Exam 1: NUR209/ NUR 209 (New 2026/ 2027 Update) Medical Surgical Nursing II Review | Q&

Exam

1 …..DLDD\\\\\\\ Exam 1: NUR209/ NUR 209 (New 2026/ 2027 Update) Medical Surgical Nursing II Review | Questions and Answers| 100% Correct| A Grade – Fort ... is Q. Problems walking correctly. Factor when performing a risk assesment Answer Unsteady gait Q. inability to control bladder and/or bowels Answer incontinence Q. Team Strategies and Tools to Enhance Performance and Patient Safety or ________________________ Answer TeamSTEPPS Q. SBAR stands for __________________. It is a consistent, clear, structured, and easy-to-use method of communication between health care personnel Answer situation, background, assessment, recommendation Q. any method, device, material, or equipment that restricts a person's freedom of movement, Answer physical restraint 2 Q. any drug that is used for discipline or convenience and not required to treat medical symptoms Answer chemical restraint Q. The practice of following good sleep habits to sleep soundly and be alert during the day Answer sleep hygiene Q. A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery. Nurses responsibility Answer medication reconciliation Q. toxic inflammatory condition arising from the spread of microbes, especially bacteria or their toxins, from a focus of infection Answer Sepsis Q. growth of bacteria in the blood Answer septicemia Q. Infectious proteins that cause several brain disease (ex: mad cow disease) Answer prions Q. infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host Answer chain of infection 3 Q. vomiting or _____________-- Answer emesis Q. A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious. Answer Standard Precautions Q. special precautions implemented on the basis of how the disease spreads Answer transmission-based precautions Q. Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted through fine particles suspended in air. Special air handing ad cantillation system needed to contain and remove infection agents Answer Airborne precautions Q. Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by secretions expelled during coughing, sneezing, talking, or laughing. Answer Droplet precautions Q. measures taken to prevent the spread of diseases transmitted by the physical transfer of pathogens to a susceptible host's body surface Answer contact precautions 4 Q. spread of pathogens through a vehicle such as air, drinking water, and food, as well as bodily fluids being handled outside the body Answer vehicle transmission Q. measures taken to keep pathogens from coming into contact with an immunocompromised or otherwise susceptible patient. . No plants or fresh fruits/vegatables Answer protective isolation Q. estimated 1:10 will contract while hospitalized Answer Healthcare-associated infection (HAI) Q. hand hygiene, barrier techniques (PPE), disinfection/sterilization Answer medical asepsis Q. skin prep, sterile field and gloves, surgical hand washing Answer surgical asepsis Q. Sterile equipment or areas must be kept ___________waist and on top of the sterile field Answer above 5 Q. ones ability to independently attend to their own primary care in areas of grooming, feeding, toileting and dressing Answer self-care Q. increased risk in skin breakdown in ______________ Answer older adults Q. a warm soak of the perineal area to clean perineal wounds and reduce inflammation and pain Answer sitz bath Q. bath administered to totally dependent patient in bed Answer complete bed bath Q. bath in which only certain body parts are bathed or in which the health care provider bathes those parts of the body that the patient is unable to bathe Answer partial bed bath Q. bathing self care deficit, feeding self care deficit, dressing self care deficit, and toileting self care are examples of Answer Nursing Dx 6 Q. urination or Answer microurition Q. A curved, smooth upper end and a tapered lower end used for patients unable to lift their hips. Answer Fracture bedpan Q. the coordinated effort of muscles, bones, and the nervous system to maintain balance, posture, and alignment during movement, especially bending, lifting, and walking Answer body mechanics Q. degenerative joint disease Answer Osteoarthritis Q. demineralization of bone Answer Osteoporosis Q. a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints. Answer Contractures Q. Decrease in blood pressure related to positional or postural changes from lying to sitting or standing Answer positions Orthostatic Hypotension 7 Q. kidney stones also called Answer Renal Calculi Q. maintaining upright posture required proper _________ of the bones muscles and joints. Physical exam: ask patient to sit, stand, walk, and visualize line of gravity. Answer Alignment Q. patients should change positions every _______ hours Answer 2 Q. lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back Answer Sims position Q. The ability of the patient to voluntarily move a limb through an arc of