J2 Comp

Assessment Findings and Anticipated Interventions

• Introduction to Assessment Findings

  • Importance of understanding patient conditions to guide assessments.

  • Need to study and practice skills related to assessments.

Atrial Fibrillation (A Fib)

• Diagnosis of A Fib

  • Method: Electrocardiogram (ECG or EKG).

  • Characteristics:

  • Irregular heart rhythm.

  • Absence of P waves.

  • Presence of QRS complex.

• Risks associated with A Fib

  • Potential to develop clots (embolism).

• Anticipated Orders from Provider

  • Order: Anticoagulant medications (e.g., warfarin).

  • Common route: Subcutaneous (Sub Q) injections.

Asthma Assessment

• Expected Findings

  • Auscultation: Presence of wheezing during breathing.

  • Timing of Wheezing: More common during expiration but can occur in inspiration.

• Anticipated Provider Orders

  • Medication: Bronchodilator (e.g., albuterol).

  • Route: Inhalation or nebulization.

Compartment Syndrome

• Key Assessment Findings

  • Monitor for the “six P's” (Pain, Paresthesia, Pulse, Pallor, Paralysis, Pressure).

Hyperglycemia Assessment

• Expected Findings

  • Breath characteristic: Fruity odor (due to ketosis).

• Anticipated Interventions

  • Medications: Administer insulin to lower blood sugar.

  • Syringe requirement: Orange needle (commonly used for insulin measuring in units).

Hypoglycemia Management

• Anticipated Interventions

  • Medication: Dextrose, available in oral or intravenous (IV) form.

Patient Interaction Protocol

• Introduction Protocol

  • Nurse must introduce themselves to the patient.

  • Importance of hand hygiene before touching the patient.

• Patient Identification

  • Importance of confirming patient identification via wristband.

  • Cross-check with Medical Administration Record (MAR).

Vital Signs Assessment

• Components of Vital Signs

  • Heart Rate: Assessed via palpation or telemetry (telly).

  • Blood Pressure: Automatic cuff method.

  • Oxygen Saturation: Using finger pulse oximeter.

  • Temperature: Forehead thermometer or oral method.

  • Respiratory Rate:

  • Count for 30 seconds if regular; measure over three minutes if irregular.

• Recording and Integrity of Data

  • Ensure accuracy in reported rates, particularly respiratory count (e.g., 16, 18).

Comprehensive Patient Assessment

• Sequence of Assessment

  1. Neurological: Orientation questions (person, place, time, situation).

  2. Allergies: Verify allergies during patient check in.

  3. Cardiac Assessment:

  • Auscultate heart sounds at least in two or three areas; key focus on the apical pulse (Z-pattern).

  1. Pulmonary Assessment:

  • Assess for symptoms of trouble breathing or cough; auscultate lungs (front and back).

  1. Gastrointestinal (GI)/Genitourinary (GU) Assessment:

  • Inquire about nausea, vomiting, diarrhea, abdominal pain, last bowel movement, and last urination.

  • Auscultate abdominal quadrants.

  1. Extremities/PV Assessment:

  • Includes checking pulse, edema, capillary refill, and temperature.

  1. IV and Tube Assessments:

  • Check the condition and function of IV lines, drainage tubes, urinary catheters.

Assessment Completion

• Next Steps After Physical Assessment

  • If abnormalities are found, prepare to call the provider using SBAR format.

• Importance of Speaking Up

  • Emphasize the importance of patient safety and advocating against any observed errors.

Medication Administration

• Rights of Medication Administration

  • Number of rights: 7

  • Administration checks: 3 times (Before, During, and After medication retrieval/preparation).

• Specifics on Medication Types and Administration Routes

  • Types: IV fluids (bolus, drip, etc.), bronchodilators, injections, etc.

  • Subcutaneous vs Intramuscular Injection Lengths

  • Subcutaneous: 5/8 inch needle.

  • Intramuscular: 1-1.5 inch needle.

IV Fluids and Infusions

• Bolus vs Continuous Infusion

  • Example Calculation: For a 300 ml bolus over 30 minutes, rate is 600 ml/hr.

Patient Education and Reassessment

• Importance of Education

  • Explain reasons behind medication to the patient (e.g., bronchodilator will expand airways).

  • Reassessments after interventions to confirm effectiveness before moving to the next task.

Hard Stop Protocols

• Important protocol reminders for patient assessments, including:

  • Always check under gowns, assess under clothing.

  • Ensure accurate and honest documentation of findings.

• Professionalism: Maintain full uniform, punctuality, and communication during clinical activity.

Final Thoughts

• Ensure competence in performing essential nursing skills previously tested, and prepare to integrate theory into practice.

• Emphasize importance of not falsifying assessment data, as it can have legal consequences.