Exam 1 Study Guide-Module Chloe Nguyen

1.1- Chapter 1, 2, 3, 4, 6, 11

Discuss nursing as both an art and a science-

As a professional nurse you will learn to deliver care artfully w/

compassion, caring, and respect for each pt's dignity and

personhood. As a science nursing practice is based on a body of

knowledge that is continually changing with new discoveries and

innovations.

Trace the roots of nursing as a profession from ancient to modern times

Nurses were nuns from the catholic and Anglican churches. It was

started in the Crimean and Civil War.

Discuss the contributions of Florence Nightingale as

Originator of contemporary nursing- she developed the first

organized program for training nurses, the Nightingale Training

School for Nursing at St. Thomas’ hospital in London

Pioneer in modern health care principles- Philosophy based on

health maintenance and restoration

State the definition of nursing according to Virginia Henderson

Defines nursing as " assisting the individual, sick or well, in the

performance of those activities that will contribute to health,

recovery, or a peaceful death and that the individual would perform

unaided if he or she had the necessary strength, will, or knowledge.

Describe the focus of definitions of nursing

The focus is on providing safe, patient-centered health care to the

global community.

Define the 4 main aims of nursing

Promoting wellness-educating and teaching patients about caring

for themselves to achieve a healthier lifestyle

Preventing illness-helping pts get better whenever they are sick

starting with holistically. Nurses main focus is to help the pt to get

back to as good as normal health as possible. Trying the least

invasive procedures first then more invasive if need be.

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Restoring health-medicating pts

Facilitating coping-rehabilitation. Rehab centers and physical

therapy

Discuss nursing as a

Discipline-as a nurse you work under an overhead where you have

to follow certain policies, rules, and guidelines. You must work

within your scope of practice.

Profession- to act professionally you administer quality pt-centered

care in a safe, conscientious, and knowledgeable manner. You are

responsible and accountable to yourself and your pts and peers.

List, define, and discuss:

Various roles traditional and expanded roles for nurses

o a higher level of being a maid

And expanded roles would be advocator, caregiver, communicator,

and educator.

Members of the health care team

o Physicians

o Physical therapist

o Pharmacy

o Anyone that come in contact with the that has to do with care

of the pt

Specialty certification- certification in a specific area of nursing

practice. Minimum practice requirements are set, based on the

certification the nurse seeks. National nursing organizations such as

the ANA have many types of certification to enhance your career

such as certification in medical surgical or geriatric nursing. After

passing the initial examination, you maintain your certification by

ongoing continuing education and clinical or administrative practice.

Describe the educational preparation for nursing

levels of basic and advanced preparation

AA-2 years of basic sciences, theory and clinical courses

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BA-4 years of education including basic sciences, theoretical nursing

courses, clinical courses, as well as social science, arts, and

humanities in supporting nursing theory.

Masters- provides advance clinician with strong skills in nursing

science and theory with emphasis on the basic sciences and

research-based clinical practice. Important degree for the roles of

nurse educator and nurse administrator. REQ for advance practice

registered nurse (APRN)

And doctorate- prepares graduates to apply research findings to

clinical nursing.

Continuing education-Continuing education involves formal,

organized educational programs offered by universities, hospitals,

state nurses associations, professional nursing organizations, and

educational and health care institutions. An example is a program

on caring for older adults with dementia offered by a university or a

program on safe medication practices offered by a hospital.

Continuing education updates your knowledge about the latest

research and practice developments, helps you to specialize in a

particular area of practice, and teaches you new skills and

techniques

In-service education-An in-service program is held in the institution

and is designed to increase the knowledge, skills, and competencies

of nurses and other health care professionals employed by the

institution. Often in-service programs are focused on new

technologies such as how to correctly use the newest safety

syringes. Many in-service programs are designed to fulfill required

competencies of an organization. For example, a hospital might

offer an in-service program on safe principles for administering

chemotherapy or a program on cultural sensitivity.

Discuss nursing professional organizations

American Nurses Association (ANA)-Our union- the body that

bargains for us

National League for Nursing (NLN)- the body that accredits schools

Specialty organizations-Professional nursing organizations deal with

issues of concern to specialist groups within the nursing profession.

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Describe the types of health care settings including

Inpatient-acute care/ hospitals

Outpatient-dr's office

Home care-nursing care provided for pts in their own home

Day care-a place where elderly adults can go while their caregivers

are busy working

Intervention centers- Crisis intervention and alcohol intervention

centers

Hospice-a service for the terminally ill pts

Discuss primary, secondary, and tertiary prevention

Levels Definition Examples

PrimaryActivities directed at

health promotion

Health education

Smoking cessation

Weight loss programs

Dental exams etc...