movement Answer Active Range of Motion (AROM) Q. the process of putting a joint through its full extent of movement by someone other than the patient Answer passive range of motion Q. lack of muscle coordination Answer ataxia 8 shaking; rhythmic muscular movement tremor Spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles Chorea communication about communication Metacommunication ex: nurse makes rounds on assigned patient, introduces herself, explains her role and presents herself in a professional manner congruent relationship A nurse communicating with a client with a harsh tone of voice,, she is already wearing sterile gloves and a mask and is busy working with her back to the client. The nurse is conveying a (an) incongruent relationship PHASE when the nurse and the patient meet and get to know each other. establish trust ad report. orientation phase PHASE when the nurse and the patient work together to solve problems and accomplish goals working phase PHASE when the nurse-patient-relationship ends due to discharge/end of care. termination phase Those who have access to a patient's information like the people in a nursing unit who have responsibility for the patient as well as the family, unless the patient objects circle of confidentiality "The process of organizing and documenting the specific goals in the treatment of an individual patient, amending the goals as the patient's condition requires, and assessing the outcomes of care" care planning 9 an assessment that organizes the collection of comprehensive physical data by proceeding through the entire body from head to toe Head to toe assessment ___________________ when activity/event occurs or shortly after Document PIE charting or problem, intervention, evaluation Focus DAR charting data, action, response SOAP Charting subjective, objective, assessment, plan use of predetermined standards and norms to record only significant assessment data. ex) focus dar, soap, pie Charting by exception A paper document or electronic screen that allows similar data to be recorded and viewed chronologically flow sheet A sheet used for documentation listing Admission Histories (i.e. review of systems and Physical Assessment), Plans of Care (i.e. Critical pathways, care plans ) , Prescriber's Orders, Entries in Progress Notes Medication Administration Record (MAR) to improve handoffs and transitions of care, opportunities to ask questions, clarify, and confirm. intro, patient, assessment, situation, safety, background, actions, timing, ownership, next I PASS the BATON consistent, clear, structured, and easy-to-use method of communication between health care personnel; it organizes communication by the categories of: Situation, Background, Assessment, and Recommendations. SBAR Occurs any time care is handed over to another provider. Report would include pertinent patient information such as identifying data, age, medical and surgical history, medical and surgical diagnoses, procedures, standard and remarkable assessment data (i.e., VS, presence of pressure ulcers) lab or 10 diagnostic results, current treatments and therapeutics Handoff Strategy used to communicate important or critical information.Informs all team members simultaneously during emergent situations. Helps team members anticipate next steps.Can be used during Code. Call Out During physical assessment look at __________________. AKA age,sex,level of consciousness, skin color, facial features. Note if appears older than stated age (chronic illness, alcoholism), if confused, drousy Pallor (paleness), cyanosis (bluish discoloration), jaundice, erythema (redness) Facial features immobile, masklike, asymmetric, drooping Physical appearance During physical assessment look at __________________. Stature (height normal range), nutrition (weight), symmetry, posture( leaning forward, sits straight, fetal position), deformities Note body proportions(tall/short), if appear emaciated/obese, rigid spine, neck, slumped shoulders, elongated arm span (marfans) body structure if more weight is carried around ____________ the person has a higher risk of heart disease and type ii diabetes waist neurologic disorders (stoke, cerebral edema, brain trauma, tumor, surgery) can reset the ____________--- of the brain at a higher lelvel thermastat without fever or Afebrile most accurate route for taking temperature. 98.6-100.6 rectal The temperature reading obtained by placing an aural (ear) thermometer in the patient's ear tympanic temperature Aprox 70mL. The amount of blood ejected from the heart in one contraction. 