Fund 50 week 2 day 3 Flashcards
Nursing Roles in The
U.S. Healthcare System
Nursing Roles in The
U.S. Healthcare System• Institute of Medicine (IOM) Report: “To Err is
Human: Building a Safer Health Care System”
• 2003: “All health professionals should be educated to deliver pt-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality
improvement approaches and informatics” (IOM)
QSEN Faculty
& National
Advisory
Board*
Proposed targets for the
knowledge skills and attitudes
(KSAs) to be developed in
prelicensure programs for each of
the competencies - this won’t change, but the language might a little bit
Using the IOM (institute of medicine) competencies,
QSEN defined quality and safety
competencies for nursing (systems are the new way of thinking)
competencies for nursing - old way, focus on individual performance. Now, we need to think about systems. New train of thought is minimize risk of harm to patient through system effectiveness and individual performance.
QSEN Faculty & National Advisory Board
Proposed targets (target the students)
for the knowledge skills and attitudes (KSAs) to be developed in
prelicensure programs for each of the competencies
Quality and Safety Education for Nurses (QSEN)(Frances Pain Bolton School of Nursing. Case Western Reserve University) (Q says, be patient, be a team, use evidence, improve quality, safety, and information)
Competency:
Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
little example of system error is…
bags taped to rolling vital signs carts so you can dispense used probe on thermometer - some places take a bag so you can dispense it right there. The probes are dirty, don’t place in bag.
2022 Hospital National Patient Safety Goals (ID me, communicate, meds, alarms, infection, risks, prevent mistakes)
• Identify patients correctly
• Improve staff communication
• Use medicines safely
• Use alarms safely
• Prevent infection
• Identify patient safety risks
• Prevent mistakes in surgery
2022 Hospital
National Patient
Safety Goals
• Identify patients correctly
• Improve staff communication
• Use medicines safely
• Use alarms safely
• Prevent infection
• Identify patient safety risks
• Prevent mistakes in surgery
Safety Hazards in the
Healthcare Facility (dont forget restraints)
BE aware of fall criteria - will need to do it every day.
1st question - what are you going to be alert for - behavior, fall risk, clutter, etc. Be alert for dangers at bedside, including fall risk.
Safety Hazards in the
Healthcare Facility
• Falls
– Falls is the most frequently
reported adverse occurrence in
adult inpatient setting
– Prevention: fall risk assessment;
environmental safety; clean, dry
floors; client education
• Restraints
• Equipment-related accidents
• Fires/electrical hazards
Equipment Related Accidents (remember heating pads)
Equipment malfunction and
failures – What is the appropriate
action:
• Label clearly, send appropriate department to be repaired
• Wrong application, inappropriate use or unapproved use - example- heating pads! (remember this) they can burn someone. Ppl with pain don’t feel the burn.
• New equipment issues
(training, lack of supervision)
make sure you are oriented to all equipment
Fires/Electrical
Hazards
Oxygen (know where the oxygen shut off valve is)
Malfunctioning electrical equipment (inspect cords and label, if not working take them out of service)
Smoking
Hospital Policies (to prevent any injury or hazards)
Fire and how to use fire exstinguisher
(RACE AND PASS)
WHAT TO DO WHEN THERE IS FIRE: (YOU NEED TO MEMORIZE THIS)
Fire
(RACE AND PASS)
WHAT TO DO WHEN THERE IS FIRE:
• Rescue the patient
• Activate alarm
• Confine fire
• Extinguish fire/Evacuate
HOW TO OPERATE FIRE
EXTINGUISHER:
• Pull out safety pin
• Aim nozzle at base of fire
• Squeeze lever and handle
• Sweeping motion
you need to know where fire alarms are, exits, and extinguishers
Types of Errors (NEPSN - never, ever put student nurse bc errors)
• “Near Miss” - reporting is just as significant as reporting errors. there are registries you can report to. seeing a med error on the 3rd check is near miss.
• Error - wrong med to patient
• Preventable Adverse Event
• Sentinel Event
• Never Event
root cause analysis
if something happens in the OR - just what is the root cause
systems to prevent error (prevent the vest and don’t forget checklist)
bar code, do not disturb vest, emr (health record) safety check lists, ***avoid workarounds
Culture of Safety
Culture of Safety
• Goal is to lessen harm to patients and providers through both
system effectiveness and individual performance
• Safety culture requires strong, committed leadership together
with engagement and empowerment of all employees
why it’s importnat that we have just culture.