Secondary

Activities directed at

diagnosis / prompt

intervention

Mammograms Prostate exams

Colonoscopies Early treatment

TertiaryActivities directed at

rehabilitation

Rehabilitation services;

speech, occupational, physical

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Discuss the theoretical basis for nursing practice that has evolved from other

disciplines

General systems theory-these are made up of separate interrelated

components which share a common purpose. We work as a open

system- anything external from the body. The chemical reaction

within a test tube is a closed system because it does not interact

with the environment

Change theory-

Adaptation theory- the process through which the patient creates a

positive response to the environmental changes. An example is a pt

with weakness on the right side learns to use a walker.

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Developmental theories of Erickson's theory of psychosocial

development pg 132

and

Maslow hierarchy of needs- page 69

Define health and illness across the health-

Illness continuum

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o As you go away from the neutral point (equilibrium) you

become more sick or well. If you start going to the left you

start experiencing signs, then symptoms, then disability, and

eventually if not treated, premature death. The more you go

to the right of the scale, the healthier you are, starting with

being aware of your health and doing something about it,

then you educate yourself and then you grow from that and

optimally you reach high level of wellness

State and define the stages of illness behavior

Stage 1- symptoms experiences- something the patient experiences

themselves, such as headaches.

Stage 2- assumption of the sick role- believing you are sick and

acting the part

Stage 3- medical center contact-you go to the doctor for further

help or self medicate

Stage 4- dependent client role- someone takes over your normal

roles b/c you are too sick

Stage 5- Recovery or rehabilitation- you get better

4.3- Chapter 39

List the functions of the skin

Protection

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Sensation

Temperature regulation

Excretion and secretion

Produces and absorbs vitamin d in conjunction with ultraviolet rays

from the sun

Factors influencing the skin’s condition

Illness

Culture

Health state

Age

Personal preferences

Basic principles that guide practices to skin care

Skin is the body’s first line of defense against infections

Skin sensitivity to irritation and injury varies among individuals and

in accordance with their health.

Moisture in contact with the skin for more than a short time can

result in bacteria growing

Body odor is caused by resident skin bacteria acting on body

secretions

Assess the integumentary system and adequacy of self-care of hygiene.

Note texture, color, turgor, hydration, temperature, and thickness of

the skin, note any lesions, pigmented spots, excoriations or

abrasions

o A healthy persons’ skin is smooth, warm, and supple with

good turgor.

Assess pts. muscle strength, flexibility, balance, visual acuity, and

ability to detect thermal and tactile stimuli.

o Pts. with limited upper-extremity mobility, reduced vision,

fatigue, or inability to grasp small objects will need

assistance.

o Assess for ROM of the joints

o Assess for fatigue and presence of pain and need for

analgesics

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Discuss how personal hygiene practices may vary widely from person to

person and culture to culture

Different cultures hold different personal ideas about how self care

is maintained.

Some cultures (western) bath everyday and use deodorant vs

cultures in Europe where they bathe less freq and use no

deodorant.

Identify factors affecting skin condition and personal hygiene

Illness

Culture

Health states- elderly is usually weak

Age – young and elderly

Personal preference

Identify how hygiene is scheduled throughout the day in a hospital setting

Early AM-getting the pt ready for breakfast, any scheduled test or

early morning surgery. RN offers bedpan or urinal if pt isn’t

ambulatory, washing the pts hand and face, and assisting with oral

care.

Morning Care-after breakfast, offer bedpan or urinal to pts confined

to bed, PROVIDE BATH or SHOWER, incl. perineal care and oral,

foot, nail, and hair care, give back rub, change pts gown or

pajamas, change bed linens, and straighten pts bedside unit. AKA

Complete AM care.

Afternoon care-incl. washing of the hands and face, assisting with

oral care, offering bedpan or urinal and straighten bed linen

HBS Care (hour before sleep) (PM care)-help pt relax and promote

sleep. Often incl changing of soiled linens, gowns or pajamas,

helping pts wash the face and hands, provide oral care, give back

massage (rub downwards; shoulders down), offer bedpan or urinal.

Some pts enjoy a beverage before bed such as juice; check diet to

determine which beverage is allowed.

Describe the priorities of scheduled hygienic care

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A Pts condition influences your priorities for hygiene care.

Seriously ill pt usually needs a daily bath bc body secretions

accumulate and the pt is unable to perform hygiene care for

themselves.

A pt with incontinence may need perineal care with every episode

of soiling.

Plan for necessary assistance for pts who are weakened and

possess poor coordination.

Timing is also important. Being disrupted in the middle of a bath

often frustrates and embarrasses the pt.

