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  • 1. Binders and bandages applied over or around dressings provide extra protection and therapeutic benefits by doing what?1) Creating pressure over a body part 1) Creatingpressure overabody part 2) Immobilizing a body part 3) Supporting a wound 4) Reducing or preventing edem 5) Securing a splint 6) Securing dressings What bandages are lightweight and inexpensive, mold easily around contours of the body, and permit air circulation to prevent skin maceration? Gauze bandages What bandage conforms well to body parts but are also for exerting pressure? Elastic Bandages What are binders made of and what are two examples of binders? Binders are bandages made of large pieces of material, like elastic or cotton, to fit a specific body part. Examples are abdominal binders and breast binders. Before applying a bandage or binder what must a nurse do? Inspect the skin for abrasions, edema, discoloration, or exposed wound edges. Covering exposed wounds or open abrasions with a sterile dressing Assessing the condition of underlying dressings and changing if soiled. Assessing the skin of underlying areas that will be distal to bandage for signs of circulatory impairment This is an physical, manual, or mechanical method or device attached to a body to restrict movement. Physical Restraint This is any medication used to control behavior and are especially dangerous in older adults because the increased sedation, drowsiness, and/or otherwise impaired cognition may increase the risk of Falling. Chemical Restraints T/F Use restraints as the first order of frustration towards a non- compliant patient without the necessity of a physicians order. False:Use restraints only as a last resort, in consultation with the PCP, and with an order stating why the restraint is
  • 2. necessary and for how long. T/F The use of restraints without an order is considered a standing order until a physician writes an order. False The use of restraints without an order is considered false imprisonment and is there fore illegal. What are the foundations of good body mechanics? 1) Coordination, 2) Maintenance, and 3) Protection What provides the framework for all tissue of the body? Skeletal system. Coordination is the result of ____, ____, and ____. Weight, center of gravity and balance The cerebellum and the inner ear controls what? Voluntary movement and balance When moving an object you should pull the object towards you. T/F False: Push objects don't pull. It is better to use minor muscles over the major muscles. When preparing to lift an object what are the procedures from beginning to end? Assess the weight of the object, tighten stomach muscles and tuck pelvis. Bend at the knees and keep the object close to your body while maintaining trunk in erect position with knees bent. At all times, avoid Twisting!!! If it is necessary lifting vertically, it is best to stand on tips of the toes for overhead objects. T/F False: Use a safe step ladder/stool, stand as close to the shelf as possible then transfer the weight of the object from the shelf to the arms and bring close the body. When moving patients what are the steps prior to the actual lift of a patient up in bed? Arrange for adequate help, encourage client to help as a
  • 3. dlib, use body mechanic principles then slide patient toward you with a draw sheet coordinating the lift by counting to three. ____ places body weight fully on each leg in turn. Normal Gait What are the steps prior to assisting a patient with ambulation? Evaluate the environment for safety, dangle pt if indicated. Support the pt at his waist, return pt to chair/bed if c/o dizziness or experiences syncopal episodes. Supporting pt with hemiplegia or hemiparesis. When in doubt, get help. What is the number one step to take before assisting with patient with any activity? PATIENT SAFETY!!! This is the act of posture being in a straight line. Body Alignment When should a RN assess, a patients alignment? When they are least aware of the observation, while sitting/lying at the foot of the bed or while standing. a position in which the head is low and the body and legs are on an inclined plane. It is sometimes used in pelvic surgery to displace the abdominal organs upward, out of the pelvis, or to increase the blood flow to the brain in hypotension and shock. Trendelenburg's a position in which the lower extremities are lower than the body and head, which are elevated on an inclined plane. Reverse Trendelenburg the posture assumed by the patient when the head of the bed is raised 45 to 60 degrees and his or her knees are elevated slightly. Fowler's Position placement of the patient in an inclined position, with the upper half of the body raised by elevating the head of the bed approximately 30 degrees. Semi-Fowler's Position A thin gauze that has be saturated in Vaseline. Vaseline Gauze What are the different restraints provided for patient safety? 1) 2pt vs 4pt 2) Mitten
  • 4. 3) Posey 4) Belt What would be the rationale of restraints? 1) Maintains immobilization, 2) Prevents pulling out of devices, 3) Prevents unintentional harm, and 4) Prevent scratching of self/other/ When placing restraints, a nurse should tie restraints to side rail to prevent patient from harming self or others. T/F False: One should never secure a restraint to a moving object. When side rails are all placed up, they are considered a restraint. T/F False: Side rails are NOT considered a restraint. How long is a restraint order written by a physician good for? 24 hr When does discharge planning take place? Admition What are the 6 Documentation qualities of patient information? Factual, Accurate, Complete, Current, Organized, and Legible Documentation that states descriptive, objective lingual that avoids vague terms, quoting subjective remarks is known as ____. Factual Documentation Documenting in universal language, spelling correctly, being concise & easy to understand. Specific to date, time, with signature and credentials avoiding generalized comments and inappropriate language keeps _____ documentation. Accurate In order to keep documentation current one must .... Document everything on a flow sheet chronologically using Military time. What do I do if I forget to chart something and remember it later? Write a late entry What do I do if I need to make a correction? Draw one line through, no writing of error or mistake just initial and that is it. What do I do if I need to continue to the next page? Start with date and time and write..."continued from
