Chapter 1: Evidence-Based Assessment
• Understand the tasks or the role of the RN with the Nursing Process. As it relates to:
The Nursing
... [Show More] Process
Know the difference between Priority Levels of Care:
• 1st level: Emergent, life threatening, and immediate
• 2nd level: Next in urgency, requiring attention to avoid further deterioration acute urinary elimination problems
• 3rd level: important to patient’s health but can be addressed after more urgent problems are addressed.
Know what belongs in each database:
• Complete total health database: Describes current and past health state and forms baseline to measure all future changes. On admission this is done
• Episodic or problem-centered database: Collect “mini” database, smaller scope and more focused than complete database. This is used in all health care settings focused on a specific area or part of the body
• Follow-up database: Status of all identified problems should be evaluated at regular and appropriate intervals.
Following up with a primary care doctor
• Emergency database: Rapid collection of data often compiled concurrently with lifesaving measures
Chapter 3: The Interview
Be able to describe the best type of: Physical Environment
• set the room temperature at comfortable level
• provide enough lighting so that you can see each other clearly but avoid strong, direct lighting that can cause squinting
• secure a quite environment. Turn off televisions, radios, and any unnecessary equipment.
• Remove distance between you and the client at 4 to 5 feet personal space is any space within 4 feet of a person. Encroaching on personal space can cause anxiety, but if you position yourself farther away, you may seem aloof and distant the personal reaction bubble depends on variety of factors including culture, gender, and age.
Chapter 4: The Complete Health History
Know what type of data is collected in each section of the health history (adult client)
• Biographic data: name, address, and phone number; age and birth date, birthplace, gender, relationship status, race, ethnic origin; and occupation, person primary language
• Source of history: Record who furnishes the information, are they reliable judge how reliable the informant seems. A reliable person always gives the same answers, even when questions are rephrased or repeated later in the interview. Note whether the person appears well or ill; a sick patient may communicate poorly.
• Reason for seeking care: Symptom: subjective sensation person feels from disorder documented in quotes
Sign: objective abnormality that can be detected on physical examination or in laboratory reports
• Present health or history of present illness: Collect all provided data and identify eight critical characteristics. Make sure that collected data are precise and accurate. Use standardized indicators to document findings
• Past health: health history in the pass childhood illness, accidents or injuries, serious or chronic illnesses, hospitalization, obstetric history, immunizations, las examination date, allergies, current meds
• Family history: family history like cancer or diseases that a patient may be at risk for
• Review of systems: The purposes of this section are (1) to evaluate the past and present health state of each body system, (2) to double-check in case any significant data were omitted in the Present Illness section, and (3) to evaluate
health promotion practices.
• functional assessment including activities of daily living (ADLs): sleep and rest, activity and exercise, personal habits, intimate partner violence, coping and stress management, illicit or street drugs.
Know CAGE assessment:
• Cut down: Have you ever thought you should Cut down on you drinking
• Annoyed: have you have been Annoyed by criticism of your drinking
• Guilty: have you ever felt Guilty about you drinking?
• Eye-opener: do you drink in the morning (Eye opener
Know how you would perform the assessment: When was your last drink of alcohol? How much did you drink that time? In the past 30 days, about how many days would you say that you drank alcohol? Has anyone ever said that you had a drinking problem?
If the person answer “yes” to two or more questions, you should suspect alcohol abuse and continue with a more complete substance- abuse assessment
Chapter 5: Mental Status Assessment
Alert: awake or readily aroused; orientated, fully aware of external and internal stimuli and responds appropriate’ conducts meaningful interactions.
Lethargic: not fully alert; drifts of to sleep when not stimulated; can be aroused to name when called in normal voice but looks drowsy; responds appropriately to question or commands but thinking seems slow and fuzzy; inattentive; losses train of thought
Coma: completely unconscious no response to pain or any external stimuli
Delirium (Levels of Consciousness): clouding of consciousness (dulled cognition, impaired alertness) incoherent conversation impaired recent memory agitated and having visual hallucinations, disoriented.
Chapter 8: Assessment Tech. and Safety in the Clinical Setting
• Know the order and how to apply the assessment techniques:
1. Inspection: Close, scrutiny, first of individual as a whole and then of each body system begins when you first meet person with a general survey need good lighting and adequate exposure
2. Palpation: Palpation applies sense of touch to assess the following texture, temperature and moisture, lumps, masses, tenderness or pain
a. Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps
b. Fingers and thumb: detection of position, shape, and consistency of an organ or mass
c. Dorsa of hands and fingers: best for determining temperature because skin here is thinner than on palms
d. Base of fingers or ulnar surface of hand: best for vibration
3. Percussion: Tapping person’s skin with short, sharp strokes to assess underlying structures
• Mapping location and size of organs
• Signaling density of a structure by a characteristic note
• Detecting a superficial abnormal mass
4. Auscultation: Tapping person’s skin with short, sharp strokes to assess underlying structures Stethoscope does not magnify sound, but it blocks out extraneous sounds eliminate extra noise
• A Safer Environment
Know the Standard Precautions and how you would teach your client
o Hand hygiene
▪ Key factor in decreasing spread of infection
▪ Before and after patient care
▪ Protocols for visibly or not visibly soiled
o Use of protective equipment
▪ Gloves, gown, mask, eye protection, or face shield
o Respiratory hygiene/cough etiquette
▪ Education, posted signs, and source control measures
Chapter 9: General Survey and Measurements
• The General Survey Know what you would assess Physical appearance
• Age: person appears his or her stated age
• Level of consciousness: person alert and oriented, attends to your questions and responds appropriately
• Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion
• Facial features: symmetric with movement
• Overall appearance: provide general statement r/t presence or absence of distress
behavior sections
• Facial expression: person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation (e.g., thoughtful, serious, or smiling)
• Mood and affect person comfortable and cooperative with examiner and interact pleasantly
• Speech: articulation (ability to form words) clear and understandable
Chapter 10: Vital Signs
Know each the following vital signs and how you would assess each one below: Pulse
• palpable flow felt in the periphery as a result of pressure wave generation from stroke volume
• Using pads of the first three fingers, palpate radial pulse at flexor aspect of wrist laterally along radius bone until strongest pulsation is felt.