Distinguish between the different classifications of hygiene assistance

required

Self-care- Pt is able to do things on their own. You’re there to mostly

supervise and help with heading them things if needed.

Partial care-Bed bath that consists of bathing only body parts that

would cause discomfort if left unbathe such as the hands, face,

axillae, and perineal area. Partial bath may also include washing

back and providing back rub. Provide a partial bath to dependent

patients in need of partial hygiene or self-sufficient bedridden

patients who are unable to reach all body parts.

Complete care- bath giving to totally dependent pts in bed

List the purposes of bathing

Cleanses skin

Skin conditioner

Relaxation

Promote circulation

Musculoskeletal exercise

Promote comfort

Sensory input improves self image

Nurse / pt relationship (communication enhancer)

Health care teaching

Assessment

Identify the nursing responsibilities involved in hygiene care regarding:

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tub or shower baths for ambulatory patients-reqs a more thorough

washing and rinsing than a bed bath. Pt still needs nurses

assistance. Some facilities have lifting devices to help position

dependent patience safely in the bath.

bed baths for self-care patients- help pts with whatever they need

such as gathering supplies and handing them things but allow them

to do it on their own to promote independence.

bed baths for partial-care patients- help pt with hard to reach areas.

Remember to wear gloves if coming in contact with body fluids.

Practice safety and privacy for pt at all times

Identify the aspects of oral care for both

Conscious patients-make sure they take out denture before oral

care if there are any. Brush the teeth and rinse mouth with mouth

rinse.

Unconscious patients- position in semi fowlers position and check

for gag reflex. Let pt know what you are doing at all times. Make

sure to suction water so that the pt doesn’t drown.

Identify aspects of care of dentures

Handle dentures with care because they break easily and they’re

expensive.

They should be removed at night so the gums can rest and prevent

bacteria buildup.

The dentures should be brushed, flossed and placed in a labeled

solution filled container placed in the bedside drawer away from the

table top where someone can knock them over.

Rinse mouth and dentures after meals to prevent denture-induced

stomatitis.

State technique for care of the eyes

Wash eyes with a clean moist washcloth. NO SOAP. Wiping from the

inner canthus to the outer canthus.

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Unconscious pts need more frequent eye care because they

secretions usually collect along the edge of the eye when the blink

reflex is absent. If the eye doesn’t close completely place, an eye

patch over the eye to prevent corneal drying and irritation. Apply

lubricating eye drops according to the HCP’s orders.

Discuss technique and legal aspects for care of the hair

Need physicians order to shampoo and cut

Shaving- consider personal preferences

Nails- physicians order to cut toenails.

Some gender depending on their culture only one same gender

nurses to assist them

Discuss technique and psychological aspects for care of the perineal area for

males and females

Always remember to assess for irritation, excoriation, inflammation,

swelling, excessive discharge, odor, pain or discomfort, presence of

urinary or fecal incontinence, recent rectal or perineal surgery,

presence of indwelling catheter, perineal-genital hygiene practices,

self-care abilities

o Each pt might prefer a same sex nurse to provide perineal

care for them.

o Provide privacy is a priority when performing perineal care.

o For males. If the pt is uncircumcised retract the foreskin and

clean the meatus and REMEMBER to return the foreskin or

else it will result in circulation being cut off and can cause

gangrene and then the amputation of the penis

o For females. As a nurse you should wash the least

contaminated to the most contaminated area. Front to back.

Identify nursing responsibilities for the care of a patient with Thrombo

Embolic Deterrent Stockings (TEDS)

Reqs physician order

Measure for proper fit

Apply with pt laying down

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Do NOT massage leg

Check heel position

Loosen toes

Remove q shift for 30 mins

Launder prn/ re-use

Discuss the implications of the back rub

To help with relaxation, circulation, touch is important, gives nurse

a chance to check the skin for breakdown.

Lotion is used. No more than 3-5 mins to complete.

Nurses aren’t allowed to do back rubs anymore.

It’s only ok to relax the pt for a couple minutes. Only stroke from

top of the shoulder down is allowed.

Identify safety features of a typical hospital bed

Position changes

Safety features- 2 rails, controls, locks, brakes

Mattresses –specialty, pressure reducing, air mattress overlays, etc

State guidelines for bed making for both

Unoccupied beds-pt is out of bed.

o Use gloves to remove the soiled linen. Hold away from your

body.

o Place linen in linen hamper

o Remove gloves and make the clean bed.

o Make sure there are not creases

Occupied beds- pt is in bed

Identify the components of a bedside unit

Bed

Overbed table

Bedside table

State the elements of a safe bedside unit

Call light in reach

Bed in lowest position, brakes LOCKED

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Side rails up, 2 upper if possible

o Any more than 2 needs a doctors order

Uncluttered walkway

Personal items in reach so pt doesn’t try to reach for something

they need and fall over and hurt themselves

Develop nursing diagnoses related to deficient hygiene measures

Activity intolerance

Bathing self-care deficit

Dressing self-care deficit

Impaired physical mobility

Impaired oral mucous membrane

Ineffective health maintenance

Risk for infection

2.4- Chapter 28

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Explain the relationship of the chain of infection to the transmission of

infection

If the chain of infection is uninterrupted the transmission of

infection has a higher chance to becoming an infection.