  • 5. previous page" What do I do if I have a countersign? If one countersigns, you are taking full responsibility of the person you, as an RN, are countersigning for. What device supports large abdominal incisions that are vulnerable to tension or stress as the client moves or coughs? Abdominal binder What device support arms with muscular sprains or fractures? Slings an abnormal condition characterized by the collapse of alveoli, preventing the respiratory exchange of carbon dioxide and oxygen in a part of the lungs. atelectasis the secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress. diaphoresis When should you remove patients abdominal binder to incourage client to cough and deep breath before reappling binder using less pressure? If clent's respiratory rate decreases. When regarding an abdominal binder, what should be recorded for proper reporting to other shift? application of binder condition of skin, circulation, integrity of dressing client's comfort level Who should ineffective lung expansion be reported to ultimatly? Health care provider immediately Elastic bandages that reduce swelling are best applied when? In the morning before getting out of bed Current JACHO standards require these assessments of all clients who are admitted to a health care institution. What are they? An assessment of: Phyical, Psycholosocial, Environmental, Self-Care, Client Education and Discharge Planning Needs Oral/Tympanic temperature: 96.8-100.4 Rectal Temperature: 98.6-100.4
  • 6. Axilla temperature: 96.6-98.6 Normal Pulse rate is 60-100 beats per minute Normal Respiration range from 12-20 breaths per minute A patient with a BP between 120/80 to 139/89 is considered to be what? Pre-hypertensive What would a patients blood pressure look like who has hypertension? 140/90 A patient with a systolic blood pressure of <90 is considered...? Hypotensive When should we take vital signs? Per physician order Any change in patient's condition After any major procedure A 72 year old male s/p open heart surgery comes to the ICU for post op recovery. Among various medications needed to assist with stabilization of this patient, a nurse would recognize vital signs like these… BP: 98/60 Resp: 30 Pulse: 58 Temp: 96.3 orally As normal or abnormal? Abnormal For the body temperature to stay constant & within an acceptable range, body mechanisms must maintain the relationship between ____ ____ and ____ ____. Heat Production Heat Loss Physiological and behavioral mechanisms regulate the balance between heat lost and heat produced,also known as ____. Thermoregulation What is believed to be the most reliable measure of core temperature? Rectal Temperature Placement of a thermometer into feces may give what kind of reading? Inaccurate Readings indicating a high reading due to heat loss from feces. What are the differences in rectal thermometer insertions for Adult, child, and infants? Adult: 1 1/2 in Child: 1 in Infant: 1/2 in Celsius=(F-32)x5/9 Fahrenheit=(9/5xC)+32
  • 7. What is the safest temperature site to check? Axillary Temperature: 5-10minutes, make sure it's dry surface What is one of the most rapid means of measuring temperature? Tympanic This is the transfer of heat from one surface of an object to another surface of an object by direct contact. Heat Loss Losing heat by removing clothing is considered what form of heat loss? Radiation The Transfer of heat from one object to another by direct contact is what form of heat loss? Conduction The patient has just finished a hot cup of coffee when you enter the room to take an oral temperature. What should you do? What 20-30 minutes to retrieve an accurate temperature. This is the visible presence of earwax. Cerumen The transfer of heat away from a surface by the movement of air or fluid is what form of heat loss? Convection The heat loss from the energy required to change a liquid into a gas is called what? Evaporation The visible perspiration primarily occurring on the forehead and upper thorax, though you can see it in other places on the body is known as _____. Diaphoresis What occurs because heat-loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. Pyrexia This is a substance which can cause a rise in body temperature. Pyrogens When does a fever become harmful to the human body? 102.5 F FUO? Fever of Unkown Origin What is an elevated body temperature related to the body's inability to promote heat loss or reduce heat production? Hyperthermia Heat loss during prolonged exposure to cold overwhelms the body's ability to produce heat causing what? Hypothermia
