NUR 207: Exam 1

Describe factors that cause variations in vital signs and their measurement, including postural changes.

exercise, disease processes, infection, stress/emotional status, environmental temperature, and age

Ulcer Staging

stage 1 - *skin intact* but red and blanches w/ pressure stage 2 - blister or *break in dermis* stage 3 - subQ destruction into the *muscle* stage 4 - involvement of joint or *bone*

Percussion

tapping motions of the nurse's hands on the patient's body ex. tapping on the chest wall produces sound based on the amount of air

Consider age, gender, condition, and culture of the patient to individualize the assessment of pain.

•Lower pain scores -Racial, ethnic minority groups -Potential patient variables -Nociceptive differences; communication processes; pain behaviors •Gender differences in pain exist -Fibromyalgia; IBS; migraines; TMJ pain -Women > Men •Sociocultural variables

Inspection

visual examination of the examination ex. look/ inspect areas of body

Auscultation

examine patient by listening to sounds from a stethoscope ex.use stethoscope to hear heart, bell for bowel movements

Implications of isolation

-Isolation refers to techniques used to prevent or limit the spread of infection. -Some form of isolation has been used for centuries, whether to protect a high-risk person from exposure to pathogens or to prevent the transmission of pathogens from an infected person to others.

Sample Question: A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

"Documentation is a communication tool for the interprofessional health care team."

Sample Question: A nurse is conducting a health promotion class for clients and their children about sun protection. The nurse should identify which of the following client responses as an indication that the teaching was effective?

"I will avoid sitting in the sun between 10 a.m. and 3pm"

Sample Question: A nurse is caring for a client who has hypertension and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of the therapeutic communication response of reflection?

"You seem upset about taking your blood pressure medication." This statement is a reflective comment that describes the patient's feelings. A reflective comment repeats what a patient has said or describes the person's feelings.

Document and communicate data from the pain assessment using appropriate terminology and standards.

-Accept the patient's data -Subjective data collection •Location •Duration •Intensity •Quality/Description •Alleviating/Aggravating factors •Pain management goal •Functional goal

Discuss HIPPA and confidentiality of Protected Patient Information

-Health care professionals must ensure confidentiality, governed by HIPAA, for all patient information, including what they document in the written or computerized record.

Identify the categories of a functional health assessment using Gordon's nursing framework.

-Health perception/ Health management -Nutritional-metabolic -Elimination -Activity and exercise -Sleep and rest -Cognition and perception -Self-perception and self-concept -Roles and relationships -Sexuality and reproduction -Coping and stress tolerance -Values and beliefs

Describe the multiple purposes of the patient medical record

-In addition to being a legal document, the medical record is used for communication among health team members, care planning, quality assurance, financial reimbursement, education, and research.

Identify important topics for health promotion and risk reduction related to pain.

-Pain can cause physical and emotional harm Inadequately related acute pain: -Impairs pulmonary function -Decreases immune response; prolongs hospital stay -May result in neuropathic pain syndromes Patient education: -Benefits of effective pain management -Negative consequences of pain medication refusal -Strategies dealing with adverse effects

Collect objective data related to pain, observing and collecting physical data.

-Pain has physiological, objective effects (Stress response, muscle tension) -Inadequately treated pain (Nausea, diaphoresis, vomiting) -Observable behavioral responses (Vocalizations, face grimacing, bracing, rubbing painful areas, restlessness, vocal complaints)

Compare and contrast various methods of documenting and communicating data for patient including SBAR, SOAP notes

-SBAR is a shared mental model for improving communication between and among clinicians. -Situation: State concisely why you are communicating. -Background: Describe the circumstances leading up to the current situation. -Assessment: Give objective and subjective data pertinent to the situation. -Recommendation: Make suggestions for what needs to be done to manage the difficulty. -The SOAP note is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. -S: Subjective assessment findings -O: Objective assessment findings -A: Analysis of the assessment data to identify a problem or indicate whether the problem is improving or worsening -P: Plan for treating or improving the problem

Standard vs. Transmission precautions:

