Session 1 - Vital Signs, Health Assessment, and Documentation

Different components of a health history

-Allergies (if reported, be sure to document the type of reaction. ex: hives, respiratory problems) -Medications (complete list. this should included any prescribed, OTC and herbal supplements) -Immunization History (lack of immunization can effect the patient's current health conditions). -Chronic Health Conditions (ex HBP, diabetes, chronic pain, etc.) -Childhood Illness and Past Surgeries (childhood illness could directly impact the patient's current health status. Past sx are important to know bc it could assist in ruling out any current problems, ex: complaints of rt upper stomach pain but has past sx is cholecystectomy then ur able to rule out that the current pain is related to gallbladder) -Support System (home life. relationships. need to know if they're homeless or don't have anyone at home because it can change discharge notes)

Devices used for proper positioning

-Pillows -Foot boards -Trochanter rolls -Hand rolls -Hand-wrist splints -Trapeze bar -Side rails -Wedge pillow

comprehensive assessment

-physical (breathing, eating, walking) -psychological (self-concept, emotions, behaviors) -social (relationship, interactions with family and friends) -spiritual (higher worshiping or interpretation on the meaning of life) Comprehensive assessment can last up to 45 minutes; however can vary in length based on the patient. Comprehensive assessment is used when examining a patient for the first time. The nurse uses this assessment to establish a baseline for the patient

Quality of pulse

0 absent 1+ weak 2+ normal 3+ bounding

Preparing Sterile Products

1. Ensure proper training 2. Clean room and laminar flow hood 3. Ensure all components are compatible 4. Ensure Stability 5. Ensure they are stored properly; keep records of preparation

Normal oral temperature range

36.5°C-37.5°C 97.7°F-99.5°F

Normal pulse rate

60-100 BPM

The normal adult temperature obtained through the oral route ranges from:

97.6 to 99.6 F or 36.4 to 37.6 C

Normal rectal temp

98.7-100.5F 37.1-38.1C

Nursing Process

ADPIE Assessment Diagnosis Planning Implementation Evaluation

adventitious breath sounds

Abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles.

dysrhythmia

Abnormal heart rhythm

Afebrile

Absence of fever; a condition in which the body temperature is not elevated

Electronic Health Record (EHR)

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization

Comprehensive health assessment

An in-depth assessment of the whole person, including physical, mental, emotional, cultural, and spiritual aspects of a patient's health

As a component of a head-to-toe assessment, the nurse is preparing to assess convergence of the client's eyes. How should the nurse conduct this assessment?

Ask the client to follow her finger as she slowly moves it toward the client's nose.

A nurse assesses a client for blood pressure. Which technique would be used for this assessment?

Auscultation

accurately assess the blood pressure

Blood pressure readings are taken with a sphygmomanometer and a stethoscope. A sphygmomanometer (a device for measuring the arterial blood pressure) consists of an inflatable cuff and a gauge. The gauge is aneroid (use of mercury-calibrated manometers is no longer advised). Inflate the cuff around the patient's arm to compress the artery, which occludes blood flow; then, slowly deflate it, which allows blood flow to resume (see the Evidence-Based Practice box). While doing this, listen at the brachial artery with the stethoscope to hear pulsating sounds. These are called Korotkoff sounds. The sounds go through five phases (Figure 11-11). At the first audible sound, make a mental note of the point on the sphygmomanometer gauge at which it occurs, and note again the point at which the sound disappears. That first point is the systolic pressure, and the second is the diastolic pressure.As the pressure is lowered, the Korotkoff sounds sometimes seem to disappear temporarily. In this case, listen for a subtle difference in the quality of what you hear as the manometer approaches the diastolic reading. In patients with hypertension, the sounds usually heard over the brachial artery disappear as pressure is reduced and then reappear at a lower level. This temporary disappearance of sound is the auscultatory gap. It typically occurs between the first and the second Korotkoff sounds. The gap in sound sometimes covers a range of 40 mm Hg and thus has the potential to cause an underestimation of systolic pressure or overestimation of diastolic pressure. Be certain to inflate the cuff enough to hear the true systolic pressure before the auscultatory gap.

Ecchymosis

Bruising or discoloration associated with bleeding within or under the skin.

Types of Assessments

Comprehensive, Focused, Time-lapsed, Emergency and Baseline assessment. The type of assessments that are performed varies depending on the clinical situation, patient status, time and purpose of data collection.