  • 8. When temperatures become extremely hot or cold, health-promoting behaviors, such as removing or adding clothing, have a limited effect on controlling temperature are factors for high risks for ___ ___. Ineffective Thermoregulation You walk into a patients room and notice the patient has increased perspiration and pulse rate is 120. You find the patients temperature is 102.0. What are some nursing interventions to reduce temperature? Monitor VS, assess skin color, temperature, turgor and lab work This is profuse diaphoresis resulting in excess H2O and electrolyte loss. Heat Exhaustion This dangerous heat emergency has a high morality rate. Heat Stroke Sub-normal temperature exposure to the body substantially causing possible this? Frostbite A group of football players are out scrimmaging on the field. One player shows signs of Hot dry skin. What is this a sign of? Heat stroke The palpable bounding blood flow in a peripheral artery noted at various points on the body is the _____. pulse The pulse is an indirect measure of ___ ____. Cardiac Output Your friend displays a pulse of 134 per minute. Is this normal Abnormal (60-100 normal) What are the sites for assessing the pulse of a client? Radial(thumb side of forearm of wrist), Apical (5th-4th intercostal space at left of mid-clavicular line), Carotid (along medial edge of sternocleidomastoid muscle) Rate of pulse, rhythm, strength, and equality are all _____ __ ____. Character of pulse This is the mechanism the body uses to exchange gases between the atmosphere to the blood and the blood to the cells. Respiration This is the movement of gases in and out of the lungs. Ventilation This is the movement of oxygen and carbon dioxide between the alveoli and the red blood cells. Diffusion This is the distribution of red blood cells to and from the pulmonary capillaries. Perfusion
  • 9. The most important factor in the control of ventilation is ? The level of CO2 in the arterial blood This is normal rate and depth of ventilation. Eupnea What should one assess when checking patients respiration? Rate, Rhythm, and Depth You note, after checking a patients O2 saturation, a level of 89%. Is this acceptable? NO! Acceptable range 95%-100% What device can indirectly measure oxygen saturation using the light absorption with photo detector checking pulse saturation (SpO2) estimates arterial saturation (SaO2)? Pulse Oximetry This is the absence of respirations. Apnea Slow breath is known as ____. Bradypnea Rapid Breathing is known as ____. Tachypnea This is an abnormal pattern of respiration, characterized by alternating periods of apnea and deep, rapid breathing. Cheyne-Strokes Respiration This is an abnormal condition in which the client uses multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe. Orthopnea This is a clinical sign of hyoxia displaying a shortness of breath usually associated with exercise or excitement, but in some clients is present without any relation to activity or exercise. Dyspnea The force exerted against the blood vessels by the blood is what? Blood Pressure A patient displays no signs of heart problems but on assessment you find the patients has high blood pressure. What is this patient at risk for? Hypertension is a major factor underlying stroke and contributing factor to heart attacks. 16 year old boy displays mottling skin, signs of clamminess, confusion, increased heart rate and mother states boy has had a decrease in urination. What would you expect upon assessment of vitals? Low blood pressure? (Hypotension)
  • 10. John's BP has been ranging around 108/62 6am every morning. One day he decides to take his BP 4:20 in the afternoon but is shocked at the results. Why was he shocked at his BP? He saw an increase in his BP because between 10am-6pm BP is the highest A patient just returned from smoking a couple of cigarettes when you enter their room for vitals. What do you do next? Return in about 15 minutes because smoking increases vasoconstriction. The thickening of arterial walls and loss of elasticity can increase the risk for... Hypertension Dilation of arteries, loss of blood volume and decreased blood flow to vital organs can increase the risk for.... Hypotension The First Korotkoff sound is known as what when taking vitals? Systolic Reading The absence of sound when taking BP is known as ____. Diastolic Reading Talking with patient during BP reading can cause what? Increase by 10%-40% When taking the blood pressure how should the patient be positioned, and what is the difference in readings? Patient should be in prone position Systolic pressure usually higher by 10-40mmHg Diastolic the same A catheter inserted in an artery that monitors the BP electronically is what known as a/an ____. Arterial Line What are the 5 vital signs? Temperature Blood Pressure Respiration Pulse Pain When assessing pain what should be factored as a means of understanding pain intensity? Provokes/palliates Quality Region/radiation Severity & setting Timing
  • 11. Pain SCALE 0----5----10 the separation and restriction of movement of ill persons with contagious diseases is ... Isolation Why is the risk for infection transmission possible in a hospital? Because every client has the potential to transmit infection via blood and body fluids. This tier of precaution is designed for the care of all clients in hospitals regardless of their diagnosis or presumed infection status. Tier One: Standard Precaution This tier of precaution is designed only for the care of clients who have known or suspected infections or have been colonized with transmissible pathogens. Tier Two: Expanded Precaution What should one take standard precautions against? Blood Body Fluids Non-intact Skin Mucous Membrane A student nurse prepares to enter a droplet Isolation room. He donns on the PPE by first placing his gown, than mask, Finally he donns gloves than enters. Did you take the proper precautions prior to entering room? NO. #1 thing everyone must do before placing PPE equipment and after removing them is WASH HANDS!!! What is the proper sequence for removing PPE equipment before leaving patients room? Remove gloves, then goggles, next gown, and then mask. Finally always wash HANDS!!! A tier two expanded precaution does not require a physicians order. Only standard precautions T/F False: Tier Two is based on mode of transmission and requires a physicians Order followed by an isolation cart, door signage, and patient restrictions. Patient Jane in on airborne isolation. You wash your hands and take proper precautions equipping yourself with what? N-95 mask, gown and gloves.