-Standard precautions for all patients to protect against blood and body fluid transmission of potential infective organisms. -Transmission-based precautions to protect against the spread of highly transmissible or epidemiologically significant pathogens in patients with documented or suspected infection -Transmission-based precautions are used in addition to standard precautions when organism have been identified and the route of transmission is known. Contact: -Contact transmission is the most frequent means of transmitting infections in healthcare facilities. -Contact transmission is by direct or indirect contact. -Ex: MRSA, C. Diff. Droplet: -Droplet transmission occurs when mucous membranes of the nose, mouth, or conjunctiva are exposed to secretions of an infected person who is coughing, sneezing, or talking. -Droplets do not remain suspended in the air for very long and seldom travel more than 3 feet; thus, transmission is not via the airborne route. -Ex: Pertussis. Airborne: -Airborne transmission occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens. -Air currents widely disperse organisms, which can be inhaled by or deposited on the skin of a susceptible host. -Ex: TB.

Sample Question: What heart sound irregularities would you find between S1 and S2 - what does an S3 heart sound mean

-The heart sound you hear when you first feel the pulse is S1, and when the pulse disappears is S2. When a valve is stenotic or damaged, the abnormal turbulent flow of blood produces a murmur which can be heard during the normally quiet times of systole or diastole -An S3 gallop or "third heart sound" is a sound that occurs after the diastole S2 "dub" sound. In young athletes or pregnant women, it's likely to be harmless. In older adults, it may indicate heart disease.

Describe the relationship between reporting patient assessment data and ensuring patient safety

-To provide safe patient care, nurses continually communicate with all members of the health care team. -Reporting occurs at handoffs, during patient rounds, during patient and family care conferences, and when calling or texting a provider to report a change in status or provide requested information. -Baseline assessment data or significant changes in patient status are crucial elements of most reporting. -The Joint Commission developed its National Patient Safety Goals that require agencies to develop a standardized approach to handoff communications, including the opportunity to ask and respond to questions.

Standard precautions for blood and body fluids and body-substance isolation

-Universal precautions relate to blood and certain body fluids and are designed to protect healthcare workers from patients who may be carrying HIV, hepatitis B virus, or other bloodborne pathogens. -Body substance isolation involves the use of barriers to provide protection from all moist body secretions. -Standard precautions decrease risk of transmission from bloodborne pathogens and transmission from moist body substances. -This system protects against the transmission of both undiagnosed and identified infections.

Collect subjective data relating to various skin lesions, cancer, and pressure injury

-previous history of skin disease changes (pigment, mole, moisture, dry) -bruising -rashes -lesions, -alopecia -hair gain (hirsutism)c -change in nails -environmental or occupational hazards -self care behaviors/ cultural considerations -Any medications causing sensitivity -skin turgor

Give advice about how to avoid overexposure to the sun and its effects on skin health.

1. Always wear sunscreen 2. Avoid the sun in the middle of the day (10am-3pm) 3. Wear protective clothing 4. Wear sunglasses

Doffing PPE

1. Gown 2. Gloves 3. Mask/ Respirator 4. Mask/ Respirator 5. Wash Hands

Donning PPE

1. Gown 2. Mask/ Respirator 3. Goggles/ Face Shield 4.Gloves

Chain of Infection Process

1. Infectious Agent 2. Reservoir 3. Portal of Exit 4.Mode of Transmission 5.Portal of Entry 6. Susceptible Host

Sample Question: A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client?

208 Answer Rationale:A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements

Sample Question: A nurse is caring for a client who has a mental health disorder. The client asks about his medications and their effects. The nurse asks the client why he needs to know this. Which of the following nontherapeutic communication techniques is the nurse using?

Asking for an explanation

Warning signs of melanoma

ABCDE Asymmetry, Border irregularity, Color, Diameter, Evolution

Discuss the significance of accurate and timely documentation

Accurate Documentation: -Assessment information that you enter into the patient's record must accurately reflect what you observe, hear, auscultate, palpate, or percuss. -Document subjective data using the patient's exact words whenever possible. -Accuracy permits comparison of current findings with future data to detect changes in patient status. Timely Documentation: -You must enter assessment data into the record in a timely manner. -Most agencies have policies regarding the frequencies of assessments. -Prompt documentation allows health care team members to use up-to-date assessment information to make clinical decisions.