Key Elements
of Culture of
Safety
Safety as organizational priority
Teamwork
Patient Involvement
Openness/Transparency
Accountability
Shared core values and goals, non-punitive responses to adverse
events and errors, promotion of safety through education/training
just culture - why it’s important
Focus is on what went wrong, rather than who
caused the error. Balance between not blaming
individuals and not tolerating egregious
behavior emphasis on accountability, integrity,
honesty, excellence, teamwork, collaboration
Just culture is important so people won’t be afraid to report.
• Culture of blame previous
prevailing attitude in healthcare
• Suggested as major source of the unacceptably high number of medical errors
health assessment - objectives
• Review components of a Health Assessment
• How to perform a Physical and Safety Assessment
• Differentiate between comprehensive, focused and
ongoing assessments
• Identify normal and some abnormal findings
• Differentiate between subjective and objective data
Purpose of Health Assessment (start w/ baseline, diagnose, monitor, screen)
Purpose of Health Assessment
● To establish a baseline
● To formulate a nursing diagnosis
● To monitor the status of an identified problem (had a stroke, and they’re not getting worse)
● To screen for health problems
Health Assessment
Determining the person’s* (use both…)
overall present health by
collecting, validating (is this accurate, person coughing during bp, you want to wait), and analyzing data, both subjective and objective.
4 Types of Assessments (I need COFE to be comprehensive, ongoing, focused and emergent) REMEMBER this
● Comprehensive
● Ongoing
● Focused
● Emergent
Comprehensive (comprehensive head to toe)*
Includes a health hx and a head to toe assessment
• Annual physical exams•
Admission to inpatient settings (patient sent from ED)
Initial home health visits
Ongoing (every 2 - 4)*
Brief ongoing assessment to monitor changes in patient status or to evaluate the effectiveness of an intervention• Physical: q4h neuro checks after a TBI or stroke•
Labs: q6h Anti-factor XA to assess need to titrate heparin drip (PE)
ex. 2-4 hour checks, changes in patient’s status or meds. BP meds, or alcohol issues - looking for withdrawal bp.
Focused (focus on rash)*
Focused on a particular topic, specific part,or function of the body•
Rash on leg.• (outline to make sure it’s not getting bigger)
Abd pain-Location, rebound, positional, last BM & void, last period, etc
Emergent (immediate) (emergency chest pain)*
Rapid focused assessment
● Acute chest pain- EKG, Troponin and other labs, CXR, angiogram
● Sudden facial droop/weakness- Neuro assessment, CT, FSBG
Health Assessment:Patient Interview (reason, history, family history)*
I. Reason for Seeking Care
• Hx surrounding current concern
• Good to record exact words from patient - “quote”
II. Health History - everything
• Chronic illness, Current medications, allergies, immunizations, Surgical hx, Obstetric hx (females)
I. Family History
• Relevant to know patient’s risks based on family history
Patient Interview IV. Social / Biographical History (personal interview)
● Primary info: ○ Place of birth (TB is large in some countries), past & current residency, primary language
● Current lifestyles
○ Living situation, Relationship/Support systems, Daily activities, Hobbies, Cultural/spiritual beliefs, Alternative health care practices
● Risk factors
○ Health habits (nutrition, caffeine, exercise, sleep, safety, exposures), Tobacco, ETOH, recreational drugs, Sexual risks, Economic risks (health access), Stress, Violence, Advanced directives
patient interview - reviews of systems (this is body systems)
GENERAL Present weight, any recent weight loss or gain,
emotional state
NEUROLOGIC Memory problems, disorientation (headaches)
HEENT EYES: Glasses, vision, blindness, light
sensitivity
EARS: Deaf, hearing aids, hard of hearing
(HOH)
MOUTH Dentures, Difficulty chewing, Regular dentist
visits, Recent dental work.
