NURS 216: EXAM 1
Pain
A client's self reports is the best way to assess pain Cause trauma surgery cancer arthritis diagnosis or treatment procedures Identify sources of pain with objective data On a scale of 0 to 10 with 0 being no pain and 10 being the worst imaginable pain how would you rate your pain level
Nomaleficence
A commitment to do no harm
Veracity
A commitment to tell the truth
Nursing diagnosis
A statement of patients health status that nurses can identify prevent, or treat independently.
0
Absent
Posterior tibial
Achilles tendon
Beneficence
Action that promotes good for others without any self Interest
General survey
The general survey is a study of the whole person the minute you come into contact with them Physical appearance Age- do they appear their stated age Sex- sexual development appropriate for gender/age Color of skin- tone even, pigmentation will vary w/ ethnic, background skin intact with no lessons, texture. Facial features- symmetric with movement, emotional expressions, eye contact, loc Indications of distress- labored breathing, extremely anxious Indications of physical abuse- bruises, cuts Indications of substance abuse- track marks, teeth Level of consciousness Is the patient alert and oriented x 4 Oriented to person? Can they state their name/ DOB? Oriented to time? Can they tell you the date, who the president? Is what time it is? Oriented to place? Can they tell you where they are right now and their address? Oriented to situation? Do they know they are there Behavior Mood and affect Eye contact ( may be different depending on culture) Speech- clear and understandable, conveys ideas clearly, word choice appropriate Dress Hygiene Grooming Odors Body structure - stature, height, weight, expected vs unexpected mobility and ROM Nutritional status Symmetry of body body parts are in proportion and equal on each side posture and usual position - kyphosis or lordosis Gross abnormalities- congenital defects, amputations Mobility Gait Any mobility aids! Limping Shuffling Movement Purposeful, tremors Range of motion full ROM I'n each joint Motor activity- each movement is deliberate and coordinated
Autonomy
The right to make one's own personal decisions even when those decisions might not be in the personal on base Interest
T
Timing when did the pain start how long does the pain last, does it come and go or all the time.
Inspection
Types direct visualization indirect using a light source and or magnifier for visualization otoscope Senses sight smell Data surface characteristics, symmetry gross abnormalities signs of distress unusual odors
Analysis
Use clinical judgment to evaluate data collection to formulate the client's problems, including actual and potential problems.
Planning
Use problem and decision making skills to prioritize outcomes and goals and develop interventions to meet those goals.
Diagnosis
Using critical thinking skill the nurse analysis the assessment to identify patterns in the data and draw conclusions about the client health status ( strength, problems, and factors contributing to the problem). The purpose of diagnostic is to identify the client's health status accuracy is essential because the diagnosis is the basis for planning patient centered goals/ interventions.
objective
What you can see for your self
Radical
Wrist- radial side
A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first
assessment
Femoral
groin area
Percussion
tapping on a surface to determine the difference in the density of the underlying structure
Communication skills
Active listening being attentive to what the client is saying verbally and nonverbally sit facing the patient, open posture, lean in, eye contact, relax Sharing observations commenting on how the client looks, sounds, or acts Sharing Empathy The ability to understand and accept another person's reality to accurately perceive feelings and communicate understanding Sharing hope communicating a sense of possibility to others encouragement with appropriate and positive feedback Sharing humor contributes to feelings of togetherness closeness and friendliness promotes positive communication in prevention, perception and perspective. Sharing feelings help clients express emotions by making observations, acknowledging feelings encouraging communication, and giving permission to express negative feelings and modeling healthy anger Using touch most potent form of communication comforting touches are especially important for vulnerable clients who are experiencing severe illnesses or stress Silence time for nurse and clients to observe one another, sort out feelings, think about how to say things, and reflect, nurse should allow client to break the silence Providing information relevant information is vital to decision making reducing anxiety and feelings safe and secure Clarifying to check whether understand is accurate or to better understand Focusing taking notice of a single idea or word expressed Paraphrasing restating another's own message, briefly, in one's own words conveys the essential idea Asking Relevant Questions to seek further information for decision making asking only one question at a time and fully exploring one topic before moving on to another open ended questions allow for taking the conversational lead and introduction pertinent information about a topic Summarizing
Respirations
Adult 12-20 breaths per minute ( Eupnea) Bradycardia vs Tachycardia
Pulse
Adult expected range is 60-100 beat per minute at rest Bradycardia- slower than normal
Basic Principle of Ethics
Advocacy Support and define clients health wellness safety and wishes and personal rights including privacy Responsibility Willingness to respect obligations to follow throughout one promise Accountability Ability to answer for one's own actions Confidentiality Protecting a privacy without diminishing access to the high quality care
Current health status immunization status
Allergies to medication food environment currently medication preparation OTC vitamins supplements herbal remedies time of last does substance use alcohol tobacco caffeine recreational drug
Verbal communication
Ask what the client's prefers to be called, otherwise address the client by using their surname. Ask open ended questions. Redirect the client as needed. Engage in active listening Restart the client's view to indicate your understanding. Restate the client view to indicate your understanding. Use everyday language and stay away from medical terms as much as possible. Keep any emotionally charged conversation for last in oder to receive any other pertinent information. Give positive reinforcement and reassurance without passing judgment or disapproval.