What are necessary communication skills to promote physical and mental health comfort during an assessment?

Creating a positive, warm, and compassionate patient experience Creating meaningful patient engagement and delivering patient education To decrease the stress and anxiety of the patient, it's important that the nurse communicates and educates on what is about to take place. Explain to the patient what a health assessment is and the order in which you're going to conduct the assessment. When educating the patient, make sure you're using terms the patient can understand; understanding the health assessment process and what to expect will increase the patient's physical and emotional comfort.

accurately assess the height and weight measurements

For patients who are able to stand, ascertain height by using the metal rod attached to the back of the standing scale, which swings out and over the top of the head. A measuring stick or tape attached vertically to the wall is also possible to use. Ask patients to remove their shoes, step onto the platform or against the wall, and stand erect, exercising good posture. After obtaining the measurement, help the patient to carefully step off the scales and return to chair or bed as needed. Cleanse the scale with appropriate disinfectant Patients are weighed to give the health care provider information for prescribing medication dosages and to determine nutritional status and water balance. Because 1 L of fluid equals 1 kg (2.2 lb), a weight change of 1 kg (2.2 lb) often reflects a loss or gain of 1 L of body fluids. A significant loss of weight frequently points to an underlying disease. Patients should be weighed at the same time of day, on the same scale, and in the same type or amount of clothing to allow an objective comparison of subsequent weighings. An ideal time to weigh patients is in the morning after voiding and before breakfast.

Way to remember the evidence-based practice components of a physical assessment.

IPA beer. I is for inspection (look) P is for palpation (touch) A is for auscultation (listening to sounds

describe the procedure for determining the respiratory rate

In assessing respirations, note the rate, the depth, the quality, and the rhythm. Assessment of the depth of respirations is completed by observing the movement by the diaphragm and the intercostal muscles. The best time to assess respirations is immediately after counting a radial or an apical pulse. The patient is unaware you are doing so and is less likely to consciously alter respirations.

A health care provider approaches the nurse caring for the client in room 25 and states, "The client is a friend of mine. What treatment is being given?" Which response by the nurse is most appropriate?

Inform the health care provider that client permission is needed to release any information.

The nurse is calling a health care provider to give an update on a client's condition. The nurse receives a telephone order and, when requests that the order be read back to the provider for confirmation, the provider states, "I don't have time for this." What is the most appropriate action by the nurse?

Inform the provider, to ensure safety for the client, it must be read back

What assessment technique would the nurse use to assess a client's chest for color, shape, or contour?

Inspection

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

It provides quick access to abnormal findings

The nurse is performing a head and neck assessment for a client. When inspecting the face, the nurse notes that the skin, sclera, and mucous membranes appear yellowish. In the electronic medical record the nurse chooses which drop-down box selection to document this finding?

Jaundice

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate?

Let me tell you what I will be doing. It should not be painful.

Emergency Health Assessment

Life-threatening situations-ABC, suicidal thoughts, social conflict leading to violent acts. Preserving the patient's life is a top priority. Emergency assessment is when breathing or pulse has stopped.

Which oxygen deliver method is most likely used to deliver an FiO2 of 24% to 44% with a flow of 1 to 6L/min?

Nasal Cannula

Which oxygen delivery method is most likely used to deliver an FiO2 of up to 95% at 8-15L/min?

Non-Rebreather Mask

vesicular breath sounds

Normal breath sounds made by air moving in and out of the alveoli.

Preparing a sterile field

Open packages away from body Touch only outer 1 inch corner Drop sterile items onto field 6 inches above Pour sterile solution onto dressing or into container after pouring out a small amount - do not let it touch Put on sterile gloves after everything is opened

A nurse is measuring the apical pulse of a client. Where should she place the diaphragm of her stethoscope in this assessment?

Over the space between the fifth and sixth ribs on the left midclavicular line

PQRST method of pain assessment

P: provocation/palliation (what causes the pain?) Q: quality/quantity R: region/radiation S: severity scale T: timing

A client has been reporting persistent headaches. Which is an example of subjective data?

Pain is 4 out of 10 on a pain scale.