11 stroke volume The rhythmic expansion and recoil of arteries resulting from heart contraction; can be felt from the outside of the body. pulse normal heart rate per minute 50-95 bradycardia under _______- bpm 50 tachycardia over ___________ bpm 100 pulse force of ________ means heart is full and bounding 3+ pulse force of ________ means heart rate is normal 2+ how many breaths per min is normal for adults 10-20 varying depth and rate of breathing, followed by periods of apnea; irregular Biot's respirations Periods of difficult breathing (dyspnea) followed by periods of no respirations (apnea) Cheyne-Stokes very deep and rapid respirations Kussmaul respirations maximum pressure felt on artery during left ventricular contraction Systolic occurs when the ventricles are relaxed; the lowest pressure against the walls of an artery Diastolic 12 *Always Recheck __________ before giving cardiac medications vitals -Location: have person point to the pain area, be precise, is the localized or radiating? Superficial or Deep? "pain behind eyes" -Character or Quality: Specific Descriptive terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting. use similes "Does the blood look like sticky tar?" -Quantity or Severity: use a scale or attempt to quantify "profuse menstrual flow soaking five pads per hour" - Timing (when it started, how long its been happening, how frequent) -Setting: where were you when it started -Aggravating or Reliving Factors: ex: exertion worsens pain -Associated Factors: what else is pt experiencing -Patients perception: patient states what they think it might be Eight Critical Characteristics past health includes allergies, injuries, operations, medications, a _______________-Assessment Measures a person's self-care ability and is Organized around Marjory Gordon's Functional Health Patterns. Functional Alert, Lethargic, Obtunded, Stupor/Semi-Coma, Coma levels of consciousness Less than full alertness (altered level of consciousness), Sleeps most of the time,Can be aroused if shaked obtunded a state of near-unconsciousness or insensibility. spontaneously conscious also known as semi-coma. be aroused if shaked or in pain stupor inability to speak aphasia 13 an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech. Delerium bones are united by fibrous tissue or cartilage and are immovable Nonsynovial joints Connect bone to bone Ligaments fluid-filled sac that allows for easy movement of one part of a joint over another Bursa Movement away from the midline of the body abduction Movement toward the midline of the body Adduction One crutch and opposite extremity move together followed by opposite crutch and extremity Two-point gait Both crutches and involved leg advance together Uninvolved leg follows Uses two canes/crutches or a walker three point gait used when both legs can bear some weight; right foot, left crutch, left crutch, right foot Four-point gait pain scale for clients who are cognitively impaired or cannot developmentally use a numeric pain scale. Example, it is appropriate for preverbal children wong baker Active Error errors caused by the actions of frontline staff, usually with immediate result Latent Error may be due to equipment design issues, faulty maintenance, or poor organizational structure 14 Culture of safety where every member of an organization contributes to the safety of its patients and employees Just culture an approach to error evaluation that examines the nature of the error to assist in determining the appropriate response to the individual who made the error Near misses events where an error was likely to occur if the situation had not been corrected 2021 Patient Safety Goals (Joint Commission) Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery QSEN competencies Patient-centered care Teamwork and collaboration Evidence-based practice (EBP) Quality improvement (QI) Safety Informatics Environmental Factors of Safety Pollution Ionizing radiation Terrorism Home Workplace Community Physiologic Factors of Safety Primary systems involved in protection and safety are musculoskeletal; neurologic and sensory; cardiovascular and respiratory; immune and integumentary Safety Aspects Primarily Under Nursing Responsibility - Using at least 2 patient identifiers - Reporting critical test and values on a timely basis - Recording and communicating accurate patient medication information 15 - Complying with and reinforcing appropriate hand hygiene guidelines - Implementing evidence-based practice guidelines to prevent HAI's - Provide safety education for the home, workplace and community - Provide a safe environment in the healthcare setting Mistake-proofing use of mechanisms or devices that make it difficult to perform an error Ex: tubing connections that are not interchangeable between enteral and intravenous connections TeamSTEPPS Team Strategies and Tools to Enhance Performance and Patient Safety Care Bundles combination of patient care elements into "bundles" that are consistently used as a whole Teaching adults to prevent falls Remove throw rugs Ensure stairways are well lighted Remove clutter Install handrails Avoid use of unstable ladders Never attempt to do anything beyond reach or physical ability Clean damp areas Asphyxiation suffocation RACE rescue, alarm, confine, evacuate PASS Pull the safety pin, aim the nozzle, squeeze the lever, sweep back and forth