  • 12. Patient Ace has pneumonia and the physician orders for an isolation cart. What isolation precaution is this? Droplet Isolation (requires a face-shield) A patient with MRSA is admitted into your unit and placed on isolation. You noticed your coworker entering the room with gloves, gown, and mask on. What should you educate him on? MRSA is a contact isolation, gloves and gown are the only things necessary in room unless there is a possibility of becoming exposed to an open wound with drainage. You just got done getting a patient situated after getting them off the bed pan. Patient was positive for C-Diff and on isolation. You remove all equipment and use a hand sanitizer soap to cleanse hands. What is wrong. C-Diff is only killed with soap and water. A kidney transplant patient is in a reverse Isolation room. Family ask if its alright to bring some flowers for them. What would be your response? Because the patient's fully strong yet, it would be best to not bring any Fresh fruits vegetables or fresh plants. You have just been notified that your patient, who is on isolation, has had an accident and needs to be cleaned. Before donning PPE you want to make sure ____. You have all supplies (extra) before entering room Then PROPER hand hygiene.!!! What type of PPE will you wear when changing an MRSA dressing? Gloves, mask w/face shield or goggles, and gown. What type of PPE will you wear when suctioning oral secretions? Sx Mask What type of PPE will you wear when transporting a patient Dx with TB? Gloves, fluid-resistant gown, mask/goggles or face shield What type of PPE will you wear when responding to an emergency where blood is spurting? Gloves What type of PPE will you wear when drawing blood? Gloves, gown What type of PPE will you wear when cleaning an incontinent patient with diarrhea? Gloves, w/wo gown
  • 13. What type of PPE will you wear when taking vital signs on a patient Dx with influenza? Gloves, gown, mask with eye shield What type of PPE will you wear when irrigating a wound? Gloves, gown, mask w/shield goggles You receive the order from the physician to place a patient on isolation. You noticed the family and the patient have a concerned look on their face. What should you do? Explain the situation Explain the Basic understandings of isolation Ease their concerns Comfort and Reassure The process or methods of bringing about a condition in which no disease-causing micro-organisms are present. Asepsis (elimination of germs) The purpose of asepsis is ... Destroying the number of microbes to an irreducible number. The purposeful prevention of the transfer of microbes from one person to another Calculated effort to keep the patient's environment from contamination & colonization This occurs when a patient has an organism in or on a body site but has no clinical signs or symptoms of disease. Colonization (Staph) What is the single most important procedure for preventing nosocomial infections? Handwashing The absense of pathogenic microorganisms. Asepsis Medical Asepsis is ____ technique where as Surgical Asepsis is ____ technique. Clean/Sterile This type of Asepsis technique reduces number of organisms present, lowers risk of transmission by good hand hygiene, using barrier techniques and antiseptics/disinfection. Medical Asepsis This type of Asepsis using sterile techniques destroying all micro- organisms and their spores. These techniques are held to a very rigid standard. Surgical Asepsis
  • 14. When starting an IV or cleaning a central line you would want to use this technique. Surgical Asepsis Antiseptics are used ____ where as disinfectants are used ____. Used on skin/ inanimate objects This method of infection control is the process to remove all organisms. Sterilization This method of infection control kills or reduces growth and replication of micro-organisms. Germicides Best Practice equals Best Care An illness produced by the invasion and multiplication of an infectious pathogen in the body. Infection This is an infection that was developed after admitting patient into the hospital. Hospital-acquired infection This is an acquired infection that is present when the patient entered the hospital. Community-acquired infection This infection comes from the microorganism outside the body. Exogenous Infection This is an infection that occurs when the part of the body's normal resistant level is abnormal. Endogenous Infection Infection acquired due to medical treatment Latrogenic Infection What factors increase nosocomial infections? Antibiotic Resistance Bad Hygiene Basic Procedures Aging/Immunocompromised Acute illness What are some defenses against infections? Normal Flora Body defense mechanisms Inflammation Vascular and cellular response Inflammatory exudate Tissue repair A patient that is receiving a broad spectrum antibiotic is at an increased risk for ___ infection: because this antibiotic upset the balance of normal flora.
  • 15. What is the chain of infection? Causative Agent Reservior Portal of Exit Mode of Transmission Portal of Entry Susceptible Host These are parasites that can be carried by mosquitos, contaminated water, food or soil, and also in ticks. Protozoans These are microorganisms that attach to the skin when a person has contact with another person or object during normal activities. Hand hygiene can remove these. Helmithes This is a place where a pathogen can survive but may or may not multiply. Reservoir Portal of exit for pathogens from a human host can happen in 4 generalized ways. Respiratory tract Skin/Wound Urinary Tract GI tract Repro Tract The physical contact between source and susceptible host is what mode of transmission? Direct The personal contact of susceptible host with contaminated inanimate object is what means of transmission? Indirect Large particles that travel up to 3 feet and come in contact with susceptible host is what means of transmission? Droplet Droplet nuclei, or residue or evaporated droplets suspended in air or carried on dust particles is what mode of Transmission? Airborne The mode of transmission that uses food is called. Ingestion A vector can transmit a pathogen in two ways. What are they? External transmission: flies-V. Cholerae Internal transmission between vector and host: mosquito-malaria, West Nile virus.
  • 16. Portal of Entry can spread by: Breaks in skin: even microscopic breaks Mucous membranes Respiratory Blood GU, GI, Reprod Track The very young, elderly and immunocompromised, multiple dx prcesses are all ____ to pathogens. Susceptible hosts This stage of infection is between entrance of pathogen into body and appearance of the first symptoms. Incubation Period This stage of infection from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms. Prodromal Stage This stage of infection is when client manifest signs and symptoms specific to type of infection. Illness Stage This stage of infection is interval when acute symptoms of infection disappear. Convalescence When your skin encounters any drainage, dried secretions or excess perspiration, use alcohol gel every time. T/F False Use soap and Water You find a patients dressing has become wet and soiled but it is not due for a dressing change until tomorrow. What do you do? Change dressing You find contaminated articles (soiled dressings/linen) in a patients room. What do yo do? Place contaminated articles in red biohazard bag. and dispose of it properly You have just contaminated your needle prior to attempting to give insulin. What do you do? Engage safety features of all sharp devices and dispose in puncture-proof container. You walk into patients room and noticed an open bottle of normal saline. What do you do? Dispose of it. DO not leave bottled solutions open for prolonged periods of time. Keep bottled tightly capped, date and time should be written on all solution from time of open.