Important patient centered care components to prepare patients and the environment for health assessment

Physical comfort, respect for patient's preferences, information and education, emotional support. When preparing the environment for health assessment, ensure that it's a comfortable and well-lit room. Prior to enter the patient's room, make sure that you have a necessary equipment, such a stethoscope and BP cuff, etc. Be sure to provide privacy and confidentiality. If there are family members in the room, ask the patient's permission for the family member's to stay. If the patient doesn't grant permission then the family member's must leave. Be sure to address any cultural or religious considerations related to performing an assessment that is specific to your patient's prior to beginning.

A nurse has an order to take the core temperature of a client. At which site would a core body temperature be measured?

Rectal

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:

Referral

Which oxygen delivery method is most likely used to deliver an FiO2 of 40% to 60% oxygen with a flow of 6% to 12L/min?

Simple Face Mask

SBAR stands for

Situation Background Assessment Recommendation

SOAP assessment stands for

Subjective, Objective, Assessment, Plan

The nurse preparing to perform an abdominal assessment on a client places the client in which position?

Supine

Identify Appropriate Pulse Locations

Temporal Carotid Apical Brachial Radial Femoral Popliteal Posterior Tibial Artery Pedal

Which organization audits charts regularly?

The Joint Commission

critical/collaborative pathways

The case management plan is a detailed, standardized plan of care that is developed for a patient population with a designated diagnosis or procedure. It includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions

Lateral (side-lying) position

The client is lying on the side and the head and shoulders are aligned with the hips and the spine and are parallel to the edge of the mattress. The head, neck, and upper arm are supported by a pillow. The lower shoulder is pulled forward slightly and, along with the elbow, flexed at 90 degrees. The legs are flexed or extended. A pillow is placed to support the back.

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal?

The client's pupils are black, equal in size, and round and smooth.

Blood Pressure Cuff size

The correct cuff should have a bladder length that is 80% of the arm circumference and a width that is at least 40% of the arm circumference, with a length-to-width ratio of 2:1. The bladder inside the cuff should enclose a child's entire limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not evenly transmitted to the artery.

Discuss methods to achieve an organized health assessment using the head to toe method

The first method to achieve is organized head to toe assessment is to start with the interview. The interview is the initial introduction the health assessment. The interview is important is establishing trust with the patient. The interview allows for the nurse to assess the patients ability to comprehend health info and identify educational needs the patient may have. The nurse will ask the patient why they're seeking healthcare. The patient's primary reason for seeking health care is known as the chief complaint. When documenting what the patient is stating, be sure to use quotations. Obtain a health history of the present illness, this is again what brought the patient in. It's important to get a good health history and family history from the patient. A good family history is important bc it can identify any predisposition to diseases and illness and any risk factors the patient may have. Psychosocial assessment includes the patient's sleep and rest pattern, emotional state, current relationships, alcohol/drug use, financial and employment status. Obtaining vital signs and pain assessment provides base line to monitor the patient's condition. Height and weight provides data in relation to the patient's growth and development, nutritional status and overall health. A general survey begins when the nurse enters the room and with every encounter with the patient. look at the room condition, is client in wheeler? how's the posture? color? Means to get information that you can gather from just walking in the client's room. Facial expressions. Head-to-toe assessment beginning at the head and moving to the toes. For example, the nurse can first assess the level of consciousness and facial symmetry then end with assessing the pedal pulses and muscular skeletal system. At the end of your assessment, be sure to ask the patient if there's anything the patient wants to discuss or add...be sure they're in a comfortable position, that you address any needs they may have, and that you have their call light within reach, and bed in the lowest position.

Blood pressure cuff position

The lower edge of the cuff is placed approximately 1 inch above the antecubital fossa.

accurately assess an apical pulse, a radial pulse, and a pulse deficit

The radial pulse rate is obtained at the radial artery, which is located on the thumb side of the inner wrist. On initial assessment, all major pulses should be palpated and the apical rate should be auscultated. Auscultation of the apical rate is essential on all cardiac patients, and when the radial pulse is irregular or is difficult to palpate or when certain medications such as digoxin (Lanoxin) make this necessary. Apical refers to apex (the tip, the end, or the top of a structure) of the heart. The apical pulse represents the actual beating of the heart. The apical pulse site is the best site to use when taking the pulse rate of an infant. When auscultating the apical rate, the "lub-dub" that is heard represents one cardiac cycle, or heartbeat. At times, a difference is found between the radial and the apical rates. This is called a pulse deficit. A pulse deficit is confirmed by one nurse listening to the apical rate, and a second nurse palpating the radial pulse at the same time, using the same watch for 1 full minute. A deficit exists when the radial rate is less than the apical rate. For example, an apical rate of 92 beats per minute and a radial rate of 88 beats per minute means there is a pulse deficit of 4. A pulse deficit signifies that the pumping action of the heart is faulty or there is a peripheral vascular issue. This is often seen in atrial fibrillation.