Sample Question: A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

Airborne

Sample Question: A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale from 0 to 10.

Collect subjective data related to pain, including pain descriptors using OLDCARTS and PQRST.

Assessment Mnemonic: OPQRST -O: Onset -P: Provocative or palliative -Q: Quality -R: Region, radiation -S: Severity -T: Timing Assessment Mnemonic: OLDCARTS -O: Onset -L: Location -D: Duration -C: Character -A: Alleviating/ Aggravating -R: Radiation -T: Timing

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Carotid Rationale:The nurse should avoid assessing the carotid pulse bilaterally at the same time. This action can induce syncope by reducing blood flow to the brain and causing a reflex drop in the blood pressure and heart rate

Secondary Data

Charts and information from family members or members besides the patient

Sample Question: A nurse is caring for a client who is about to have a colonoscopy. The client states, "I am so nervous about what the doctor might find during the test." The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" With this question, the nurse is using which of the following communication techniques?

Clarification

Identify the components of the comprehensive health history and review of systems.

Comprehensive Health History: Identifying Data, Chief Concern, Present Illness, Past History, Family History, Social History, Review of Systems Review of Systems: series of questions about all body systems that helps to reveal concerns as part of a comprehensive health assessment, and health promotion

Sample Question: How do differing skin levels of melanin affect evaluating for cyanosis, pallor and rubor?

Cyanosis: -light-skinned is dark-blue tint to the skin & mucous membranes -dark-skinned is white/ gray around the mouth Pallor: -light-skinned where skin appears lighter than usual -dark-skinned where it's only detected in the eye and mouth lining Rubor: -light-skinned causes rednesss of the skin/ inflamamtion -dark-skinned causes a light redness

Primary Data

Data from patient

Techniques/ Qualities of Auscultation

Diaphragm: -higher pitched sounds -breath and heart sounds Bell: -lower pitched sounds -heart defects and bowel movements

Describe the purpose of the general survey in the comprehensive physical examination.

General Survey may include: -skin color and obvious lesions -grooming/ dress -personal hygiene -facial expression -odors of the body and breath -posture, gait and motor activity

Communicable Disease

Illness directly transmitted (one person or animal to another by contact with body fluids) or indirectly transmitted (contact with contaminated object or vectors)

Describe accurate techniques of BP measurement according to evidence based standards, including contraindications to BP in a site

Indirect mesure of BP: -auscultatory method (stethoscope to listen to heart sounds and sphygmomanometer/blood pressure cuff)-Sphygmomanometer measures pressure in cuff-finger pulse transducer Contradiction: low reading: cuff too large high reading: cuff too small

Subjective Data

Information from the client's point of view ("symptoms"), including feelings, perceptions, and concerns obtained through interviews

Order of assessment when obtaining subjective data & health assessment

Inspect Auscultate Percussion Palpation

Proper Order of Examination

Inspection Palpation Percussion Auscultation

Infection

Invasion of body tissue by microorganisms with the potential to cause illness or disease

Active Listening

Is the ability to focus on patients and their perspectives. It requires that you constantly decode messages, including thoughts, words, opinions, and emotions

Sample Question: A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Nausea

Identify normal and abnormal findings related to the integumentary system including ulcer staging and warning signs of melanoma

Normal: The skin colour consistent with the person's ethnicity, and consistent over the body surface. Freckles, moles and striae Abnormal: Cyanosis, ecchymosis, erythema, jaundice, pallor, and petechiae

Objective Data

Observable and measurable data ("signs") obtained through observation, physical examination, and laboratory and diagnostic testing

Demonstrate knowledge and techniques of taking accurate vital signs including routes, indications, and contraindications for different routes of temperature.