  • 17. Empty and dispose of drainage suction bottles according to facility policy. Empty all drainage systems on each shift unless otherwise ordered by a physician. Never raise a drainage system (e.g., urinary drainage bag) above the level of the site being drained unless it is clamped off. Drainage Bottles and Bages Surgical wounds Keep drainage tubes and collection bags patent to prevent accumulation of serous fluid under the skin surface. Strict asepsis with wounds/care. At portal of exit cover mouth when coughing, sneezing, teach pt/family to do this, gloves, gown, eye wear if possibility of contact with body fluid The principles and science of preservation and science of healing and prevention of disease. Promotion of Well-being What is the purpose of hygiene? Cleanse Comfort, relax Promote healing Safety The Nursing Process? Assessment (data-subjective & objective) Nursing Diagnosis (plan) Implementation (action) Evaluate (response) Document Epidermis, dermis, and subcutaneous tissue consist of what? The Skin What is the function of the three parts of the skin? Epidermis (protection) Dermis (support) Subcutaneous (temperature regulation)
  • 18. The purpose of this is to protect, sensory perception, temperature, regulation, and excretion/secretion. Skin The base or edge of a nail, that could be a portal of infection, is called ____. Cuticle The white area on the visible nail area is known as the ____. Lunula What is the pink, moist, mucous membrane, which includes tongue, teeth, gums? Oral/Buccal Cavity This maintains hygiene comfort within the oral cavity. Buccal Glands The process of chewing Mastication The disease of the gum is called Gingivitis When assessing the sclera and the conjuctivae, what should you see ideally? sclera: white, moist Conjuctivae- pink, moist, free of lesions When assessing a patients ears what should you note? The auricles symmetry, color and position. The outer ear canal free form excess cerumen. What should be considered when assisting with patient hygiene? Social practice Personal Preferences Body Image Socioeconomic Status Health Beliefs and Motivation Cultural Beliefs Physical Condition When assessing patients skin, what should you note? Any risks in impairment of skin such as dryness, acne, rashes, inflammation, open lesions or abrasions. The loss of hair (thins with age) is known as? Alopecia Head lice is known as? Pediculus Capitis Body lice is known as? Pediculus Corporis
  • 19. Crab lice (perineal) is known as? Pediculus Pubis What is are glands that assist in perspiration of the palms, soles, and forehead. Eccrine Glands What is are glands that assist in perspiration of the axillae, scalp, face, abdomen, and genital area? Apocrine Glands These glands are more active in adolescent which leads to acne (thermoregulation). Sebaceous Glands Who loses elasticity of skin, skin becomes thin and sweat glands decrease in secretions? Elderly With increased age what happens with the feet, hair and nails? Feet-↑age=loss of balance & ↑pain, Hair-↑age=loss of hair, alopecia; adolescence are more aware of body image Nails-↑age=more brittle Oral cavities are found in what ages groups? The young and elderly. High sugar intake and teeth become brittle. How does one keep accountability of the nursing process? Evaluation of the Nursing process This is a technique used in physical examination in which the examiner feels the texture, size, consistency, and location of certain body parts with the hands. Palpation A technique in physical examination of tapping the body with the fingertips or fist to evaluate the size, borders, and consistency of some of the internal organs to discover the presence and evaluate the amount of fluid in a body cavity. Percussion This is the act of listening for sounds within the body to evaluate the condition of the heart, blood vessels, lungs, pleura, intestines, or other organs or to detect the fetal heart sound. Auscultation This is the act of smelling. Olfaction Techniques for physical assessment includes all sense such as: seeing, feeling, listening, smelling and tasting. T/F False:Techniques for assessment includes all senses
  • 20. except taste!!! When performing a proper inspection, what can you do to promote favorable conditions for visual inspection of the patient? Make sure there is Good Lightning. (Use additional lighting/devices for some areas of body such as eyes, ears, throat) When performing a visual examination, what are some characters a nurse should observe for? Color: eyes, skin, nail bed, wounds Shape/symmetry: Movement: jerky, trimmers, steady gait Position: posterior, anterior, distal When examining the patients' symmetry, it is best to have the patient in a standing anatomical position. T/F False: It is best with the patient in a sitting position A nurse is assessing a new admit. You notice the nurse checking the consistency of the patient's neck, the texture and resilience of the abdomen and the temperature of an immobile extremity. All with the use of her hand. What tactic did you just see implemented? Assessment with palpation Tympany, resonance, hyper-resonance, dullness, and flatness are all ____. Sounds of Percussion Percussion between the intercostal space over the lungs and over the trapezoid muscle will generate this type sound? Resonance Percussion over the area above the stomach will generate this type sound? Tympany Percussion over the area above the liver and heart generates this type sound? Dullness. Percussion over the surface of muscle and bones generates this type sound? Flatness When assessing auditory auscultation what characteristics should you be aware of? Frequency, Loudness, Quality, & Duration of the sound