Discuss the six components of the chain of infection

Infectious agent-are microorganisms such as bacteria, viruses,

fungi, and protozoa.

Reservoir-is a place where the microorganisms survive, multiply,

and await to transfer to a susceptible host.

Portal of exit- these incl blood, skin, and mucous membranes,

respiratory tract, genitourinary tract, gastrointestinal tract, and

trans placental.

Mode of transmission-is the way a microorganism is transferred

such as airborne, droplet, or contact. They can also be transferred

indirectly through inanimate objects (needles or sharp objects,

dressings, environment), vehicles (water, drugs, solutions, blood,

food), and vectors (mosquito, louse, flea, and tick).

Portal of entry- the organisms can enter the same routes they used

for exiting.

Host- if the host’s immune system is compromised the pt will be

susceptible to being infected. It depends on the degree of the

infection and how the pts immune system is.

Describe nursing interventions used to break the chain of infection

HAND HYGIENE!! Esp for c diff and neutropenic infection- low wbc

Alcohol base

Identify patients at risk for developing an infection and the body’s normal

defenses against infection

Age- the very young and the very old

Hereditary

Those who are physically and emotionally stressed

Nutritional status

Medical therapy

Diagnostic procedures

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Medications

Disease process

Identify factors that reduce the incidence of nosocomial infection

Meticulous hand hygiene

Use of chlorhexidine washes

Identify situations in which hand washing is indicated

ALL the time!

When your hands are soiled.

When dealing with immune compromised pts such as neutropenia

pts and chemo or cancer pts

Identify the components of proper hand washing

Control the water, as warm as you can stand

Wet hand

Get soap

Lather for a good 15 seconds

Rinse with finger pointing down

Wipe hand with a dry paper towel from fingers to wrist and discard

when it hits the wrist and grab another towel to finish drying off

hands

Use a dry towel to turn faucet off

Discuss normal flora that are found on the hands

Transient bacteria- It is bacteria that it is in the surface of the skin

and therefore come and goes as we touch things and as we move

around.

Resident flora- encompasses a wide variety of microorganisms, and

the interactions between microbes and host creates a mutualistic

relationship that both entities benefit from

Identify nursing diagnoses associated with a patient who has an infection or

is at risk of developing an infection

Risk for infection

Imbalanced nutrition: less than body requirements

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Impaired oral mucous membrane

Risk for impaired skin integrity

Social isolation

Impaired tissue integrity

Readiness for enhanced immunization status

Differentiate between types of techniques and protocols for isolation-

Contact precautions : Used for direct and indirect contact with

patients and their environment. Direct contact refers to the care

and handling of contaminated body fluids. An example includes

blood or other body fluids from an infected patient that enter the

health care worker's body through direct contact with compromised

skin or mucous membranes. Indirect contact involves the transfer of

an infectious agent through a contaminated intermediate object

such as contaminated instruments or hands of health care workers.

The health care worker may transmit microorganisms from one

patient site to another if hand hygiene is not performed between

patients

Droplet precautions : Focus on diseases that are transmitted by

large droplets expelled into the air and travel 3 to 6 feet from the

patient. Droplet precautions require the wearing of a surgical mask

when within 3 feet of the patient, proper hand hygiene, and some

dedicated-care equipment. An example is a patient with influenza.

Airborne precautions : Focus on diseases that are transmitted by

smaller droplets, which remain in the air for longer periods of time.

This requires a specially equipped room with a negative air flow

referred to as an airborne infection isolation room. Air is not

returned to the inside ventilation system but is filtered through a

high-efficiency particulate air (HEPA) filter and exhausted directly to

the outside. All health care personnel wear an N95 respirator every

time they enter the room.

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Protective environment: Focuses on a very limited patient

population. This form of isolation requires a specialized room with

positive airflow. The airflow rate is set at greater than 12 air

exchanges per hour, and all air is filtered through a HEPA filter.