Describe evidence-based practice related to the ausculation components of a physical assessment.

The technique of using a stethoscope to listen to the sounds of the body. ausculation means to listening to sounds within the body. When the nurse is auscultating, the nurse is listening to normal and abnormal sounds in the body. Auscultation is used to many body systems including respiratory, cardiovascular, intestinal. When using the stethoscope, use the ear pieces in facing forward towards your jawline. Examples of lowpitch sounds are called murmurs. The bell of the stethoscope is used to hear low-pitch sounds. when using bell, press lightly on skin. think: bell to press lightly for low pitch The diaphragm of the stethoscope is used to hear high-pitched sounds. High-pitched are heart, lung & valves sounds. Place firmly or hard against the skin. think: diaphragm to lay hard for high pitched. If stethoscope doesn't have bell, use diaphragm like a bell by placing lightly against the skin to hear the low pitch sounds and hard to hear the high pitched sounds.

During a head-to-toe assessment of a client, the nurse carefully palpates the client's nails. Which is the best rationale for this technique?

To assess capillary refill and oxygenation.

Purpose of an incident report

To monitor the outcome of a situation and prevent reoccurence

Which oxygen delivery method is most likely used to deliver a precise FiO2 to the patient ranging from 24% to 60%?

Venturi Mask

Methods based on evidence-based practice that are used to obtain accurate vital sign measurements

Vital signs are a part of the database obtained during assessment. The procedure for assessing vital signs is not routine. Part of the nurse's task is to individualize the procedure to each patient's needs and condition. Nurses must ensure their skills include all of the following: •Measuring vital signs correctly •Understanding and interpret the values •Communicating findings appropriately •Beginning interventions as needed Whether and how frequently vital signs are measured depend on the nurse's judgment of the need, the patient's condition, and the orders of the health care provider. If a possibility of contact with body secretions exists, gloves should be worn while obtaining vital signs.

A client who is an avid runner has been monitoring her pulse at home. Recently, her pulse has been below the normal range of 60 to 100 bpm for adults. Today her pulse is 58 bpm. The client asks the nurse at her annual screening if she should be concerned. What is the most appropriate response by the nurse?

Well-conditioned athletes can run lower pulse rates because of the greater efficiency and strength of the heart muscle from regular cardiovascular exercise.

When is a rectal temperature contraindicated?

When a patient has heart disease, is neutrapenic ( low white blood cells), patients with neurological disorders, or patients who have had spinal cord injuries or low platelets and infants less than 1 month

The nurse should use the bell of the stethoscope during auscultation of:

a client's heart murmur

Focus charting

a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

a dysrhythmia

graphic record

a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics

Outcome and Assessment Information Set (OASIS)

a nursing assessment instrument completed by Home Health agencies at the time the patient has entered for Home Health Services score determines Home Health Resource Group (HHRG)

auscultatory gap

a period of diminished or absent Korotkoff sounds during the manual measurement of blood pressure

ISBAR communication (Identity/Introduction, Situation, Background, Assessment, Recommendation)

a process for effective handoff communication among health care professionals about a patient's condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back

incident report

a report of any event that is not consistent with the routine operation of the health care facility that results in or has the potential to result in harm to a patient, employee, or visitor

Minimum Data Set (MDS)

a standard established by health care institutions that specifies the information that must be collected from every patient

Clients demonstrating apnea have what?

a temporary cessation of breathing

What is a thready pulse?

a weak, rapid pulse.