  • 21. When assessing a patient using the stethoscope for auscultation of the heart, it is alright to place the diaphragm (of scope) over clothing for better hearing. T/F False: Always bet directly placed on skin What is the bell of the stethoscope best used to auscultate for? Low pitched sounds (vascular & some heart sounds) What is the diaphragm best used to auscultate for? High pitched sounds (bowel and lung sounds) In which case should you initiate the use of the olfaction to test what is abnormal vs normal? Alcohol on breath. Foul smelling odor from wound. USUALLY DESCRIPTIVE IN NATURE How do you prepare for Assessment? 1) Gather equipment 2) Introduce self 3) Use standard precaution 4) Wash hands before & after 5) Clean stethoscope and cuff 6) Make client comfortable and offer privacy and protect confidentiality A 13yr old boy is brought to the ER, by his step-father, with a broken right femur. During your Assessment on the unit, the patient states his accident was caused by falling off a tree. You notice on the ER report, it states "patient broke femur falling from the stairs." What is this a possible indication of? Possible sign of Abuse. (behavior issues: insomnia, anxiety, isolation) Responsive eye movement is an indication of what level of consciousness? Alert A state of dullness, sleepiness, and drowsiness is what level of consciousness? Lethargic Being in a state of reduced consciousness and diminished spontaneous movement is what LOC? Stuporous The state of profound unconsciousness, no response to eye movement, vocalization, or physical movement is what LOC? Comatose
  • 22. When assessing a patient's orientation it is always best to use open ended questions. T/F False: Question like "Is your name Jim Bob?" is an open ended question and should never be asked. Questions that require oriented responses such as "Can you tell me your name?" is best This is an additional Neuro check that is tested by coarsely running a tongue blade or reflex hammer up the lateral aspect of the foot from heel to big toe. Babinskie Reflex (aka plantar relfex) You are apply the Babinski Reflex on a patient and notice the toes extend and separate. What is the result of the Babinski test? Positive Babinski sign= Abnorm Reflex (Reflex is normal in newborns but abnormal in children and adults, in whom it may indicate a lesion in the pyramidal tract) a pathway composed of groups of nerve fibers in the white matter of the spinal cord through which motor impulses are conducted to the anterior horn cells from the opposite side of the brain. These descending fibers, the nerve cell bodies of which are found in the precentral cortex, regulate the voluntary and reflex activity of the muscles through the anterior horn cells. Pyramidal tract The absent of the Babinski sign, as evidence by flexion of the foot is known as? Normal reflex The hair on the scalp, axillae, pubic and beard are known as... Terminal hair Soft tiny hairs covering the body except palms and soles are known as? Vellus hair What are some characteristics that should be noted when assessing the nails? Transparent Smooth Rounded Convex Hygiene What is synchronized movement of the eyes? Consensual Movement
  • 23. The ability of the eyes to follow a moving object is known as... Tracking What is the 20 foot distant chart used to test both eyes together then loosely covers one, reading smallest print testing visual acuity? Snellen Chart Six directions of gaze (Cardinal fields of gaze) Extra-ocular movements Alignment of the eye Corneal light reflex Checks peripheral vision Visual Fields Accomodation of the eyes reacting to change in light. Pupillary Reflex What does PERRLA stand for? P= Pupils E= Equal R= Round R= Reactive L= light A= Accommodation This disorder is the farsightedness, or an inability of the eye to focus on nearby objects. Hyperopia This is the condition of nearsightedness caused by the elongation of the eyeball or by an error in refraction so that parallel ray are focused in front of the retina. Myopia This is an abnormal condition of elevated pressure within an eye caused by obstruction of the outflow of aqueous humor. Glaucoma This is a progressive deterioration of the maculae of the retina. Macular degeneration A hyperopic shif to farsightedness resulting from a loss of elasticity of the lens of the eye. Presbyopia The abnormal progressive condition of the lens of the eye, characterized by loss of transparency. Cataract An abnormal condition of the eye in which the light rays cannot be focused clearly in a point on the retina because the spheric curve of the cornea of lens is not equal in all meridians. Astigmatism An abnormal ocular condition in which the visual axes of the eyes are not directed at the same point. Strabismus
  • 24. A group of noninflammatory eye disorders. Major contributing conditions include diabetes, hypertension and atherosclerotic vascular disease Retinopathy Involuntary rhythmic movements of the eyes; the oscillations may be horizontal, vertical, rotary, or mixed. Nystagmus What are the parts of the ear consist of? External: auricle, outer ear canal, and TM Internal: Bony ossicles Inner: Cochlea vestibule, and semicirclar canals You notice a nurse in a patients room with a vibrating tuning fork positioned at the center of the person's forehead. What test is this nurse likely performing? Weber's test The sound heard the loudest in the unaffected ear, using Weber's Test is _____. Sensorineural When performing the Weber's Test on a patient, what indicates "conductive hearing loss?" Sound is heard louder in affected ear. (sounds heard by bone conduction) When assessing the nose and the area of the sinuses, what should a nurse take note of? Nose: Patentcy, mucosa, drainage Sinuse: frontal and maxillary The pharynx, palate, tongue, buccal mucosa, and teeth are all physical components of what area of assessment? Oral Cavity What are some components should considered during a physical assessment of the neck? Trachea: is it midline? Thyroid glands: are nodules swollen? Muscle stregnth Lymph nodes Carotid arteries and jugular veins When inspecting and palpating the chest/thorax, what should one take note of? Inspection: symmetry and shape of chest; spinal