Evaluation
Assess the effectiveness and achievability of the goals and the need for interventions to be adjusted.
A nurse has performed pre operative care on a client and transferring the client to the surgical holding area when the client started, I have changed my mind I do not want to have this surgery which of the following ethical principles is the client using
Autonomy i right to make decisions about their Care in a right to refuse treatment
Nonmalalefiecence
Avoiding hurt or harm to others
Initial planning
Begins with the first client contact refers to the development of the initial comprehensive care plan
Popliteal
Behind the knee
Justice
Being open and fair
4+
Bounding
2+
Brisk expected
Implementation
Carry out the interventions that have been established, use clinical judgment to monitor the client's process towards achieving their goals.
Ongoing planning
Change made in the plan allows you to prioritize the problem the client has
Current health history
Chief concern a brief statement in the client's own words of the reason for seeking care History of present illness HPI a detailed chronological description of why the client seeks care details about the manifestation
Past health history
Childhood illnesses Surgeries Hospitalization Serious injuries Medical problems Immunization Recent travel or military service
Family history
Client Spouse Children Siblings Parents Aunts and uncles Grandparents healthy status or if deceased age and cause of death
Critical thinking and clinical judgment
Contextual awareness Analysis assumptions Exploring alternative Using credible sources Reflecting and deciding
DAR
D= data A= action R= response
Medicaid diagnosis
Describe a disease, illness, or injury purpose is to identify a pathology so appropriate treatment can be given to cure the condition,
1+
Diminished
Ausucultation
Directly listening for sounds high and low pitch sound Combination head with bell and diaphragm flat side best for high pitch sounds use heavy pressure. Bell cone shaped best for low pitch sounds use light pressure Heart sounds high medium, and low pitch Lung sounds high Bowel sounds high Vascular sounds low
A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy?
Do not expose any of the clients body than required at a time
Documentation
Document LOC and whether the client is oriented to person place and time Example client is A & O x 3 T= 37 degrees C P = 95 RR = 12 bpm BP = 124/80 Pt verbalize pain of 4 on scale of 0 -10
Brachial
Elbow elbow area ulnar side
planning
Encompasses identifying goals and outcomes, choosing interventions, and creating nursing care plan.
Pulse Qximetry
Expected range 95-100 Client with chronic lung disease may tolerate as low at 85% Choose an intact non edematous site Place digit probe onto finger Use earlobe or bridge of nose for clients with peripheral vascular disease Sole of foot or toe for infants Wait until the number is stable Avoid nails with paint or gel
Nonerbal
Face the client when speaking and maintain an awareness of personal space.
Justice
Fairness in care deliver and use of resources
Tachycardia
Faster than normal Count for 30 seconds and multiple and by 2 if irregular count for the full minute and compare to apical rate
Palpation
Finger pads tips best to assess fine sensations
Process evaluation
Focuses on the activities preform it does not describe the results of the activities preformed, it focuses on what was done and how well it was done
Outcomes Evaluation
Focuses on the observable and measurable changes in the client's health status resulting from the care given
Structure Evaluation
Focuses on the setting in which care is provided
Fidelity
Fulfillment of a promises
Assessment
Gather data from the client through interview. Physical exam, and observation to make judgment.