• If rhythm is regular, count number of beats in 30 seconds and multiply by 2.
• The 30-second interval is most accurate and efficient when heart rates are normal or rapid and when rhythms are regular.
60 to 100 beats per minute (bpm) Heart force:
• 3+ Full, bounding
• 2+ Normal
• 1+ Weak, thread
• 0 Absent
Respirations
• Normally person’s breathing is relaxed, regular, automatic, and silent
• Because most people are unaware of their breathing, do not mention that you will be counting respirations, because sudden awareness may alter normal pattern.
• Instead, maintain your position of counting radial pulse and unobtrusively count respirations.
• Count for 30 seconds or a full minute if you suspect an abnormality
• Adult normal rate 10-20
Orthostatic (postural) Vital Signs:
• Take serial measurements of pulse and blood pressure in the following situations:
• You suspect volume depletion.
• Person is known to have hypertension or taking antihypertensive medications.
• Person reports fainting or syncope.
• Position changed from supine to standing, normally slight decrease (less than 10 mm Hg) in systolic pressure may occur.
• Have person rest supine for 2 or 3 minutes, take baseline readings of pulse and BP, and then repeat with person sitting and then standing
Know how the vital signs change in the: The Aging Adult
• Temperature: changes in body’s temperature regulatory mechanism leave aging person less likely to have fever but at greater risk for hypothermia
Temperature is less reliable index of older person’s true health state; sweat gland activity is also diminished.
• Pulse: normal range of heart rate is 60 to 100 bpm, but rhythm may be slightly irregular
Radial artery may feel stiff, rigid, and tortuous in older person, although does not necessarily imply vascular disease in heart or brain.
Increasingly rigid arterial wall needs faster upstroke of blood, so pulse is easier to palpate.
• Respirations: aging causes decrease in vital capacity and decreased inspiratory reserve volume You may note shallower inspiratory phase and an increased respiratory rate.
• Blood pressure: aorta and major arteries tend to harden with age
As heart pumps against a stiffer aorta, systolic pressure increases, leading to widened pulse pressure.
In many older people, both systolic and diastolic pressures increase, making it difficult to distinguish normal aging values from abnormal hypertension.
Know how to define Hypotension and the number value
• Hypotension: Seen in acute myocardial infarction (AMI), shock, hemorrhage, vasodilation, and/or Addison’s
disease Blood pressure lower than 95/60mmHg
Know the cardiovascular risk: Major risk factors
• Prevention and management
• Weight loss
• Limit alcohol use
• Increase aerobic exercise activity pattern
• Reduce sodium intake
• Maintain adequate sources of dietary potassium, calcium and magnesium
• Smoking cessation
• Reduce intake of saturated fats and cholesterol
Know the Lifestyle Modifications for Hypertension Prevention and Management
• Lose weight
• Limit alcohol intake to no more than 1 oz (30ml)
• Increase aerobic physical activity (30-45min most days of the week)
• Reduce sodium
• Maintain adequate intake of dietary potassium and calcium and magnesium
• Stop smoking and reduce intake of saturated fat and cholesterol for cardio health
Chapter 11: Pain Assessment
• Recognize and understand: PQRSTU
o Provocative or Palliative. What brings it on? What were you doing when you first noticed it? What makes it better? Worse?
o Quality/quantity: How does it look, feel, sound? How intense/severe is it?
o Region/radiation: Where is it? Does it spread anywhere?
o Severity: How bad is it (on a scale of 0 to 10)? Is it getting better,
▪ Worse, staying the same
o Timing: Onset—exactly when did it first occur? Duration—How long
▪ Did it last? Frequency—how often does it occur?
o Understanding: Onset—
Known the difference between:
Acute: Short-term and self-limiting: Often follows a predictable trajectory, and dissipates after an injury heals
Nonverbal response in acute pain
• Exhibit the following behaviors:
• Guarding, grimacing
• Vocalizations such as moaning, agitation, restlessness, stillness
• Diaphoresis,
• Change in vital signs
Chronic: Chronic pain can be further divided into malignant (cancer related) and nonmalignant. In contrast, chronic (or persistent) pain is diagnosed when pain continues for 6 months or longer. It can last 5, 15, or 20 years and beyond.
Nonverbal response in chronic pain
• Bracing, rubbing
• Diminished activity
• Sighing
• Change in appetite
Know the clinical manifestations of pain in
Nociceptors: are the nerves which sense and respond to parts of the body which suffer from damage
Neuropathic: Pain due to a lesion or disease in the somatosensory system
• Dementia Patient’s Dementia does not impact the ability to feel pain, but it does impact the person's ability to effectively use self-report tools they communicate pain through behavior agitation, pacing, repetitive yelling
• Known the Physiologic responses to pain
Chapter 12: Nutritional Assessment
• Know the difference between the types of Nutritional Assessments:
o Food Frequency: Advantage obtains information about multiple time frames. Disadvantage: (1) it
does not always quantify amount of intake, and (2) like the 24-hour recall, it relies on the individual’s or family member’s memory for how often a food was eaten.
o Food diaries: A food diary is most complete and accurate if you teach the individual to record information immediately after eating. Disadvantage: (1) noncompliance, (2) inaccurate recording,
(3) atypical intake on the recording days, and (4) conscious alteration of diet during the recording period. [Show Less]