  • 25. alignment; skin condition Palpation: expansion/chest excursion, tactile/vocal fremitus and chest wall. What is a tremulous vibration of the chest wall caused by vocalization that is primarily palpated during physical examination. Fremitus What are signs of a normal chest/thorax configuration? Elliptical shape, ribs slope downward. A patient with chest configuration that appears rounded with their ribs horizontal rather than at a downward loping angle has chronic asthma. What type of configuration of the thorax does this patient have? Barrel Chest You notice, during your assessment of the patient, they have a sunken sternum. They state they have had that since birth. What type of chest configuration does this patient have? Pectus excavatum A sternum that protrudes somewhat resembling a "pigeon breast" is known as _____. Pectus Carinatum A lateral S-shaped curve of the spine is called ____. Scoliosis The "humpback" appearance of the spine is called ____. Kyphosis The anterior concavity of lumbar spine is known as? Lordosis When testing this one uses the palms of the hands placed on the posterior of the thorax and observes for normal expansion during inspiration. What is this called? Chest Excursion Loud hollow high pitched sounds heard over the trachea is known as____. Bronchial Breathing sounds Blowing, medium pitched sounds heard posteriorly between the scapulae is what sound? Bronchovesicular Breath sounds Soft breezy, low pitched sounds heard over the periphery smaller airways is known as ____. Vesicular Breath Sounds Moving the stethoscope across in this equal fashion is known as _____. Contralatteraly The high pitched "rice krispie" sounds heard at the base of the lungs are... Crackles
  • 26. The rumbling coarse sounds heard over trachea and bronchi is _____. Rhonchi The high pitched musical sound heard over all lung fields are known as ____. Wheezes The rubbing/grating sound heard over the thoracic cavity is known as ____ Pleural Friction Rub The Ventricles contacting, blood moving from left vent jnto the aorta and from the right vent into pulmonary arteries is known as the... Systole The ventricles relaxing and atria contracts, blood moves from atria into ventricles and coronary arteries is known as _____. Diastole A fine vibration, felt by an examiner's hand on a patient's body over the site of an aneurysm or on the precordium, the result of turmoil in the flow of blood, indicating the presence of an organic murmur of grade 4 or greater intensity. Thrill This is the "Lub" sound of the mitral/tricuspid valve closing. S1 This is the "Dub" sound of the aortic/pulmonic valves closing. S2 This sound is located at the right base, second intercostal space to the right of the sternum. Aortic This sound is located at the left base, second intercostal to the left of the sternum. Pulmonic This sound is located left lateral sternal border, fifth intercostal space to the left of the sternum. Tricuspid This sound is located at the apex: midclavicular line at 5th intercostal spaces. Mitral The blowing swooshing sounds that are graded from i-vi with grade i being barely audible and grade vi being the loudest (heard without stethoscope) Murmurs This test checks for proper circulation in the distal parts of the upper extremities by completely cutting off circulation from the distal upper extremity and releasing. Allen test This is the ultrasound device that detects pulse. Doppler
  • 27. What are the 3 "P's" of physical assessment of venous/arterial insufficiency? Pain Pallor Pulselessness Capillary refill should be less then ____ 2 seconds This type of edema is typically around the feet and ankles. Prominently in older adults and those who stand a lot. Dependent Edema This type of edema is caused by venous insufficiency of R heart failure resulting in fluid accumulation in tissue. Pitting Edema You are doing a physical assessment on a client. Prior to palpations over the abdomen what should you make sure is done first? Empty bladder When assessing normal bowel sounds what should you hear? 5-35 sounds per minute This is an audible abdominal sound produced by hyperactive intestinal peristalsis. Borborygmi What is the release of palpation that is followed by a feeling of pain called? Rebound tenderness What are some things to assess for on an IV site? Patency, Integrity of Site, and what is being infused pertaining to the nose and stomach, as in aspiration of the stomach's contents. Nasogastric This law consists of civil and criminal. Statutory Law This prevents harm to society and provide punishment for crimes such as felonies and misdemeanors. Criminal Law This protects the rights of individual persons within out society and encourage fair and equitable treatment among people. Civil Law This reflects decisions made by administrative bodies such as State Boards of Nursing when they pass rules and regulations Administrative Law This is the results from judicial decisions made in courts when individual legal cases are decided. Common Law The willful acts that violate another’s rights, such as assault, battery, and false imprisonment. Intentional Torts
  • 28. These are acts where intent is lacking but volitional action and direct causation occur, such as found with invasion of privacy and defamation of character. Quasi-Intentional Torts This includes negligence or malpractice. Unintentional Torts This is required for all routine treatment, hazardous procedures such as surgery, some treatment programs such as chemotherapy, and research involving clients. Consent This is conduct that falls below the standard of care. The law established the standard of care for the protection of others against an unreasonably great risk of harm. Negligence This is one type of negligence and often referred to as professional negligence Malpractice Nurses can call this when the assignment given to them is unsafe and can cause potential harm to patient safety Safe Harbor This is a photograph of the interaction between the health care providers and a patient at a particular moment in time. The quality of the photograph is dependent on the skill of the picture taker. Medical Record The purpose of this organization is to protect and promote the welfare of the people of Texas. This purpose supersedes the interest of any individual, the nursing profession, or any special interest group. The board fulfills its mission through two principle areas of responsibility: (1) regulation of the practice of professional and vocational nursing, and (2) accreditation of schools of nursing. Texas Board of Nursing This organization represents the interests of the nation's 2.9 million registered nurses through its constituent member nurses associations and its organizational affiliates. ANA This organization advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the general public. ANA Mission: Moving the nursing profession forward through leadership, advocacy and innovation. Vision: The trailblazer for nursing! TNA
