Nursing exam 2 (Kent state)

HEENT

head, eyes, ears, nose, throat

What is assessed in a HEENT assessment?

carotid arteries, jugular vein, lymph nodes, thyroid gland, and trachea

assessing facial features for symmetry

eyelids, eyebrows, nasolabial folds, and mouth. Assess for any facial droop

What could facial drooping mean?

Stroke or bells palsy

Ptosis

eyelid drooping

Normocephalic

refers to round symmetric skull that is appropriately related to body size

hydrocephalus

accumulation of cerebral spinal fluid in the ventricles of the brain

TMJ

temporomandibular joint (Mandible and maxilla)

exophthalmos

bulging eyes

What causes exophthalmos?

over activity of the thyroid gland or hyperthyroidism

strabismus

crossing of the eyes

lacrimal gland function

continuously supply tear fluid that's wiped across the surface of your eye each time you blink your eyelids

Conjunctivitis

inflammation or infection of the transparent membrane (conjunctiva) that lines your eyelid and covers the white part of your eyeball

PERRLA

pupils equal, round, reactive to light and accommodation

How are pupils measured?

In millimeters

Pupils response to light

should constrict directly and with consensual response of the opposite pupil to light

Cataracts

clouding of the lens in the eye that affects vision
due to aging

Glaucoma

Aqueous humor (the liquid of the eye)is always being made behind the colored part of the eye (the iris)

Intraocular pressure (IOP)

pressure build up in the eye due to the slowing or blocking of aqueous humor

macular degeneration

Deterioration of the macula which is the area on the retina that is responsible for central vision
Age related
Can destroy central vision

risk factors of macular degeneration

smoking, hypertension, and high cholesterol

hyperopia

Farsightedness, can see things better at a distance

Myopia

common vision condition in which you can see objects near to you clearly, but objects farther away are blurry. Often called nearsightedness

presbyopia

Loss of accommodation, an inability to maintain focus on near object
Caused by age and the eye lens hardening

astigmatism

Curvature of the cornea and lens of the eye
Light is diffuse rather than sharply focused on the retina

retinopathy

Any disorder of the retina
arteriosclerotic, diabetic, hypertensive, solar

Why do we document?

Communication
Orders
Care planning
Quality improvement
Research
Legal
Reimbursement

Effective documentation

Accurate
Clear
Concise
Consistent
Legible/readable
Thoughtful
Timely
Sequential
Reflect the nursing process
Relevant
Retrievable

documentation guidelines

Avoid words like "good" or "normal"
Note problems in the order which they occur
Always record precautions or preventative measures
Do not use stereotypes or generalizations
Always record when providers were notified
Know your institutions documentation standards

what to chart

Shift assessment
Provider visits
Responses to interventions
Teaching - be specific
Changes in patient status
Transport or discharge

Nursing assessment

Care plan Patient care summary
Critical pathways
Flow sheets / graphic records
Progress notes
MAR's (medication record)
Acuity levels
Discharge or transfer

When to chart

Add entries in a timely manner
If you forget something do it as soon as you can
Date and time (written)
Use 24 hour clock
NEVER NEVER NEVER document something before you do it

How to chart

Make sure you have the right chart pulled up in the EMR
If you are recording on paper, use black ballpoint pen
Use proper grammar and correct spelling
Only use standard abbreviations

Electronic medical record

Make sure you are logged in under your own name / account
The program will automatically time/date stamp everything you do
Every entry you create will be linked to your name
Deleted entries never really go away

Paper record

First initial, last name
No white-out or erasing
Every page needs to have patient's name and medical record #

Bad Documentation

Sloppy or unreadable
Untimed / undated or unsigned
Missing or incomplete data
Entering data into the wrong chart
Using the wrong abbreviations
Documenting subjective data

Violating patient confidentiality

Discussing patients in a public area
Leaving medical documents out
Leaving a computer unattended/forgetting to log off
Sharing / not protecting passwords
Improperly accessing data for friends/relatives
Improperly accessing data out of concern or curiosity

Delegation

RN's are responsible for supervising unlicensed coworkers' charting
Know and follow your facility's rules

Benefits of Computerized Documentation

Up-to-date
Quick access
Secure data / enhanced privacy
Fewer errors
Improved communication between providers
Safer prescribing
Legible

Drawbacks to EMR

Expensive (hardware and software)
Can be time consuming
Can interfere with patient interactions
Computer to staff ratio