Oral temperature: temperature by mouth it is the most common site. -Normal body temperature is 97 to 100 degrees Fahrenheit with an average of 98.6 degrees Fahrenheit. Patients must be able to close mouth and must wait 20 to 30 minutes after eating or smoking. -Contraindications of oral temperature are unconscious patients, patients with seizures infants or young children oral disease or surgery mouth breathing or Oxygen mask Rectal temperature: reliable and normally higher than oral temperature by 1 degree Fahrenheit. Rectal temperatures are contraindicated for patients with Rectal Surgery diarrhea mental disease or heart disease. A patient with heart disease can have the vagus nerve stimulated which can cause bradycardia Axillary temperature: Assessed by using a probe under the armpit. Contraindicated for checking for fever. Measurement often lags behind core temperature. Usually one degree lower than oral temperature Tympanic temperature: is readily accessible and is not affected by eating smoking or cerumen. It is measured in the ear canal. Measured by an electric thermometer designed for tympanic temperature measurement. It has the most variability of measurement requires the removal of hearing aids requires a disposable sensor and contraindicated for patients who have had surgery of the ear or tympanic membrane. Inaccuracies reported by in correct positioning of handheld unit.

Identify myths and issues in difficult-to-assess patients, such as those with opioid tolerance, those who cannot verbalize pain, and those with dementia.

Patients unable to report pain •Attempt self-report; try to identify potential pain causes. •Observe behaviors; ask family/care providers. •Attempt analgesic trial. •Patients with opioid tolerance •Pose difficult challenges in pain assessment. •Opioid hyperanalgesia; health care provider bias •Patients with substance abuse history are entitled to pain relief.

Sample Question: A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

Places clean linen that touched the floor in the soiled linen bag.

Differentiate the pre-interaction, beginning, working, and closing phases of the interview process.

Pre-interaction:Before meeting with the patient, you collect data from the medical record, including the previous history of medical illnesses or surgeries, current medication list, and problem list Beginning: Introduce yourself by name and state the purpose of the interview. Pull drapes around patients if conducting the interview in a hospital room, or close the door if working in an examination room. In community settings where patients are disclosing personal information, identify an area where others cannot overhear the conversation before beginning the interview. Working: Collect data by asking specific questions. Two types of questions used to collect information are closed-ended and open-ended questions. You also chart the patient's history and health problems. Closing: You end the interview by summarizing and stating what the two to three most important patterns or problems might be.

Sample Question: A charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching?

Purpose of hand hygiene: 1. Reduce the numbers of resident and transient bacteria on the hands. 2. Prevent transfer of microorganisms from healthcare personnel to the patient and others. Assessment: -Inspect hands for breaks or cuts in skin or cuticles. -Identify appropriate times for handwashing before, during, and after patient contact. -Identify need to repeat handwashing if hands become contaminated during a procedure. -Determine whether waterless alcohol-based product is appropriate or if soap and water are necessary.

Sample Question: A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

Repeat auscultation after asking the client to breath deeply and cough

Sample Question: A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?

Reporting laboratory findings to a member of the client's family

Collect objective data on the skin, including turgor, temperature, color, and moisture.

Skin: color tan-pink, warm to touch, dry, smooth, turgor good, no edema, no bruises, no lesions. Hair: even distribution & texture, color brown, no lesions on scalp, no seborrhea noted Nails: nail beds firm, pink with cap. refill of 2 sec., no clubbing or deformities

Hand Hygiene

Step 1: Wet Hands Step 2: Rub Palms Together Step 3: Rub the Back of Hands Step 4: Interlink your fingers Step 5:Cup your Fingers Step 6: Clean the thumbs Step 7: Rub Palm with Your Fingers

Sample Question: A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan?

The client's self-report of pain severity

Infectious Disease

any disease caused by microorganisms, transmitted from one person to another or from animal to person

Therapeutic Communication

being caring, using empathy, and self-concept

Identify the basic conditions that may cause the lesions

common causes of skin lesions: injury, aging, infectious diseases, allergies, and small infections of the skin or hair follicles

What to consider to individualize the integumentary assessment

condition, age, gender, and culture of the patient

Knowledge of precautions for infection control and safety

the intention of standard precautions is to prevent disease transmission during contact with nonintact skin, mucous membranes, body substances, and blood-borne contacts

Palpation

to examine by touch ex.palpate light or deep on the abdomen for mass