  • 29. “State of complete physical, mental, and social well-being, not merely the absence of disease or infirmity” Health (WHO, 1947) Health is an acute state of being perfect health then severely ill. T/F False: Health is viewed on a continuum that goes between "perfect" health to severe illness and death. This model is the relationship between a person's belief and behavior. Health Belief Model This health model looks at the relationship between multidimensional persons and their environment. Health Promotion Model This health model looks at the relationship of needs and survival. Basic Human Needs Model This programs goal is to achieve a high level of wellness to avoid preventable illness by active and passive processes such as working out, stop smoking, clinics, schools, etc. Health Promotion Program This level of preventative care is health promotion & protection. Simply a preventative action before any signs and symptoms arise. Primary This level of preventative care is early treatment & interventions, limiting "harm." (You find an aching wrist so you go to the doctor for a check up. No hospitalization required most of time) Secondary This level of preventative care is treatment when condition is permanent or irreversible: restoration and rehabilitation. (ex: ISRD) Tertiary This is an alteration in body functions which causes reduced capacity or shortened life span Disease This is a state in which the person perceives physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired. Illness This is a sudden onset and severe illness Acute The duration of these type of illness appears in a six month span and has varying limitations. Chronic Illness This is an illness that ultimately results in death. Terminal Illness How people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the health care system. Illness Behavior
  • 30. What are some internal influences of Behavior on illness? The client's perception of the illness. The nature of the illness (acute, chronic, etc) The client's coping skills. Spiritual belief Pre-contemplation--> Contemplation--> Preparation--> Action--> Maintenance Stage--> Poss ??relapse?? These are the stages of ____. Health Behavior Change What are some components of Self Concept? Identity Body Image Role performance Self Esteem Any real or perceived change that threatens identity, body image, or role are stresses toward ____. Self Concept If stress is not successfully managed by client what could be the result? May lead to negative self Concept This stage of Development consists of early adulthood (18-40) with the task of establishing intimate bonds of love and friendship. Intimacy vs Isolation This stage of Development (middle adulthood 40-65) has the task of fulfilling life goals that involve family, career, and society. Generativity vs Stagnation This stage of Development takes place in later adulthood (65-Death) with the task of looking back over one's life and accepting its meaning. Integrity vs Despair The imparting or interchange of thoughts, opinions, or information by speech, writing, or signs. Communication What are some result of poor communication? Threatens Professional credibility Increases Risk of Liability Worst Outcome---- May result in harm to client. This type of communication is within ones self, either positive or negative. Intrapersonal This form of communication is face to face. Interpersonal This form of communication is within a spiritual aspect/domain. Transpersonal
  • 31. This form of communication is the interaction with an audience and is the most formal form of communication!!! Public This zone of personal space usually is between 0-18inches with great sensitivity needed before approaching. (Genitalia, rectum) Intimate Zone This zone of personal space is between 18in-4ft usually between close friends. Personal Zone This zone of personal space is between 4-12ft that does not require permission. Social Zone This zone of personal space is 12ft and greater. Public Zone Pre-interaction Phase--> Orientation Phase--> Working Phase--> Termination Phase. All part of the phases of___. Helping Relationships This is one of the fundamental impediments of critical thinking. Egocentric thinking This is to understand, comprehend, decipher & explain the meaning of written materials, verbal & nonverbal communication, empirical data & graphics. Interpret (Interpretation) To examine, organize, categorize, or prioritize variables such as signs & symptoms, evidence, facts, research findings, concepts, ideas, beliefs & points of view. Analysis To assess the credibility of sources of information, to assess the strength of evidence, to assess the relevance, significance, value or applicability of information in relation to a specific situation, & to assess information for biases, stereotypes, & clichés. Evaluation To continuously monitor, reflect on, & question one’s own thinking, to reconsider interpretations or judgments as appropriate based on further analysis of facts or added information, & to examine one’s own views with sensitivity to the possible influence of personal biases or self- interest. Self-Regulation What is the ABC's of the nursing process? Oxygen, Circulation, Neurosensory, Nutrition, Elimination, Mobility, and Aging What are some good attributes and characteristics of Critical Thinking? Open-minded, flexible, inquisitive, reflective,
  • 32. creative, self-directed This implies that a person is conscientious in actions, knowledgeable in the subject, and responsible to self and others Professionalism the diagnosis and treatment of human responses to actual or potential health problems (ANA, 1980) Professional Nursing What is the nursing process? Assessment Analysis Planning Implementation Evaluation What are the levels of Health Care? Preventive Primary Secondary Tertiary Restorative Continuing