Categories of Restraints - Physical: any manual method or physical device that restricts movement or normal access to one's body Vest, mitt, wrist, or ankle; four side rails up - Chemical: a medication used to control behavior or restrict a person's freedom of movement that is not a standard of treatment Sedation medication - Nonviolent/non-self destructive: used when a patient's behavior interferes with treatment Physical or chemical used to prevent pulling out lines or tubes - Seclusion: involuntary confinement of an individual in a room alone from which the person is prevented from leaving 16 Patient wants to leave hospital without provider's orders 6 components of the chain of infection infectious agent, source, portal of exit, mode of transmission, portal of entry, susceptible host Medical asepsis ("Clean Technique"): Measures taken to control and reduce the number of pathogens present Hand hygiene Disinfection and sterilization Portal of entry a way for the causative agent to enter a new reservoir or host Susceptible host a person likely to get an infection or disease, usually because body defenses are weak Healthcare - Associated Infections (HAI) A term that encompasses infections contracted in any healthcare settings Risk Factors of HAI's Environment Therapeutic regimen Patient resistance Proper hand hygiene is the single most effective method to prevent HAIs. Surgical asepsis ("Sterile Technique"): Measures taken to prevent the introduction or spread of pathogens from the environment into the patient' to be free of all microorganisms -Skin preparation - Surgical hand-washing - Maintenance of sterile fields -Use of sterile gloves Factors contributing to poor compliance of hand hygiene - Lack of awareness of patient care activities that require hand hygiene - Misunderstanding that wearing gloves and gowns can substitute for hand hygiene - Understaffing and high workloads leading to perceived time constraints - Inaccessibility of sinks or dispensers for soap or alcohol-based cleanser -Skin irritation and dryness 17 Disinfection The process of destroying pathogens Sterilization The process of destroying all microbes Standard precautions used for all patients to protect against known and unknown infectious organisms transmitted by blood and body fluids Transmission-based precautions used for patients with known or suspected infection or colonization with highly transmissible or epidemiologically significant pathogens Airborne precautions Precautions: Private AIIR respirator; mask worn by patient during transport out of room Indications: transmission via airborne route; tuberculosis, measles, varicella Droplet precautions Precautions: private room or cohabitation with the patient infected with the same organism; mask required when working within 3 feet of patient; mask worn by patient during transport Indication: transmission of large droplets through sneezing, coughing or talking; Influenza, Neisseira meningitis, rubella, common respiratory viruses Contact precautions Precautions: private room or cohabitants with patient infected with same organisms; gloves at all times (don before entering room and remove before leaving); change gloves when moving from soiled contact to cleaner contact; hand hygiene immediately after removal of gloves; gown and protective barriers when in direct contact with patient; daily cleaning of bedside equipment; patient-dedicated items such as stethoscope and blood pressure cuff Indication: multi-drug resistant organisms; infectious diarrhea, including C. Difficile, Shigella, and Norovirus; infectious skin conditions such as impetigo, and herpes; and conditions involving drainage, secretions or body fluids that cannot be contained TeamSTEPPS - Team Strategies and Tools to Enhance Performance and Patient Safety - Developed in 2006 by the US Department of Defense (DOD) Patient Safety Program and the Agency for Healthcare Research and Quality (AHRQ) - SBAR - Call-out - Check Back - Handoff - I PASS THE BATON - CUS 18 'I PASS THE BATON' Comprehensive handoff report - I NTRODUCTION - P ATIENT - A SSESSMENT - S ITUATION - S AFETY CONCERNS - B ACKGROUND - A CTIONS - T IMING - O WNERSHIP - N EXT Sentinel Events unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness Purposes of the Health Record - Assessment - Care Planning - Legal Document - Quality Assurance (audits) - Reimbursement - Research - Education Principles of Documentation CONFIDENTIAL ACCURATE (erasure is not permissible) CONCISE AND COMPLETE OBJECTIVES ORGANIZED AND TIMELY (chronologically) Patient Care Summary (Kardex) - Document that provides current patient information - Not a permanent part of patient's record - Entries are made in pencil so they can be erased if updating is needed Charting by Exception (CBE) - Permits the nurse to document only those findings that fall outside the standard of care and norms that have been defined -"If it wasn't documented, it wasn't done" - Requires less nursing time - Changes in patient status can readily be detected 19 SOAP Note Progress note that relates to only one health problem "S" = subjective "O" = objective "A" = assessment "P" = plan = plan PIE Note Simplifies documentation by incorporating the plan of care into the progress notes "P" = problem "I" = intervention "E" = evaluation Increased efficient and flexibility; better care planning focus; better tracking of patient problem, nursing interventions and patient outcomes; less redundancy FOCUS DAR Note - Organizes entries by data (D), action (A), and response (R). - System is broader in its view because a focus can be a problem area but does not need to be - An entry can be made on a significant event, positive growth, or learning that occurs during a teaching session - Patient documentation can focus on the patient's strengths as well as problems Plan of Care goals, interventions, desired outcomes, and criteria for discharge Clinical Pathways case management tools used to communicate the standardized, interdisciplinary plan of care for a particular group of patients; care guidelines and outcomes are specified for each day of the patient's stay Incident Report Includes date and time of incident, events leading up to it, patient's response, and a full nursing assessment Not attached to patient's chart Outcome and Assessment Information Set (OASIS) A prospective nursing assessment instrument completed by home health agencies at the time the patient is entered for home health services. Scoring determines the Home Health Resource Group (HHRG) Resident Assessment Instrument (RAI) Governs documentation in long-term care settings Tracks goal achievement among long-term care residents and includes minimum data set, triggers, resident assessment protocols, and utilization guidelines 20 batch charting waiting until end of shift or until all patients have been assessed to document findings from all of them (SHOULD BE AVOIDED) Orientation Phase introductions and an agreement made between nurse and patient about their mutual roles and responsibilities Working Phase exploring and developing solutions that are enacted and evaluated in subsequent interactions Termination Phase review of health changes and how the patient has dealt with physical and emotional responses; includes discharge planning Positive regard underlying assumption is that the person is worthwhile and has value and dignity; avoids unnecessary labeling The Johari Window a visual representation of components of the self that are known or unknown to the self and to others - The Open Pane: the "mask" exhibited to others - The Blind Pane: qualities not recognized by the other individual, but are noticed and known by others - The Hidden Pane: qualities known only to the individual - The Unknown Pane: qualities unknown or not yet discovered by oneself or others Cognitive reframing assists clients to identify negative thoughts that produce anxiety, examine the cause, and develop supportive ideas that replace negative self talk Rescue Feelings When the nurse feels essential to the patient's welfare; feels that he or she has exceptional abilities to help the patient (non-therapeutic) False Reassurance Giving reassurance that is not based on the real situation; "Don't worry everything will be fine" - Violates patient's trust (non-therapeutic) Non-Therapeutic Responses 21 rescue feelings, false reassurance, giving advice, changing the subject, being moralistic, non-professional involvement Structures of the musculoskeletal system bones, joints, muscles Adduction Movement toward the midline of the body Abduction Movement away from the midline of the body Flexion bending a joint; reducing the angle between two bones Extension Straightening of a joint Hyperextension extension beyond anatomical position Supination movement that turns the palm up Pronation movement that turns the palm down Principles of body mechanics - Assess the situation carefully before acting - Use the large muscle groups of the legs - Work at the appropriate height for body position -Use mechanical lifts or assistance when possible aerobic exercise requires oxygen, occurs during vigorous, continuous muscle movement (walking, running, cycling, skiing, tennis) Anaerobic exercise intense physical activity that requires little oxygen but uses short bursts of energy 22 isotonic exercise dynamic form with constant muscle tension, contraction, and active movement. Most activities (walking, running, performing ADLs) Isometric exercise static exercise by which the patient tenses a muscle, holding it stationary while maintaining the tension (strength training with weights) Normal Gait Phases The stance phase: heel strike, midstance and push-off The swing phase: acceleration, swing through and deceleration osteoporosis loss of bone density Kyphosis excessive outward curvature of the spine, causing hunching of the back. Factors Affecting Mobility - alterations in muscles - injury to the musculoskeletal