Nursing fundamental Final Review

Health is a state of complete _____, _______*, and ___*_____ well-being and not merely the absence of disease or infirmity__

physical, mental and social well-being

Wellness is a dynamic state of heath in which an individual actively progresses ______________________, ahcieving an optimal balance ebtween internal and external environments

progresses towards a higher level of functioning

health promotion are activities that help persons ____ __or__ ____ their present level of health and reduce their risk of developing certain diseases

maintain or enhance

disease is___ __or__ ___ of biological or phycological processes

malfunctioning or maladaptation

QSEN strides for

patient centered nursing care

Person centered care has what 6 values

promoting respect, honoring choice, promoting positive well-being, supporting independence, improves quality of life, and empowers recipient of care

Patient safety is the ____ __and ____ of patient injuries of adverse events__ ______ of health care delivery

avoidance and prevention

resulting from the processes

Adverse event is an __ __caused by__ ______________ that delays discharge and/or results in disability

adverse event

types of data

subjective (symptom) and objective (sign)

sources of data for assessment

primary sources and secondary sources

types of physical assessment

inspection, palpation, percussion, and auscultation

what is the regular order of assessment? what about for abdominal

for regular assessments its

inspection → palpation → percussion → and auscultation

but in abdominal assessments' its

inspection → auscultation → percussion → and palpation

When inspecting …

concentrated watching. Involves looking, listening, and smelling for unexpected findings when interreacting with patients

identify degree of distress, provide private conditions with adequate lighting and exposure. Look for size, shape, color, symmetry, position, and abnormalities

when palpating

use touch to gather info. Using parts of the hand to detect different characteristics of the skin, organs, glands, blood vessels, and thorax. Hands should be warm, with short fingernails. Technique should be slow, gentle, and systematic. Palpating tender areas last, start with light palpation and end with deep palpation

percussion is

tapping the body with fingertips to produce a vibration to determine location, size, and density of structures

when auscultating

listen to sounds produced by the body such as lungs, heart, blood vessels, and abdomen using our ears and stethoscope. We are assessing for frequency, loudness, quality, and duration

when considering cultural sensitivity

respect differences and avoid stereotyping. Consider health beliefs, use of alternative therapies, nutrition habits, relationships with family, and comfort with physical closeness

colonization occurs with the present and growth of microorganisms within a host but ___________ or damage

without tissue invasion

infection is the __ __of a susceptible host by a pathogen or microorganism__ _____________

invasion

resulting in disease

assessment of infection risk include

age, lifestyle, occupation, nutritional status, travel history, stress, procedures, and disease

chain of infection

reservoir, infectious agent, susceptible host, portal of entry way in, mode of transmission, portal of exit way out, and reservoir

medical asepsis

clean technique to reduce the number and transmission of disease causing microorganisms after they leave the body, but doesn’t necessarily eliminate them

universal precautions

to prevent the transmission of bloodborne pathogens from exposure to blood and other potentially infectious materials. Avoiding bloodborne pathogens from bodily fluids

standard precautions

to prevent and control infections and its spread to all persons. Based on the principle that all blood, body fluids, secretions, excretions, nonintact skin, and mucous membranes may contain transmissible infectious agents

key elements of standard precautions

hand hygiene, use of PPE, safe injection practices, equipment handling, and respiratory hygiene/cough etiquette

when should u wash your hands

when hands are visibly dirty, after known or suspected exposure to C diff or other infectious __diarrhea__ during norovirus outbreaks. After exposure to bacillus anthracis is suspected or proven, before eating, and after using a restroom

use hand sanitizer for

everything else when washing hands are not needed

PPE includes

gloves, gown, mask or respirator, and goggles or faceshield

To don PPE, what is the order

gown → mask or respiratory → goggles or faceshield → gloves

to take of PPE what is the order

gloves → goggles of face shield → gown → mask or respirator

contact precautions

direct patient or environmental contact

droplet precautions

respiratory tract transmission over short distances

airborne precautions

remains in the air, infective over time and distances

protective environment

limited patient population

levels of communication

intrapersonal, interpersonal, small group, public, electronic

four phases of nursing patient relationship

preinteractions, orientation, working, and termination

Active listening means being ____ to what a patients is saying both ____ and _____