Apnea

absence of breathing

Health Information Exchange (HIE)

an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient's vital medical information

precordium

anterior surface of the chest wall overlying the heart and its related structures

To assess subjective data related to a client's elimination pattern, the nurse:

asks the client about changes in elimination patterns

To obtain subjective data about a newly admitted client's sleep pattern, the nurse:

asks the client what promotes sleep.

activities of daily living (ADLs)

basic self-care tasks such as eating, bathing, toileting, walking, and dressing

Hypertension

blood pressure above the upper limit of normal

hypotension

blood pressure below the lower limit of normal

vital signs

body temperature, pulse and respiratory rates, and blood pressure; synonym for cardinal signs

Change of shift report

communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped

febrile

condition in which the body temperature is elevated

ongoing assessment

continuing assessment activities that proceed from the initial nursing assessment

discharge summary

description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals

pulse pressure

difference between systolic and diastolic pressures

pulse deficit

difference between the apical and radial pulse rates

dyspnea

difficult or labored breathing

When assessing a client's respiratory rate, the nurse should take which action?

do it immediately after pulse assessment so the client is unaware

variance charting

documentation method in case management that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate

source-oriented record

documentation system in which each health care group records data on its own separate form

problem-oriented medical record (POMR)

documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes

PIE charting

documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)-intervention (I)-evaluation (E) format, and evaluated each shift

occurance charting

documentation when a patient fails to meet an expected outcome or a planned intervention is not implemented, including the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate; typically used for variances that affect quality, cost, or length of stay

pyrexia

elevation above the upper limit of normal body temperature; synonym for fever

fever

elevation above the upper limit of normal body temperature; synonym for pyrexia

diaphoresis

excessive sweating

List the factors that affect vital signs readings

factors that affect pulse rate: age, exercise, fever, heat, acute pain, anxiety, chronic pain, medications, hemorrhage, postural changes, metabolism, pulmonary conditions.factors that affect respiration rate: disease or illness, stress, fever, age, gender, body position, medications, exercise, acute pain, smoking, brainstem injury, hemoglobin function.factors that affect BP: age, anxiety, fear, emotional stress, pain, medications, hormones, face, obesity, gender, diurnal

Focused Assessment

focus on identified problem or chief complaint. A focused assessment includes general survey, vital signs and assessment of specific area related to the patient problem or chief complaint. Focused assessment differs from comprehensive assessment because the comprehensive assessment focuses on all body systems. An example of a focused assessment would be if the patient were complaining of shortness of breath. The nurse would do a general survey, obtain vital signs, assess respiratory system and any other important systems. You can do multiple focused assessments throughout the day

Blood pressure

force of blood against arterial walls

respirations

gas exchange between the atmospheric air in the alveoli and blood in the capillaries

What is the purpose of a Health Assessment?

gather info about health status of patient to create a nursing intervention and evaluate patient outcomes

flow sheet

graphic record of abbreviated aspects of the patient's condition (e.g., vital signs, routine aspects of care)

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records

hyperthermia

high body temperature

systolic pressure

highest point of pressure on arterial walls when the ventricles contract

A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?

immediately

Soiled linens should be placed:

in the linen container

Describe evidence-based practice related to inspection

inspection is a visual examination; general observation of the patient as a whole, progressing to specific body areas. inspection begins immediately when entering a patient's room. During an inspection, a patient's anatomic structures are inspected for abnormalities to identify. During inspection, the nurse should ensure the body parts that are being inspected are exposed and there is adequate lighting. During inspection, the nurse is noting such factors as color, shape, symmetry, pulsation, movement, and texture of the body part. The nurse will use the patient as a comparative. The nurse should ask herself if the left side matches the right side...is it symmetrical OR asymmetrical.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document

bronchial breath sounds

loud, high-pitched, hollow sounds normally heard over the trachea and the large bronchi

hypothermia

low body temperature

Sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

sterile field/ aseptic technique

maintain things within line of vision, 1 in border is contaminated, nothing bellow waist, dont tie dr's gown in the BACK-thats contaminated, dont turn your back on the field, tight hands together above waist

eupnea

normal breathing

What is the rate of pulse?

number of beats per minute

Rate of respirations

number of respirations per minute normal is 12-20

Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?

nutritional consult

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"?

oriented to person, place, and time

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur?

orthostatic hypotension

pallor

paleness

Describe evidence-based practice related to the palpation components of a physical assessment.

palpation is an examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts "palp-" means to feel or touch. While palpating, the nurse uses the finger tip and palms of her hands. The nurse uses light palpation (0.5 to 1 inch) OR deep palpation (1.5 to 2 inches). -light palpation is used for pulsation, areas of edema and tenderness. temperature, moisture. -deep palpation is used to assess organ size or deep masses. light palpation will ALWAYS precede deep palpation. If the patient complains of discomfort in any area, avoid deep palpation. During palpation, the nurse is also assessing texture, fremitus (vibration), temperature. The finger tips are used to assess the texture of the skin and hair. The palm of the hand is used to assess fremitus (vibration). The dorsum (back of the hand) is used to assess temperature.