Patients are not allowed to have dried or fresh flowers or potted

plants in these rooms

When using the isolation guidelines of the CDC, refer to additional

CDC documents to prevent health care–associated aspergillosis and

Legionnaires’ disease in immunocompromised patients and the

spread of multidrug-resistant organisms

Regardless of the type of isolation system, follow these basic

principles:

o Use thorough hand hygiene before entering and leaving the

room of a patient in isolation.

o Dispose of contaminated supplies and equipment in a manner

that prevents spread of microorganisms to other persons as

indicated by the mode of transmission of the organism.

o Apply knowledge of a disease process and the mode of

infection transmission when using protective barriers.

o Protect all persons who might be exposed during transport of

a patient outside the isolation room.

Identifying equipment needed and nursing responsibilities for each

standard Precautions (Tier One)- always don gloves

transmission Categories (Tier Two)-

o Airborne precautions-always don N95

measles, chickenpox (varicella), disseminated varicella

zoster, pulmonary or laryngeal TB

o Droplet precautions- always don mask

Diphtheria (pharyngeal), rubella, streptococcal

pharyngitis, pneumonia, or scarlet fever in infants and

young children, pertussis, mumps, Mycoplasma

pneumonia, meningococcal pneumonia or sepsis,

pneumonic plague.

o Contact precautions- always don gloves and gown

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Varicella zoster disseminated

MRSA

VRE

C diff

Reverse or protective isolation: Discuss the psychological implications of

isolation for the patient

Reverse isolation is when I protect myself from the patient

Protective isolation is when I protect the pt from me.

o Private room; positive airflow with 12 or more air exchanges

per hour. HEPA filtration for incoming air.

o Some psychological implications of isolation for the pt are

Pt can feel lonesome bc normal social relationships are

disrupted

This can be psychologically harmful, esp for children.

These pts suffer more depression and anxiety and were

less satisfied with their care

Describe techniques for medical and surgical asepsis

Medical is a cleaning technique

Surgical is when you want absence of all organisms for surgery or

invasive procedures etc

Define medical and surgical asepsis

Medical asepsis- technique to reduce or prevent the spread of

microorganisms. Objects referred to as clean ( Absence of ALMOST

ALL microorganisms).

Surgical asepsis-technique that keeps an area or object FREE from

ALL microorganisms. Objects are referred to as STERILE ( absence

of microorganisms)

Identify areas and occasions when surgical asepsis is used

Used in procedures involving sterile areas of the body.

o OR

o Labor and delivery rooms

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o And when inserting IV and catheters

o And special diagnostic areas

GI prep

State the nurse’s responsibility in maintaining sterility

Anticipate patient sneezing so offer them a mask

Patient prep

Ask the pt about toileting

Not to talk, sneeze, etc while setting up a sterile field

List the principles of sterile technique and state the rationale for each

Sterile object touches only sterile object

o Bc non sterile objects are contaminated

Only sterile object placed on sterile field

o Bc any other item is contaminated when wet, open, or

punctured

Sterile object or field out of range of vision or below waist is

contaminated

o Nurses should never turn their back to a sterile field bc you

never know what could have fell into the sterile field while you

were not looking. Any thing below the waist is contaminated

because it cannot be viewed at all times

Sterile object or field contaminated by prolonged exposure to air

o Microorganisms can travel by droplet through the air into the

area of the sterile field.

o Do not cough, laugh, or sneeze when preparing a sterile field

Sterile surface comes in contact with wet, contaminated surface is

contaminated

o Can contaminate other sterile objects in the field via capillary

action.

Fluid flows in direction of gravity

o To avoid contamination during a surgical hand scrub, hold

your hands above your elbows. This allows water to flow

downward without contaminating your hands and fingers.

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Edges of sterile field contaminated (1 inch)

o Because it is exposed to the air after being opened

State the techniques for

Handling sterile objects

o Sterile object touches only sterile object

o Only sterile object placed on sterile field

o Sterile object or field out of range of vision or below waist is

contaminated

o Sterile object or field contaminated by prolonged exposure to

air

o Sterile surface comes in contact with wet, contaminated

surface is contaminated

o Fluid flows in direction of gravity

o Edges of sterile field contaminated

Pouring sterile solutions

o Pour over the sterile field not too far up but not to close to the

sterile field to contaminate it

o Hold the bottle outside the edge of the sterile field

o Label is always faced up so that you don’t get solution on the

label and deface it

Opening and adding sterile supplies to a sterile field

o Open with both hand while still holding the sterile supplies in

the wrapper that it came in and drop it into the sterile field

carefully to not knock it off or spill anything.

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2.2- Chapter 29

State the components that constitute vital signs.

Temperature (96.8-100.4°F)

Pulse (60-100 beats)

Respirations (12-20 breaths/min)

Blood pressure (100/60-119/79 mmhg)

Pain (0-10) subjective

Oxygen saturation (95-100 SpO2)

Discuss parameters for frequency of vital-sign measurement.