Active listening means being **attentive** to what a patients is saying both **verbally** and **nonverbally**

SOLER in active listening

sit facing the patient

open position

lean towards the patient

eye contact

relax

Empathy is the ability to ______ and accept another person’s ________ accurately perceive feelings, and communicate the understanding to the other person

Empathy is the ability to understand and **accept** another person’s **reality** accurately perceive feelings, and communicate the understanding to the other person

_________ is one of the most potent and personal forms of communication

touch

types of communication barriers

cant speak clearly, cognitive impaired, hard of hearing or deaf, vision loss, unresponsive or does not speak english

aphasia

injury to speech center in the cerebral cortex. lost their ability to understand or express speech as a result of brain damage

dysarthria

weak, slow moving, or non moving muscles of the mouth

In the interview stage of history

gathering subjective data to obtain information and built report. Its to record a complete health history

three phases of the interiew

introductory, working, and closure

during the health history you collect

Biographical data, sources of history, reasons for seeking care/chief complain, history of present illness, past health, family history, review of systems, functional assessment, perception of health

PQRSTU

provocation/palliation

quality and or quantity

region or radiation

severity scale

timing onset, duration, frequency

Understand patients perception and/or unable to do

provocation or palliation

what brings it on? what were you doing when you first noticed it, what makes it better? worse?

quality and/or quantity

How does it look, feel, or sound? How intense/severe is it

Region and/or radiation

Where is it? Does it spread anywhere else

Severity scale

How bad is it (1-10 scale)? Is it getting better, worse, or staying the same

timing onset, duration, frequency

onset - exactly when did it first occur? Duration - How long did it last? Frequency - How often does it occur

Understand patients perception and/or unable to do

What do you think it means? What are you not able to do as a result

vital signs include

blood pressure, temperature, pulse, respiration, oxygen saturation, and pain

when to measure vital signs

on admission to a healthcare facility, when assessing a patient during home care visits, in a hospital on a routine schedule'

before, during, after medications and treatments or procedures

before, during, and after nursing interventions influencing a vital sign

when a patients general condition changes

when a patient reports nonspecific symptoms of physical distress

factors affecting body temp

age, exercise, hormonal level, environment, circadian rhythm, temperature alterations

temperature measurement sites

oral, axillary, rectal, tympanic, and temporal

average temperature ranges

normal: 36 - 38 C (96.8 - 100.4 F)

average oral/tympanic: 37 C (98.6 F)

average rectal: 37.5 (99.4)

average axillary: 36.6 C (97.6)

factors that can influence pulse

exercise, temperature. emotions, medications, postural changes, pulmonary conditions, hemorrhage

tachycardia, eucardia, and bradycardia

tachycardia: >100 bpm

eucardia: 60-100 bpm

bradycardia:

when assessing radial pulse check for what elements

rate, rhythm, strength/amplitute, and equality

other than radial you can measure pulse using

apical pulse. listening at 5th ICS, mid-clavicular line. Check for rate and rhythm, (not strength)

ventilation

the movement of gases in an d and out of the lungs

diffusion

the movement of oxygen and carbon dioxide between the alveoli and the red blood cells

perfusion

the distribution of red blood cells to and from the pulmonary capillaries

mechanics of breathing

inspiration is an active process. expiration is a passive process

factors affecting breathing

exercise, acute pain, anxiety, smoking, body positions, medications, neurological injury, and hemoglobin function

respiration ranges

tachypnea > 20 per minute

eupnea: 12-20 per minute

bradypnea:

respiration assessment should include

rate, depth, rhythm, and effort

blood pressure is when

the **force exerted on the walls of any artery** by the pulsing blood under pressure from the heart. The peak of the maximum pressure when ejection occurs is the **systolic** pressure. **Diastolic** is the minimal pressure exerted against the arterial walls at all times