Non-therapeutic communication
Give personal opinions Ask for explanation Give false reassurance Use plural pronouns like we Give approval and disapproval
A nurse is preparing to irrigated a client's leg wound. Which of the following pieces of personal protective equipment should the nurse wear while performing this task? Select all that apply
Google grown gloves
Autonomy
Having self control
Beneficence
Helping others in a positive manner
Confrontation
Helping the patient become aware of inconsistencies in his or her feelings, attitudes, beliefs, and behaviors
Directive (structured) closed ended
Highly structured Used to elicit short one or two word answers or yes or no answers Use them in the following situations After opening narrative to fill in details person many have left out When you need many specific facts about past health problems or during review of systems To move the interview along Examples Are you feeling better today ? Do you have any allergies ? When did you have your first knee surgery?
Apply cuff
I inch above Ac with brachial artery in line with marking on the cuff
ISBARR The nurse will communicate with other members of the health care team. ISBARR is a tool to have clear communication for effective client care.
Identify state the team members name and title. Situation provide the circumstances that have required the communication to occur. Background provide the background data regarding the client to assist the provider with familiarity. Assessment provide the most recent set of vital signs or other data relevant to the communication. Recommendation provide any suggestions that may be helpful to the situation. Read back orders repeat the orders that are given and clarify anything that is unclear
3+
Increased strong
A nurse just received report on a newly admitted client who reports abdominal tenderness in lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment
Inspection
Assessment
Involves gathering data about the patient and their health status info is related to the physiological, psychological, sociological, development, and spiritual status of the individual.
Implementation interventions
Involves preforming or delegating planning interventions, carries out the care plan.
Inspection
Is looking carefully and throughly at a client
Therapeutic communication
Keep questions focused and relevant to the context and situation Keep and emotionally charged conversations for last. Clarify to see if the information is accurate Be vigilant throughout the conversation Redirect the client as needed
Evaluation
Last step and carries out the care plan judgment about the client's progress towards desired health outcomes, the effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting.
Apical
Left center of your chest, just below the nipple between 5th and 6th rib or at the 5th intercostal space midclavicular line use for infant prior to cardiac meds, or validating a rapid or irregular pulse
BMI
Less than 18.5 reflects under weight and has increased effect on cardiovascular health risk. 18.5 to 25.9 reflects weight and has no effect on cardiovascular health risk 25 to 34.9 overweight 30 to 34.9 obese 35 and greater severely obese
Critical thinking
Lifelong learning and the ability to acquire relevant experience that can be reflected on continuously to improve nursing judgment. Competencies, attitudes, and intellectual and professional standards. Facilitated by seeking truth in an open minded manner and being inquisitive about why something is effective or ineffective, Follows a systematic process or pattern, not jumping to conclusions but using reason to guide decisions.
Medical vs nursing history
Medical - focuses in diagnosis and treatment of illness Nursing - focuses on diagnosis and treatment of human responses to health problems
Equipment used for assessments
Nasoscope nostrils nasal mucosa turbinate septum Transilluminator sinuses scrotum fontanels Tape measure/ruler lengths circumferences liver size jugular venous pressure lesions
Carotid
Neck
Blood pressure
No smoking or caffeine within 30 minute Sitting in chair Leg uncrossed Do not take Bp in arm with iv side where a client had a mastectomy or Av shunt or fistula Pulse pressure different between the systolic and diastolic pressure readings Orthostatic position from lying to sitting or standing
Types of questions
Nondirective client control the pace open ended questions Use to begin interview Use to introduce a new section of questions Use whenever the client introduces a new topic Examples What kind of outcomes would you want to achieve from your plastic surgery operations? Describe how you are feeling When you say it hurst what do you mean by that
Blood pressure classifications
Normal less than (systolic) and less than 80 (diastolic) Elevated -120 to 129 and less than 80 Stage 1 hypertension 130 to 139 or 80 to 89 Stage 2 hypertension 140 to 90
Rate
Number of times per minute you feel or hear the pulse
Implementation
Nurse base the care they provide on assessment data, analyses, and the plan of care they developed in the previous step of the nursing process, they must use problem solving, clinical judgment, and critical thinking to select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain, or restore health.