system - poor posture - impaired central nervous system - health status and age Paraplegia decreased motor and sensory function to the legs Hemiplegia paralysis of one side of the body Tetraplegia paralysis of the arms and legs and all muscle movement below the level of injury Ataxia lack of muscle coordination Athetosis bizarre, slow, twisting, writhing movement, resembling a snake or worm 23 Contracture progressive shortening of a muscle and loss of joint mobility resulting from fibrotic changes in tissues surrounding the joint Osteoarthritis degeneration of the articular surface of weight-bearing joints Impact of Immobility of Physiologic Function - Muscle atrophy and weakness - Contractures and joint pain - Increased cardiac workload - Orthostatic hypotension - Thrombus formation and embolism - Decreased lung expansion - Decreased metabolic rate - Negative nitrogen balance - Anorexia - Disuse osteoporosis - Impaired immunity - Pressure ulcers - Urinary status - Urinary tract infection - Renal calculi (kidney stones) - Constipation - due to muscle atrophy - Sleep and rest disturbance Deep Vein Thrombosis (DVT) A blood clot in a deep vein, most often an extremity Impact of Immobility of Psychosocial Function Cognition and pain Self-perception and self-concept Roles and relationships Coping and stress tolerance Sexuality Neurovascular assessment Assess color, edema (swelling), capillary refill, pulses, mobility, sensation, temperature and pain to the affective area Physical Assessment of Mobility - Alignment - Balance - Coordination 24 - Gait - Joint Structure and Function - Muscle Mass, Tone and Strength - Postural Blood Pressure - Risk of Falls - Activity Intolerance Crepitus crunching or grating sound which can occur when bones rub against one another during movement Arthroscopy visual examination of a joint Supine Flat on back Indications: alternative for patient on bed rest, used after spine surgery and some spinal anesthesia Contraindications: patients with dyspnea or risk for aspiration Fowler's Sitting with head raised Indications: Improves cardiac output, promotes ventilation, and eases talking, eating and watching TV Contraindications: After spine or brain surgery Semi-Fowler's Semi Sitting position with patient's head slightly elevated Indications: Improves cardiac output, promotes ventilation, and eases talking, eating and watching TV Contraindications: After spine or brain surgery Prone Face down Contraindications: After abdominal surgery, patients with respiratory or spinal problems Side-lying Indications: Patients with pressure on bony prominences of the back and sacral pressure sores Contraindications: After hip replacement or other orthopedic surgeries Sims' Semi-prone, patient lays on side with weight distributed toward anterior ilium, humerus and clavicle Indications: enemas Contraindications: patients with spine or orthopedic conditions Trenedelenburg's 25 patient lies supine with head 30 to 40 degrees lower than feet Indications: postural drainage and to promote venous return Contraindication: hypotension Logrolling Technique used for turning patient who have had surgery or an injury involving the back or spine Draw or turning sheet used, place pillows between the legs Passive ROM patient needs nurse's assistance to perform ROM Active ROM patient can participate in ROM exercises without assistance Dangling the legs -Preliminary step to ambulation, especially for patients who may be unable to ambulate initially -Involves sitting on the side of the bed with the legs dependent -Usually recommended on the evening after surgery or when weight bearing is not permitted Transfer belts Should be used if the patient is weak or has problems with coordination If the patient becomes dizzy or starts to fall, slowly and gently lower the patient to the floor and call for help Walkers - Lightweight, tubular metal structures that provide more support than canes - Four rubber-tipped legs give a wide base of support - Patient grips walker ahead 6-8 inches, picks it up and moves it forward - Patient may use a 2 or 3 point gait - Assist by walking behind and to the side of pt. using walkers Canes and Quad canes - Useful for patients who can bear weight but need support for balance, or for who have decreased strength in one leg - Cane acts as an additional "leg" by providing the patient with three points of support during ambulation - Patient holds cane in hand opposite the weak or injured leg and moves the affected or weak foot forward with the cane as the weight of body remains on stronger extremity - On stairs: going up - good leg first and coming down - weaker leg first Crutches - Allows the patient to walk without bearing weight on the legs - Sprain, fracture, non walking cast - Underarm crutches 26 - Pt. must use arms, not the shoulders, to support body weight - 2 inches below axilla, 6 inches to side of feet - Using the shoulders can cause skin breakdown at the axilla and nerve damage to the