an increase or decrease in any of these factors can affect blood pressure

cardiac output, peripheral resistance, blood volume, viscosity, elasticity

factors that influence blood pressure

age, stress, ethnicity, gender, daily variation, medications, activity and weight, and smoking

normal blood pressure value

less than 120/80

abnormal blood pressure ranges

elevated/hypertension: >120 /

common errors in BP measurement

taking BP when person is anxious, smoking/caffeine, position of arm above heart, position of arm below heart, wrong cuff size, cuff wrapped too loose, failure to wait 1-2 minutes before repeating BP, arm not supported

korotkoff sounds

sounds heard over an artery distal to the blood pressure cuff when the cuff is deflated

auscultatory gap

gap in between the first and second Korotkoff sounds. Causes underestimation of SBP or overestimation of DBP. be sure to inflate the cuff high enough to hear the true SBP before gap and avoid this by using the palpatory method before auscultatory method

when is electronic blood pressure not appropraite

hypertension, hypotension, irregular heart rhythm, peripheral vascular obstruction, shivering, seizures, excessive tremors. and inability to participate

avoid taking Bp when

patient is on hemodialysis with a AV shunt, has had a mastectomy, has a central venous/PICC lines, has an open wound

documenting BP

blood pressure value, site used

oxygen saturation evaluates

diffusion and perfusion. the percent of hemoglobin that is bound with oxygen in the arteries is the percent of saturation of hemoglobin

normal SPO2 value

93 - 100%

documentation of SPO2

measured value, flow rate of oxygen, and method of oxygen delivery device

factors affecting SPO2 measurement

patient motion, nail polish, and artificial nails

general survey is a

brief study of the whole persons **general health state** and obvious **physical characteristics**. Provides an **overall** impression and includes **objective** parameters that apply to the **whole** body including physical appearance, body structure, and mobility

general survey includes what factors

gender and race, age, signs of distress, body type/stature, posture, gait, body movements, nutritional status, hygiene and grooming, dress, body odor, affect and mood, speech, signs of abuse, substance abuse, and height and weight

psychological assessement

evaluation of one’s mental health and social well-being in a collection of subjective data

what to assess and tools you can use in a psychological assessment

psychiatric and psychological history - PHQ2 or 9: GAD

medications

history of dug or alcohol use - CAGE, AUDIT -C

violence risk: suicide, intimate partner violence : ASQ, HITS

coping skills

attitude beliefs

factors of a social health assessment

social, family, employment, dedication, and developmental history, legal trouble, financial situation and culture

factors of acute pain

short term(

chronic pain

lasting 6 months or longer, malignant/non-malignant

three types of pain scales

numeric rating scale, verbal descriptor scale, and face pain scale revised

pain >7 you should

assess Q and R.

A: how would you describe your pain

R: show me where it hurts. does it stay there or does it spread somewhere else

then immediately report the QRS of pain to your nurse or clinical instructor

pain 1-6

assess PQRSTU mnemonic. Ask at what level would you like your pain to be when moving around? then report to your nurse, clinical faculty your patient’s response

PAINAD

pain assessment in advanced dementia. use numeric rating scale or verbal descriptor scale

acute pain behaviors

autonomic and protective responses

guarding, grimacing, vocalizations (moaning, agitation, restlessness, stillness)

diaphoresis

changes in vital signs

chronic pain bhaviors

adaptation has occurred so more variability

bracing, rubbing, diminished activity, sighing, and change in activity

Falls are a common cause of ______ and ________

hip fractures and traumatic brain injury

non-modifiable risk factors for fall

age, sex, race/ethnicity, history of fall

modifiable health factors for fall prevention

difficulties with gait and balance, lower extremity weakness, adverse drug events and polypharmacy, vitamin D deficiency, orthostatic hypotension visual impairment, foot issues or improper footwear, and home hazards