Upon admission (as part of physical exam)

Routine schedule in a hospital

Before & after surgical/diagnostic procedures

Before, during & after blood administration

Before & after certain medications

Changes in a patient’s physical condition

Before & after interventions that influence VS

Subjective complaint

Gather a baseline

Identify the nurse’s responsibility for vital-sign measurement

Nurse assigned to client is responsible not the UAP

Nurse should make sure equipment is functional and appropriate for

accurate assessment

Evaluate against pts baseline vs standard book values

To help make intervention as needed

Make sure the equipment is correct size

Check medications that pt is taking

Control external factors

Document any major changes

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Discuss body temperature

How temperature is regulated

o Hypothalamus controls the body temp

Anterior hypothalamus controls heat loss

Posterior hypothalamus controls heat production

Methods of heat loss

o Radiation-transfer of heat between two objs WITHOUT

physical contact

o Conduction- transfer of heat WITH physical contact

o Convection- transfer of heat away by air movement

o Evaporation-transfer of heat energy when liquid (sweat) is

turned in to gas

Methods of temperature measurement

o Orally- make sure pt hasn’t smoke, ate, or drank anything in

the last 15 minutes

o Axillary- make sure the site is dry

o Rectally- remember to LUBERCATE the probe. Only go in 1-1.5

inch

o Temporally-

o Tympanic-for adults pull pinna backward, up, and out point

probe towards midline between eyebrow and side burns. For

kids older than three, pull pinna up and back.

Locations

o Mouth

o Underarm

o Anus

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o Forehead

o Ears

Equipment

o Glass thermometers

o Electronic thermometers

o Electronic tympanic thermometers

o Disposable thermometers-sweat impairs adhesion

Contraindications

o Oral

Contraindicated in infants, small children, or confused,

unconscious, or uncooperative pts

Contraindicated following oral surgery, trauma, history

of epilepsy, or shaking chills

o Rectal

Contraindicated in newborns and other conditions

Expected values at each location

o Oral & tympanic

98.6°F (37°C)

o Rectal

99.5°F (37.5°C)

o Axillary

97.7°F (36.5°C)

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Recognize the terms associated with temperature

Febrile-with fever

Afebrile-without fever

Pyrexia- Fever 100.4°F due to infectons; pyrogens

Hyperpyrexia-elevation of the body temp above 106°F

Hyperthermia-100.4°F due to external factors

Hypothermia-decreased body temp

Malignant hyperthermia- a hereditary condition of uncontrolled heat

production

Discuss basic information related to the patient’s pulse

Physiology of the pulse-

o Arterial walls expand each time left ventricle contracts to

eject blood into the aorta

o Expansion can be felt as an artery travels over a bony

prominence, called a pulse

Developmental changes associated with normal pulse rate

o Babies have a faster pulse at 100-160 beats/min

o Males have a slower rate than females

o People who are thin have a slower rate

o Increased age may be associated with a slower pulse

Terms associated with pulse including

o Tachycardia- Rapid beating >100

o Bradycardia- Slow beating <60

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Factors that will increase pulse rate

o Medications

o Pain

o Strong emotions (fear, anger, anxiety, or surprise)

o Exercise

o Application of heat for a long period

o Decreased in BP

o Elevated temperature

o Any condition resulting in poor oxygenation or blood

Decrease pulse rate

o Some meds –digoxin

o Person just woke up or is resting

o People who are thin

o Older people

o Males have slower rates than females

Characteristics of pulse including

o Rhythm-is the pattern of the pulsations and the pauses

between them

o Amplitude-

Reflects the volume of blood ejected against the arterial

wall with each contraction and the condition of the

arterial vascular system leading to the pulse site

May be graded or described as strong, weak, thready, or

bounding

0 Absent pulse or not felt

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1+ Thready/Weak, not easily felt, slight pressure

occludes it

2+ Normal

3+ Bounding, stronger than normal e.g.

after increased activity

Assessment sites

temporal-side of forehead

carotid-side of neck, under chin

apical- between 4th and 5th intercostal space

radial-at wrist on thumb side

brachial-in the antecubital space

femoral- groin area

popliteal –behind the knee

posterior tibia- ankle area

dorsalis pedis-top of foot, towards the inside

Apical-radial pulse assessment

Method

o Locate the mitral valve loudest sound S1 at 4th and 5th

intercostal space mid-clavicular line

o Count with a stethoscope for 60 seconds

Indications as to when to take apical pulse

o When the radial pulse is irregular.

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o When knowing the central pulse is essential for

treatment/meds (i.e. Digoxin).

o To determine presence of pulse deficit (2 nurses count at

same time, using same watch).