brachial plexus Two-point Crutch Gait requires at least partial weight bearing on both feet. Each crutch moves at the same time as opposing leg Swing-through Crutch Gait no weight bearing. Move both crutches forward then swing the body beyond the crutches to propel themselves forward Four-point Crutch Gait when a client can bear partial weight on both feet. The right crutch ie placed forward followed by the left foot, and then the left crutch is moved forward followed by the right foot Three-point Gait when a client can bear weight on only one foot. Both crutches and weaker leg move forward, followed by the stronger leg Hip surgery precautions - Prevent adduction of the affected hip and leg - Use abductor pillows - Avoid hip flexion of greater than 90 degrees - Keep operative leg in neutral position Purpose of Assessment to make a judgement or diagnosis about the client's health state Types of Nursing Diagnoses actual, potential/risk, health promotion (wellness) Medical Diagnosis used to evaluate the etiology of the disease process Nursing Diagnosis used to evaluate the response of the whole person to actual or potential health problems Four Types of Assessments Complete (total health) Episodic or problem-centered Follow-up database (chronic diseases) 27 Emergency Inspection Always comes first -First look at the "whole" and then the individual systems - Compare right and left sides - Peripheral vascular problem (DVT) - Requires good lighting, exposure and occasional instruments (otoscope, penlight, ophthalmoscope, speculums) (Skin color, size, fatigue, etc.) Palpation Confirms points noted on inspection Use sense of touch - assess texture, temperature, moisture, organ location and size, swelling, vibration, pulsation, and the presence of lumps or tenderness or pain Percussion Direct and indirect method Assess location and size of an organ, reflects the density of the underlying structure, elicits pain and elicits deep tendon reflexes using the percussion hammer Tympany air in stomach Auscultation Most body sounds are soft and must be channeled through a stethoscope - Diaphragm - high pitched sounds - Bell - low pitched sounds General Assessment Survey 1. Physical Appearance 2. Body Structure 3. Mobility and ROM 4. Behavior 5. Measurement 6. Vital Signs Purpose of Health History First step of the nursing process ACTIVE LISTENING Baseline subjective data base Assists in guiding the physical exam Allows for communication that identifies patient/family learning and health needs Identifies self care behaviors of client 28 Provides a complete picture of the patient's past and present health Health History Categories - Biographical Data - Reason for seeking Care - Present health or history of present illness - Past history - Family history - Review of systems - Functional assessments (ADLs) Health History Data is SUBJECTIVE DATA. it provides a picture of the patient's present and past health Primary Source the patient Secondary Source the family, caregiver etc. must be reliable Eight Critical Characteristics P = provocative or palliative Q = quality or quantity R = region or radiation (location) S = severity scale: 1-10 T = timing or onset U = understand patient's perception of problem When the body temperature exceeds 37.5°C, this is termed ___ hyperthermia, fever or pyrexia Afebrile the state of normal body temperature Radiation exposure to cold environment increases radiant heat loss Conduction the transfer of heat from one object to another (swimming) Convection loss of heat through air currents (breeze or fan) 29 Evaporation diaphoresis (sweating) during strenuous exercise or when one if febrile Factors Affecting Body Temperature Age: Some older adults may have lower body temperatures because baselines body temperature may drop as an individual ages Environment: Hot or cold extremes; Death may occur if a person's core temperature drops to 25°C (77°F) or rises to 45°C (113°F) Time of Day: Temperature is usually lower in the morning and higher in the late afternoon and early evening Exercise: diaphoresis causes heat loss Stress: Increases heart rate, and heat production Hormones: Low estrogen Factors Affecting Temperature Measurement - Recent smoking - Recent chewing gum - Oxygen administered by mask or cannula - Recent intake of hot or cold liquid drinks or food - Diaphoresis (sweating) Oral Thermometer Most commonly used site Advantages: easy access and patient comfort Contraindications: unconscious or delirious patients, or patients with seizure disorders Rectal Thermometer Most reliable because most closely reflects core body temperature; Not well tolerated due to discomfort or embarrassment Precise position: Sims' position with one leg straight and the other bent about 1.5 inches (4 cm) for adult Contraindications: patients in presence of diarrhea, rectal surgery, rectal diseases and cancer patients who are neutropenic, Hemorrhoids Tympanic (ear) temperature High degree of variance when compared to