Health information exchange

Allows providers to securely access patient information electronically
Improves quality and safety of care
Facilitates healthcare in emergency situations

Problem-oriented medical charting

Organized around a patient's problems
Entire health care team works together
SOAP & PIE charting

SOAP (and SOAPIE)

Subjective - patient says pain at surgical incision is "8/10"
Objective - patient is moaning and reluctant to get out of bed, pulse 100
Assessment - patient is having incisional pain
Plan - relieve pain to acceptable level
Implementation - medicate with ibuprofen, reposition for comfort
Evaluation - check on patient within one hour to reassess pain

PIE charting

Problem - data from your assessment
Intervention - what you do to help
Evaluation - patient's response

Charting by exception

Uses well-defined standards of practice
Only significant findings or "exceptions" are emphasized
Quicker

Reporting care

Giving your account of the patient during your shift
What was done, seen, heard or considered
Often given in SBAR format
Face-to-face
Phone
Messengers
Written

What should you always remember to include in your report?

Basic info
Current health status
Patient progress toward goals
Labs or scans
Abnormal findings
Pain level
Current orders
Medications
Upcoming tests
Changes in care
Anything that was not done?
Patient or family concerns

Reports to family or significant others

Keeping loved ones updated
Working together toward goals
Always ask patients who is entitled to reports
Be mindful with sensitive information
If patient is unable to communicate, use best professional judgement
Always be honest, compassionate, and respectful

Giving report to the provider

When would you contact the provider to give them report?
Identify your name and role
State the exact reason you are calling
Be ready to give current data: vital signs, lab results, medications
Record per your facility's policy

SBAR

Situation: what is happening right now?
Background: what are the circumstances that led to this?
Assessment: what do I think the problem is?
Recommendation: what should we do to correct the problem?

Receiving Verbal Orders

Read back the order to verify accuracy
Record the orders in the patient's chart immediately
Write VO (Verbal order), the name of provider, and your name
Supposed to be done in an emergency situation only

Incident report

Something out of the ordinary
Could or did cause harm
Used for identifying risk and changing processes
Not intended to be used for disciplinary action

Conferring about care

Consultation
Getting help outside of the nursing scope of practice
Example: social work
Referral
Sending a patient to another source of assistance
Example: specialist

purposeful rounding

Proactive and systematic
Evidence-based
Helps nurses anticipate needs and head off problems
Promotes patient safety
improves patient satisfaction

Values

A belief about worth of something or about what matters that acts as a standard to guides one's behavior

Value system

An organization of values in which is ranked along a continuum of importance
Influences a persons attitude, beliefs, behavior

Values Essential to the Professional Nurse

Altruism: Concern for the welfare of others
Autonomy: Respects the patient's rights
Human dignity: Treat as being of worth
Integrity: Provides care based on the Code of Ethics
Social justice: Fairness: Equal access to all

Value clarification

Essential for nurses
Prevents moral distress when faced with ethical and patient care concerns
A person clarifying values learns to make choices when alternatives are presented and determines whether choices are carefully made

Ethics

Standards of conduct and moral judgment
Professional ethics involve principles and values with universal application and standards of conduct to be maintained in all situations

Code of ethics

an implied contract through which the profession informs society of the principles and rules by which it functions

Nursing code of ethics

Ethical obligations and duties of every nurse
Profession's nonnegotiable ethical standard
Understanding of its commitment to society

The virtues of nursing

Competence
Compassionate
Subordination of self-interest to patient interest
Self-effacement
Trustworthy
Conscientious
Intelligence
Practical Wisdom
Humility
Courage
Integrity

Theories of ethics

Utilitarianism
Greatest good for the greatest number of people
Focuses on the effect of an action
Deontology
Focuses on the rights of the individual
Does not consider the greater good or consequences of specific actions on others

Principle-Based Approach

Beneficence
Doing good or promoting good on behalf of others
Nonmaleficence
Avoidance of doing harm; preventing harm to others
Autonomy
Respect for a person's right to make their own decisions
Justice
Fairness
Veracity
Telling the truth; commitment to honesty
Fidelity
Commitment to keep promises

Statutory Law

Created by elected legislative bodies
Nurse Practice Acts
Standards of Care
Licensure

Administrative Law

Created by administrative bodies
Rules and regulations established by State Boards of Nursing
Protects the public from harm

Criminal laws

Prevent harm to society
Provide punishment
Felony: Prison sentence > 1 year
Misdemeanor: Lesser crime; fine or < 1 year in prison

