Exam 1 Blueprint Flashcards
Assessment of Infection
Trending vitals increasing -> infection present;
Labs: Complete blood count (with WBC differential)
Culture and sensitivity
C-reactive protein (CRP)
Erythrocyte sedimentation rate (ESR)
Serological tests to detect specific antibodies or viruses
Radiology: X-rays
MRI
CAT
PET and indium scans
Hospital-Acquired Infection (risk factors)
Health care workers don’t hand hygiene properly, don’t wear PPE; common HAIs are Central Line Associated Bloodstream Infections, Catheter Associated Urinary Tract infections, Surgical Site Infections, Ventilator Assisted Pneumonias
Prevention Strategies: Weakening the chain of infection
Primary: vaccines, hygiene, good nutrition, exercise, socioeconomic status (ability to get care and preventative checks), good rest, educate the community
Secondary: early detection through screening and preventing it from getting worse (mammogram, pap smear, routine blood tests, screening for high risk populations)
Prevention Strategies: Education of health team members, patients, and community
Tier 1 Transmission Precautions
Standard Precautions
Tier 2 Transmission Precautions
Contact Precautions, Droplet Precautions, Airborne Precautions, Protective Environment
Evaluation of interventions (how do nurses know if interventions were successful)
Clients don’t get sick, are treated quickly, or vital signs/complete blood count go back to normal
Therapeutic communication approaches
“purposeful use of communication”; Plan and allow time to communicate, Active listening , Caring attitude, Honesty (open, direct, sincere), Trust, Empathy, Nonjudgmental attitude
Non-therapeutic communication approaches
passive, aggressive, passive-aggressive
Things that support effective communication
listening, planning, silence, good environment, privacy
Things that hinder effective communication
developmental/cognitive deficits, language barriers, poor/too bright lighting, excessive noise, extreme elements, strong emotions, cultural, what else can you think of?
Effective communication tools for health care team/nurses
ISBARR
ISBARR
introductions (identify self/title), situation (facility, patient, room number, briefly state the problem), background (brief and pertinent patient history, labs, meds), assessment (nurse’s assessment of situation, most recent vitals/changes), recommendation (make specific request), repeat (what other health care worker says)
Documentation: How to document patients own words
subjective
Documentation: Importance of documenting patient education
keeps other health care workers in the team up to date on what the patient has been informed, written history for the patient
Data Collection components of General Survey
appearance, behavior, body structure/mobility, height, weight, BMI, vital signs (including pain)
Data Collection components of Health History
P-past medical history/pertinent family history/childhood illnesses, hospitalizations, surgeries, immunizations, health maintenance screenings
L- last oral intake
E-events leading to illness or injury
A-allergies/reactions
S-symptoms of chief complaint
E-each medication (OTC, prescription, herbal, vitamins)
Health promotion behaviors
Review of systems (ROS) – information about the functioning of all body systems and health problems
Functional Health-questions regarding:
stress, occupation, sleep, substances, self-concept, relationships, abuse
Data Collection components of Physical Assessment
Inspection (vision, smell, hearing), Palpation (touch), Percussion (tapping body parts with fingers/small instruments), Auscultation (listening to sounds with stethoscope or doppler)
Techniques used for physical assessment
- Skin is pink
- Skin is warm
- Hair is thinning
- Lung sounds clear
- No abdominal tenderness
- inspection
- Palpation
- Inspection
- Auscultation
- palpation
Documentation of data collection
what limb used for data collection, time, date, who collected it, if for BG did patient just eat? if HR was patient sedentary?
Collection components of vital signs including pain
temperature, BP, pulse, RR, pain, Pulse Ox
Assessment and measurement of data for vital signs
measure vital signs as frequent as necessary, assess trends and your client, not individual measurements
Documentation of vital signs including pain
document all vital signs in patient’s chart, vital signs flow sheets for routine, pulse ox: include if patient is on room air or oxygen (amount), note if there is a change in patients status
Delegation of vital signs including pain
action of obtaining the vital signs may be delegated to unlicensed personnel, but interpretation of results remains in the nurse’s responsibility; if abnormal -> recheck data
Unexpected findings and appropriate nursing actions for temperature (know normal ranges, and what abnormal is/looks like)
Hyperthermia – body temperature 40 C or 104.4 F
Nursing actions – obtain specimens; lab results; provide fluids, rest; antipyretics; provide comfort measures for chills, dry clothing and linens
Hypothermia – body temperature less than 35 C or 95 F
Nursing actions – warm environment, heated humidified oxygen, warming blanket, or warmed oral or IV fluids; head covered; continuous cardiac monitoring; emergency resuscitation equipment on standby
Patient presentation with alterations of vital signs including pain: 1. Tachycardia
- Bradycardia
- Hypertension
- Hypotension
- Difficulty breathing
Pain: grimacing/they tell you; 1. sweaty, red, cant stay still, sometimes hyperventilating, constantly clutching at their chest
- Low energy, out of breath, tired, fatigued
- Red, sweaty, headache,
- Pale, dizzy, might pass out, tired
- Restlessness, clutching at their chest, increased resp rate, looking distressed/anxious, change in color of lips (bluish)
Developmental considerations of vital signs including pain
Pain: developmental stage can alter how much a person can communicate; temp: kids run hot, older adults run colder; Pulse/respirations: gradually decreases with age; BP: gradually increases with age (decreasing elasticity of blood vessels);
Ethical considerations of vital signs including pain
Hepatitis A nursing considerations
Contact precautions; spread person-person (specifically through blood/waste) and through unclean food/water
Hepatitis C nursing considerations
Contact precautions; spread person-person specifically through blood; CDC says Standard Precautions
Respiratory Syncytial Virus nursing considerations
Contact Precautions
Influenza nursing considerations
Droplet precautions
Meningococcal meningitis nursing considerations
Droplet precautions
MRSA nursing considerations
Contact precautions
Mumps nursing considerations
Droplet precautions
Norovirus nursing considerations
Contact Precaution
C. Diff nursing considerations
Contact Precaution
Varicella zoster nursing considerations
Airborne and Contact Precautions
Pertussis (Whooping Cough) nursing considerations
Droplet precautions
Unexpected findings and appropriate nursing actions for respiration (know normal ranges, and what abnormal is/looks like)
normal 12-20, if abnormal respirations find out source and correct the source
Unexpected findings and appropriate nursing actions for Pulse Ox (know normal ranges, and what abnormal is/looks like)
normal range: 95-100 (COPD can be as low as 85%), if low put on oxygen
Unexpected findings and appropriate nursing actions for BP (know normal ranges, and what abnormal is/looks like)
normal: systolic less than 120, diastolic less than 80; hypotension: systolic less than 90; hypertension: systolic above 140
Unexpected findings and appropriate nursing actions for pulse (know normal ranges, and what abnormal is/looks like)
normal: 60-100 beats/min at rest, regular rhythm/strength/equal on both sides; pulse deficit = difference between apical and radial rate; dysrhythmia = irregular heart rhythm