Evaluation
Nurse evaluation client responses to nursing interventions and form a client judgment about the extent to which client have met the goals and outcomes
Planning
Nurse must establish priorities and optimal outcomes of care they can readily measure and evaluate theses established priorities and outcomes of client care then direct nurse in selecting interventions to include in a plan of care to promote, maintain, or restore health.
Analysis/data collection
Nurse use critical thinking skills to identify clients health statuses or problems, interpret or monitor the collected database, reach an appropriate nursing judgment about health status, and coping mechanisms, and provide directions for nursing care.
Standard of Care
Nurses basis practice on establish standard of care or legal guidelines of care including the following. The nurse practice act of each state Published standard of nursing practice form professional organization and specialty groups (ANA, AACN, and AAOHN Health care facilities policy and procedures, which established the standard of practice for employees of that facility. They provide detailed information about how the nurse should respond to or provide care in specific situations and while preforming client care procedures Standard of care define and direct the level of care nurse should give and they implicate nurse who did not follow theses standards in malpractice lawsuits. Nurse should refuse to practice beyond the legal scope of practice or outside of their areas of competence regardless of reason staffing shortages, lack of appropriate personal Nurse should use the formal chain of command to verbalize concerns related to assignments in light of current legal scope of practice, job description, and area of competence
Primary data
Obtained directly from the patient subjective what the patient says/ tells you
Secondary data
Obtained secondhand from the medical record or another care provider
PIE
P= problem I= interventions E= Evaluation
A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take?
Palpate the tender areas of the abdomen last.
A nurse preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination
Penlight, tape measure, tongue depressor
Documentation
Physical or electronic record is a legal document Accurately Concisely Objectively Record by systems Chart pertinent negatives If it is not documented it is not done
P
Precipitating/ palliative factors what causes the pain and what relieves the pain palliative what make it better provocation what make it worse
Discharge planning
Process of planning a self care and continuity of care after the client leave the healthcare setting promotes client progress towards health/disease management outside of facility care and reduces chances of readmission to hospital care
Confidentiality
Protecting the privacy of others
Summarizing
Pulls together information for documentation a concise review of key aspects of an interaction
Equality
Pulses should be symmetrical (equal)
The client interview
Purpose of the Heath interview Gather subject data Goal- have a structured conversation with the client Stage of the interview process Opening stage start of the assessment first contact with the client Information gathering stage continuation of the assessment with client taking vitals going over medical history and family history Closing stage coming up with a plan of care
Q
Quality/ quantity of symptoms what does the pain feel like is it sharp stabbing dull crushing
A nurse is completing documentation in a client's medical record. Which of the following actions should the nurse take?
Record the client most recent assessment results.
Strength
Reflects the volume of blood ejected against the arterial wall with each heartbeat
R
Region radiation related symptoms where did the pain start where does the pain travel to
Rhythm
Regularity of impulses
A nurse has just received report on a newly admitted client who speak a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process
Request assistance from an interpreter during the assessment.
Assess for rate
Rhythm amplitude and quality
Documentation of findings.
SOAPIE S= subjective data O= objective data A = assessment P= plan I = interventions E= evaluation
S
Severity how bad is the pain using 0-10 pain scale how much does it affect your life
A nurse is preparing to perform palpitations on a client during a physical assignment. Which of the following findings is the nurse assessing during palpation
Skin temperature moisture and abnormalities
Self disclosure
Subjectively true, personal experiences about self that are intentionally revealed to another.
Assessment/data collection
Systematic collection of information about clients present health statuses to identify needs and additional data to collect based on findings
Vital signs
Temperature general temp 96.8 - 100.4 degrees f Oral-mouth Rectal - sims position right leg flexed use lubrication, insert 1 to 1.5 inches Axillary - armpit Temporal- hold flat against forehead and scan across forehead and temporal artery, lift thermometer and touch probe to skin behind earlobe Tympanic- pull ear up and back adult or down and back wàs we e
Nursing care plan
The comprehensive central source of info needed to guide holistic, goal-oriented care to address each client's independent nursing actions necessary.