Pulse deficit- the difference between the radial and the apical pulse

Discuss respirations

Physiology of respirations

o Movement of air in and out of lungs

o CO2 -out and O2 -in

Developmental changes associated with the normal respiration rate

o Children seem to breath faster than adults

Factors that will increase or decrease respiratory rate

o Exercise (I)

o Acute pain (I)

o Anxiety (I)

o Smoking (I)

o Body positions (I) (D)

o Medications

Opioids, analgesics, general anethetics and sedative

hypnotics DEPRESS rate and depth

Amphetamines and cocaine sometimes INCREASE rate

and depth

Bronchodilators DECREASE rate by causing airway

dilation

o Neurological injury- impairs respiratory center and inhibits

respiratory rate and rhythm

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o Hemoglobin function

Decreased hemoglobin levels (anemia) increase

respiratory rate because of the reduced oxygen carrying

capacity of the blood.

Increased altitude lowers the amt of saturated

hemoglobin which increases the respiratory rate and

depth

Abnormal blood cell function (sickle cell disease)

reduces the ability of hemoglobin to carry oxygen which

increases respiratory rate and depth.

terms associated with respiration

o Apnea- without breath

o Dyspnea- difficulty breathing

o Orthopnea- difficulty breathing when laying down

o Tachypnea-rapid breathing

o Bradypnea-slow breathing

o Cheyne-Stokes- The pattern of breathing with gradual

increase in depth and sometimes in rate to a maximum,

followed by a decrease resulting in apnea; the cycles

ordinarily are 30 seconds to 2 minutes in duration, with 5–30

seconds of apnea

Discuss blood pressure

Terms associated with blood pressure

o Systolic pressure- Maximum pressure is exerted upon left

ventricular contraction or systole, thus the highest pressure is

the systolic measure

o Diastolic pressure- When the heart rests between beats the

pressure is at its lowest point and is referred to as the

diastolic measure

o Pulse pressure-the difference between systolic and diastolic

measurements. Eg: BP 120/80 = pulse pressure of 40

o Hypertension-asymptomatic; most common alteration in BP

Dx in adults: when 2 or more readings on at least 2

subsequent visits indicates diastolic pressure > or =90

mmhg or systolic pressure > or =140 mmhg

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Prehypertension- systolic is between 120-130 or

diastolic is between 80-89

Stage 1– systolic is between 140-159 or diastolic is

between 90-99

Stage 2- systolic is >160 or diastolic is>100

o Hypotension-systolic falls below 100 or lower

Symptoms: pallor, skin mottling, clamminess, confusion,

dizziness, chest pain, increase HR, and decreased urine

output

Life threatening

o Orthostatic (postural) hypotension- low blood pressure assoc.

with weakness or fainting when one rises to an upright

position (sitting or standing)

o Factors responsible for maintaining blood pressure

Medication

Exercise

Diet

o Factors responsible for deviations of blood pressure

Disease

Race

Gender

Stress

Age

Time

Obesity

o Contraindications for site selection

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Usually, one should avoid obtaining a blood pressure in

the same arm in which an arteriovenous fistula (such as

used in hemodialysis) is present, or where lymphadema

exists or if there has been a mastectomy done.

Furthermore, caution should be used if the patient is at

high risk for developing lymphedema (such as after

lymph node dissection for treatment of breast cancer).

In these instances, using the other arm is

recommended; if bilateral arteriovenous fistulas or

lymphedema exist, then obtaining a lower extremity

blood pressure is recommended

2.3- Chapter 30

Describe the purpose of nursing history and physical assessment

Gather baseline data about the client’s health status

Supplement, confirm, or refute data obtained in the nursing history

Confirm & identify nursing diagnoses

Make clinical judgments about a client’s changing health status &

management

Evaluate the physiological outcomes of care

Discuss psychological and physical preparation of the patient.

Psychological Preparation Tips:

o Provide an explanation regarding the purpose and steps of the

examination

o Use simple, understandable terms

o Encourage client questions

o Inform client to tell you if there is any discomfort

o Professional yet relaxed demeanor

o Observe for client emotional responses

Physical Preparation Tips:

o Comfort for client is essential

o Before beginning assessment ask client if they need to use

the toilet

o Client is dressed & draped appropriately

o Provide privacy for the examination

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o Use towels & linens to drape client for privacy as well as

warmth

o Frequently inquire about client comfort

List and describe the four primary assessment techniques

Inspection-you’re assessing the pt by “looking at” them

Palpation-uses the sense of touch. You’re feeling for any

abnormalities

Percussion-involves tapping the body with the fingertips to evaluate

o Size

o Borders

o Consistency of body organs

o Fluid filled cavities

Auscultation- act of listening to sound produced by the body

o With or without stethoscope

Discuss the components of the general overview

Should include the following

o Sex & race

o Body build, posture & gait, movements

o Hygiene & grooming, dress

o Signs of illness

o Affect: attitude, mood, speech

o Cognitive status (orientation, memory)

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o VS, weight & height

Identify the techniques, anatomy, and expected findings of the basic physical

assessment of the adult patient, system-by-system, head-to-toe.