the oral route, but closely reflects core body temperature You are able to access the vasculature of the inner ear Must pull the ear up and back for adult Temporal artery (forehead) More accurate than tympanic thermometers and comparable to oral thermometer readings Affected by perspiration or air blowing over the face Axillary temperature 30 Least accurate and least reliable site Sweat and ambient air temperature may influence reading What is the pulse? - Ventricular contractions eject blood into the arteries - Blood entering the aorta from the left ventricle causes aortic wall distention - As the aorta expands and contracts, a pulse wave travels along the blood vessels - The pulse wave or pulsation can be felt where the arteries lie close to the skin surface Tachycardia Pulse rate over 100 beats per minute Bradycardia pulse rate under 60 beats per minute Factors Affecting Pulse Rate Age: Normal pulse rate changes with age; Decreases as a person ages; Infants and children usually higher than adults Autonomic Nervous System: Stimulation of the vagus nerve in the parasympathetic nervous system results in decreased pulse rate; Stimulation of the sympathetic nervous system results in increased pulse rate Medications: Medications that decrease intravascular volume (diuretics) can cause a reflect increase in pulse rate; Other medications mimic or block the effects of the autonomic nervous system Pulse deficit Difference between the apical and peripheral pulses Tidal Volume the amount of air moving in and out with each breath hypercapnia Increased carbon dioxide level in the bloodstream. Factor Affecting Respirations Age: as adult ages, lung elasticity decreases Medications Stress: Fight or flight response Exercise Altitude Gender: Men may have a lower respiratory rate eupnea normal respiratory rhythm and depth 31 Apnea absence of respirations Cheyne-Stokes respiration pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea (usually death) Kussmaul respirations Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body. Tachypnea more than 20 breaths per minute Bradypnea less than 12 breaths per minute Pulse Pressure the mathematical different between the systolic and diastolic blood pressures Factors Affecting Blood Pressure Age: Blood pressure gradually increases Autonomic Nervous System: Influences heart rate, cardiac contractility, systemic vascular resistance and blood volume; Increased sympathetic nervous system activity results in increased heart rate, stronger contraction of heart muscle, changes in vascular smooth muscle tone, and increased blood volume due to retention of water and sodium Circulating Volume: A decrease in circulating volume (blood or fluid loss) results in lower BP; Fluid volume deficit (diarrhea, diaphoresis); Excess fluid, such as congestive heart failure or renal failure can cause elevated BP Medications: Any medication that alters listed factors may change BP; Diuretics - decrease blood volume; cardiac medications - affect heart's rate or force; opioid analgesics - reduce pain and sympathetic nervous system activity; antihypertensive agents Normal Fluctuations Do NOT measure blood pressure in any arm with - Arteriovenous fistula (access for somebody on dialysis) - Peripheral access for hemodialysis - PICC line (peripherally inserted central catheter) - Mastectomy on same side Hypertension 32 blood pressure is chronically elevated "Silent killer" you don't really feel it until something happens; Affects big and small vessels If their on medication it should be what is good for them (their normal BP) Hypotension blood pressure is below 100/60 mm (looking at trends and manifestations per pt.) Vital Sign Considerations - Frequency of vital signs - Appropriate and relevant therapeutic communication with client - Delegation of vital signs - Documentation of vital signs - Critical thinking in assessment of vital signs - Reporting a change in vital signs (SBAR) - Lifespan considerations Pain Pattern Identification Scales Number rating scales (NRS) Verbal descriptor scale Wong-Baker FACES pain rating scale What are SCD's? SCD'S are a method of DVT prevention that improves blood flow in the legs. They are shaped like "sleeves" that wrap around the legs and inflate with air one at a time. This imitates walking and helps prevent blood clots. What are IPC's? IPC's are used to help prevent blood clots in the deep veins of the legs. The devices use cuffs around the legs that fill with air and squeeze your legs. This increases blood flow through the veins of your legs and helps prevent blood clots. What are TED's? Thrombo-embolic disease Stockings, brand name of antiembolism elastic stockings Contraindications for compression devices - They should not be used in patients with documented deep vein thrombosis - Not used on open wounds or cellulitis What anatomic site regulates the pulse rate and force? Cardiac sinoatrial (SA) node 33 91

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