Intentional torts

Assault
Threat of harm
Battery
Touching without consent
Defamation of character
Slander-oral
Libel-printed
Fraud
Invasion of privacy
False imprisonment

Unintentional torts

Negligence
Practice below standard of care
Malpractice
Professional negligence
The nurse had a duty to the patient/client
The nurse failed to meet standards of care
The patient/client was injured
The nurse's actions caused the injury
Intent to injure need not be shown

Safeguards to Competent Practice

Respect Legal boundaries of practice
Follow institution's policies & procedures
Owning personal strengths and weaknesses
Evaluating proposed assignments
Keep current in nursing knowledge and skills
Respect patient's rights
Careful documentation

Advance Directives

Living Will
Durable Power of Attorney for Healthcare
Do Not Resuscitate
Tissue and Organ Donation

Legally Challenging Nursing Issues

Controlled Substances
Uniform Determination of Death Act-1980
Cardiopulmonary standard
Whole brain standard
Terminal Sedation
Passive Euthanasia
Active Euthanasia
Voluntary Active
Physician Assisted
Involuntary Active

Good Samaritan Law

Protect health care professionals practicing within standards of care
May require nurses in some states to stop and help in an emergency
Providing emergency care outside of a nurse's place of employment is not legally required in the State of Ohio

Methods of Conducting Nursing Research

Quantitative Research Methods
Basic research
Applied research
Qualitative Research Methods
Application of Research to Practice

Evidence-Based Practice

Problem-solving approach to making clinical decisions using the best evidence available
Critical thinking and appraisal of research
One's clinical expertise
Client preferences and values

Benefits of EBP

Yields better patient outcomes
Promotes practices based on research rather than tradition
Improves patient care experience
Provides higher level of satisfaction among nurses
Increases quality of care while decreasing healthcare costs
Engages nurses in the research process
Contributes to the evolution of nursing practice

Implementing EBP

Identify a relevant question
Collect the most relevant and best evidence
Assess or appraise the evidence
Integrate the evidence with clinical expertise, patient preferences & values
Evaluate the whole process

PICO

patient ,population, or problem of interest
intervention of interest
comparison of interest
outcome of interest

Critical Reasoning

Ways of thinking about patient issues

Clinical Judgment

Conclusions, decisions or opinion

Critical Thinking

Includes both reasoning and judgment
Helps choose solutions or identify options for
patient care situations

critical thinking begins by asking three questions

What do I really know?
How do I know it?
What options are available to me?

How To Use Diagnostic Reasoning

Diagnostic reasoning is the process of gathering and clustering data to draw inferences and propose a diagnosis

Essential Critical-Thinking Traits

Confidence
Independent thinking
Fairness
Responsibility & Accountability
Risk-taking
Discipline
Perseverance
Creativity
Curiosity
Integrity
Humility

Nervous System Functions

Initiation/coordination of movement Reception/perception of sensory stimuli
Organization of thought processes
Control of speech
Storage of memory

Integration of Neurological Assessment

Evaluate cranial nerves while assessing the head and neck
Assess mental and emotional status during the intake interview
Focus the neurological assessment
-Patient health status
-Patient concerns

Alertness/Orientation

A & O ×4
Person Place Time Reason

Level of Consciousness

Glasgow Coma Scale
- Objective numerical scale
- Measures level of consciousness

Assessing language

Access cerebral cortex function
Ability to understand spoken or written words
Ability to express thoughts

Aphasia

Sensory (receptive)
- Inability to understand written or verbal speech Motor (expressive)
- Inability to write or speak appropriately
May be both (global)
- Depending on area of cerebral cortex damage

Intellectual function

Memory
- Recent/Short term
- Remote/Long term
Knowledge
Abstract thinking
- Interprets colloquialisms
Association
- Identifies related concepts
Judgment
- Logical decision making

Cranial nerve 1

Olfactory (smell) sensory

Cranial nerve 2

Optic (vision) sensory

Cranial nerve 3

Oculomotor (eye movement) motor

Cranial nerve 4

Trochlear (up and down eye movement) motor

Cranial nerve 5

Trigeminal (Sensory nerve to face, motor nerve to jaw muscles) both

Cranial nerve 6

Abducens (lateral eye movement) motor

Cranial nerve 7

Facial (Facial expression, taste on front of tongue) both

Cranial nerve 8

Auditory (hearing) sensory

Cranial nerve 9

Glossopharyngeal (Gag reflex/swallow, taste on back of tongue) both