Skin: define and discuss

Flushing-reddened appearance of the skin

Cyanosis-blueness of the skin- increased amt of deoxygenated Hgb

( assoc w/ hypoxia)

Jaundice-yellow/orange color change as a result of increased

bilirubin in tissue

Pallor-decrease in color, reduced amt of oxyhemoglobin, may be

due to anemia or shock

Ecchymosis-(bruise) collection of blood in the tissue

Petechiae-small red ecchymotic changes that occur due to capillary

rupture in the dermis

Turgor-the fullness or elasticity of the skin and is usually assessed

on the sternum or under the clavicle.

Diaphoresis-(sweating) when the entire skin is moise (usually cool in

temp as well)

Edema-characterized by swelling, with taut and shiny skin over the

edematous area.

Nails- should be 160 degrees and no more than that

Head

o Hair and scalp- should have not masses, depressions, or

lesions

o Ears- pinna shouldn’t be lower than eye level; if it is lower and

has a deviation in alignment it can be a form of down

syndrome

Face- should be symmetrical, with some slight deviations but not

major. Bells palsy will be a major deviation

o Check sinuses

Nose- check smell CN 1. Check for patency- one nostril at a time.

Eyes, identify

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o PERRLA- Pupil, Equal, Round, Reactive to Light,

Accommodating

o EOM- extra ocular muscle

Convergence

Neck Assess:

o ROM

o Lymph nodes- check for any masses that are palpable usually

lymph nodes aren’t palpable

o Trachea- listen for breathe sounds and adventitious sounds-

trachea will have bronchial sounds

Carotid pulse- assess the pulse one at a time

Listen to the pulse with the bell and diaphragm to

assess any bruits

Chest-check ap diameter, note any masses or bulging or retraction

of ICS

Lungs: define:

o Normal breath sounds:

o Bronchial sounds- should be around neck and trachea region;

high pitch, long and loud expiration

o Bronchovesicular- heard over major bronchi and over upper

right posterior lung field; moderate in pitch and intensity.

Inspiration=Expiration

o Vesicular- over entire lung field, heard over lesser bronchi,

bronchioles, and lobes; low pitch, low intensity, soft and short

expiration

o Adventitious

Crackles-heard during inspiration. Discontinuous. High

pitch. The cause is the random and sudden inflation of

groups of alveoli. Disruptive passage of air through

small airways

Rhonchi- heard on insp and expiration. Rumbling course

sound, like a snore. Mainly heard over trachea and

bronchi. If loud enough it can be heard over lung fields.

Cleared with cough. Continuous.

o When auscultating lung fields

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The vesicular lung sounds is the only one to be heard

when assessing it laterally.

Heart. Locate and discuss: listen with bell and diaphragm

o S1”lub”- is the sound of mitral and tricuspid valves closing.

Mitral is located between 4th and 5th Intercostal space

midclavicular

Tricuspid is at the 4th intercostal space left of sternum

o S2”dub”- the sound of the pulmonic and aortic valves closing

Aortic is located at the 2nd intercostal space to the right

of the sternum

Pulomonic is located at the left side 2nd intercostal space

left of sternum

Auscultation sites for aortic valve- right of sternum 2nd intercostal

space, pulmonic valve- left of sternum 2nd intercostal space,

tricuspid valve- left of sternum 4th ICS , and mitral valve 5th ICS

midclavicular

o Erb’s point-3rd ICS left of sternum

o PMI- between 4th and 5th intercostal space midcalvicular

o Apex-5th intercostal space

o Breasts-

o Axilla-

o Abdomen- aortic, renal, iliac, and femoral regions

o Bowel sounds- LR, UR, UL, LL

Pain assessment of the abdomen-

o Pattern of characteristics of pain help determine source.

o If pt has tender areas- assess those areas last

Detecting ascites-

Genitalia-

o Male

Remember to return the foreskin to original position to

prevent phimosis

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o Female-

Know

Gravida- number of pregnancies

Parity- number of births

Musculoskeletal-

Nervous-

Peripheral vascular- Assess the pulse points for similar rhythm and

rate. Check bilaterally.

Identify common abnormal findings associated with each system

Discuss the documentation of findings in narrative nursing notes format,

identifying acceptable terminology and abbreviations and following head-to-

toe forma

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1/14/13 9:14 PM

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