A nurse needs to test a client's pupillary response to light and accommodation. Which item will the nurse need for this assessment?

penlight

A nurse is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment?

penlight or flashlight

purposeful rounding

proactive, systematic, nurse-driven, evidence-based intervention that helps nurses anticipate and address patient needs

Narrative notes

progress notes written by nurses in a source-oriented record

patient centered care

providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions

edema

puffy swelling of tissue from the accumulation of fluid

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

pulse is felt with difficulty and disappears with slight pressure

tachycardia

rapid heart rate

tachypnea

rapid rate of breathing

erythema

redness of the skin

What is the rhythm of a pulse?

regular or irregular

rhythm of respiration

regular or irregular

Identify Proper communication of data collected during the health assessment

remember that the patient's health assessment is part of the patient's permanent record and will be reviewed by all members of the inner disciplinary team. When documenting, document head-to-toe chronological order. Documenting should be brief and to the point. State the facts, avoid interpretation. document objectively. When documenting a statement from the patient, be sure to use quotations around the statement. Avoid use of abbreviation and terms such as "good" "average" or "within normal limits"

Oxygen Delivery methods

room air nasal cannula simple mask venturi mask non-rebreather

A client with dark skin color who has jaundice has been admitted to the health care facility. Which body area is the best place to assess jaundice?

sclera

Korotkoff sounds

series of sounds that correspond to the changes in blood flow through an artery as pressure is released

Charting by exception (CBE)

shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes

bradypnea

slow breathing

bradycardia

slow heart rate

petechiae

small, purplish hemorrhagic spots on the skin that do not blanch with applied pressure

bronchovesicular breath sounds

sounds that are heard over major bronchi that are usually moderate in pitch and intensity

Bedside report

standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family

Various sounds are heard when the nurse assesses a blood pressure. What does the first sound heard through the stethoscope represent?

systolic pressure

A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?

tachycardia

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?

tachycardia

list the various sites for pulse measurement

temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibia, dorsalis pedis

orthostatic hypotension

temporary fall in blood pressure associated with assuming an upright position; synonym for postural hypotension

Turgor

tension of the skin determined by its hydration

Define oxygen saturation

the amount of oxygen molecules attached to the red blood cells to be transported to the body cells

When taking the client's temperature, the student nurse will require further education when they state:

the axillary route is the most accurate of all routes

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

the blood pressure increases

The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?

the client is dehydrated

Supported Fowler's Position

the head of the bed is elevated 45 to 60 degrees, and the patient's knees are slightly elevated without pressure to restrict circulation in the lower legs

diastolic pressure (DP)

the least amount of pressure exerted on arterial walls, which occurs when the heart is at rest between ventricular contractions

While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation?

the nurse could be fined or even go to jail for violating HIPAA

diastolic blood pressure

the pressure remaining in the arteries when the left ventricle of the heart is relaxed and refilling

Depth of respiration

the quality of each breath

Subjective Data

things a person tells you about that you cannot observe through your senses; symptoms The patient supplies the nurse with subjective data, this is obtained during the interview process and should be documented using direct quotations. ex: patient's health history or chief complaint.

How to convert between Celsius and Fahrenheit?

to convert from celsius to fahrenheit you multiply degrees Celsius by 9/5 (1.8) and add 32 to convert from fahrenheit to celsius you subtract 32 from the degrees fahrenheit and then multiply by 5/9(.556)

variance report

tool used by health care facilities to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor; also called an incident report or occurrence report

orthopnea

type of dyspnea in whcih breathing is easier when the patient sits or stands

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml

Define Korotkoff sounds

vibrations that are heard, through the use of a stethoscope, as a result of blood flow through a constricted artery

The nurse is preparing to assess the client's vital signs. The client just had morning coffee. What explanation and action does the nurse take in this situation?

wait 30 minutes, then assess the oral temperature because the client had a beverage

pulse

wave produced in the wall of an artery with each beat of the heart

Objective Data

what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination ex: any health assessment findings or diagnostic test results.

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

wheezes

A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?

write it down