- bp

What part of the brain works has a "thermostat mechanism" for the body?

the hypothalamus

What are common influences on temp.?

- diurnal cycle
- menstrual cycle
- exercise
- age

What is the diurnal cycle and how does it affect human temp.?

earth's rotation over 24 hrs that affects the human temp. thru surface temp. fluctuations

What are the common routes when taking a pt's temp.?

- oral
- axillary
- rectal
- tympanic

Oral temp. should be what?

35.8-37.3 C

Rectal temp. should be what?

0.4-0.5 C higher than oral (36.2-37.7 C)

What happens to our heart beat as we age?

BPM gets slower as we age until old age when our body systems start to weaken and compensation mechanisms start (BPM^)

BPM per different age grps

- infants = 100-180
- children = 80-100
- adult = 60-100
- older adult = 75-130
- athletes = 40-60

Bradycardia BPM

< 60 BPM

Tachycardia BPM

> 100 BPM

When should you take respirations during vitals?

take secretly after physically doing the pulse
("I will take your pulse again just to ensure accuracy" - then pretend to take pulse with eyes on chest or shoulders)

What is the correct range of respirations?

14-20
(range will differ from 14/12-16/18/21...)

What is the ratio btwn the pulse rate and respiratory rate?

4:1
(60:14, 80: 20...)

What is a normal bp range?

120/80 mm Hg
(mine is usually 110/70 :) )

When manually taking bp in the clinical or lab setting, what should you ask the pt?

"what is your normal bp?" then go 30 mm Hg over the systolic number (upper) when pumping air into the cuff

What are common influences on bp?

- age
- ethnocultural background
- weight
- stress
- exercise
- sex
- emotions
- diurnal cycle

Korotkoff's sounds

1. systolic pressure (120)
2. muffling
3. diastolic pressure (80)

Orthostatic hypotension

low bp from standing/ sitting up too fast
(bp drops by 10-20 mm Hg in < 3 mins)

What is different abt the bp on the thigh compared to the upper arm?

thigh bp is higher by ~17 mm Hg

When should a child be screened (x-rayed) for coarctation of the aorta?

when...
- !! heart murmurs
- breathing is laboured/ rapid
- weak femoral (groin) pulse
- pale/ grey appearance

What is coarctation of the aorta?

birth defect where aorta has a narrow section

What does a heart murmur sound like while auscultating?

whooshing/ rasping/ humming noises

When are the order of priorities used?

when pt has more than 1 H issue

What are the order of priorities?

1. first-lvl priority = emergencies, life-threatening, immediate
2. second-lvl priority = urgent
3. third-lvl priority = important to pt H but can be approached after urgent problems
4. collaborative problems = treatment involves multiple disciplines (alcohol withdrawal + its implications on the cardiovascular/ central nervous system)

What is included in first-lvl priorities?

- establishing an airway
- supporting breathing

What is included in second-lvl priorities?

- mental status change
- acute pain
- acute urinary elimination problems
- untreated medical problems
- abnormal lab vals
- risk of infection
- safety to security