patient interview cont
RESPIRATORY/
PULMONARY
SOB, Dyspnea, waking up tired, frequent day naps,
orthopnea
CARDIOVASCULAR Chest pain on exertion or inspiration, palpitation (swelling in legs w/ heart failure)
PERIPHERAL VASCULAR (diabetes - sores, swelling)
Numbness, tingling of extremities, cool/hot skin, color
GASTROINTESTINAL Diet, appetite, last BM and characteristic, normal frequency of BM, constipation, bloating/cramping
URINARY Urinary retention, incomplete emptying, straining, change in force or stream; MEN – weaken stream; WOMEN: incontinence when laughing, sneezing
SEXUAL HEALTH Changes in sexual relationship, erectile dysfunction, vaginal dryness, pain during intercourse
MUSCULOSKELETAL Gait change – balance, weakness, difficulty with steps, fear of falling; Use of assistive device, joint pain, muscle pain (yoga helps)
INTEGUMENTARY Wounds (healed/non-healing), changes in sensation to pain, heat or cold, discoloration, changes in moles
Patient Interview
VII. Functional Assessment/Psychosocial
How does the person manage activities of daily living (ADLs & IADLs) and the impact of disease on activities and quality of life (QOL)
❖Self concept, self esteem, depression
❖Suicidal Ideation
❖Occupation
❖Activities and Exercise
❖Sleep and Rest
❖Interpersonal Relationship / Resources – support system
❖Coping & Stress Management – recent change, death, loss of work
❖Environmental Hazard – home safety (stairs, rugs, getting into tub)
Clinical Setting
Assessment Requirements
A basic head-to-toe exam (hand squeeze, check eyes, do 4 areas of visual field - short check in ER), Vital Signs (frequency is usually per unit policy), and ongoing assessment are standards of care every shift (this is always done)
● Does not require a comprehensive physical assessment
● Additional assessments are specific to the unit and the patient, and will be in the patient’s orders)
Here are some examples of additional assessments that might be ordered:
• Full neuro exam
• (frequency varies)
• Neck circumference s/p thyroidectomy
• Puncture site monitoring post cath lab
• Monitoring for opiate and/or ETOH withdrawal (CIWA/COWS) (temp, heart rate, anxious, tremors) - maybe every 4 hrs, then 6, 8
Findings Requiring Attention
Standard call parameters: (Notify provider if:) (if not in chart, call doc and ask for parameters and then put it in the chart)
• BP: Systolic <90 or >160, Diastolic <60 or >100
• Temperature ≤ 36° C or ≥ 38° C (conversion to Farenheit,96.9/100.4°
• Heart rate <60 or >100 BPM
• Respirations ≤12 or ≥24/min
• O2 saturation <92%
• Urine output <30 or <240 mL/8 hours
• Dark amber or bloody urine
• Uncontrolled postoperative nausea or vomiting (PONV)
• Surgical pain not controlled with medication and/or chest pain
• Bleeding, new or unexpected increase/decrease.
• Change in level of consciousness (LOC), confusion, difficulty arousing
• Sudden restlessness and/or anxiety
Head to Toe Approach
Start at the head and proceed down the body to the feet
Body Systems Approach
Examine each body system in a predetermined order
(Neuro, CV, MSK, etc.)
➢ Pick an approach
➢ Modified based on pt need and time constraints
➢ Be systematic and consistent
➢ It takes practice
Assessment Sequence
(look at the trend, if bp is high, then look at trend)
• Starts before entering patient room
• Handoff report from previous shift
• Note orders and verify door signs such as isolation
precaution, latex allergy, or fall precautions
• Upon entry into patient room
• Introduce yourself as patient’s nurse/nurse student
for the next 8 hours or 12 hours
• Set rapport
• Make eye contact
• Ask how patient is feeling; any pain or discomfort
• How did patient spent the previous shift
Step 1: General Appearance
Initial interaction will elicit such information as:
• Neuro status:
• (LOC), alert and oriented, attentive to your questions or
lethargic, difficult to arouse
• Follows direction, understands language/speech, hearing, sight
• General appearance:
• Facial expression and body language: relaxed or tense and fidgety; grimacing, withdrawn
• Skin color: normal for ethnicity, flushed, diaphoretic
• Nutritional status: weight appears in healthy range
• Grooming
➢ Complete initial assessment by verifying correct name/DOB on ID band (Ask how pt prefers to be addressed)
Step 2: Vital Signs
Vital Signs
• Temperature
• Pulse
• Respiration
• Blood Pressure
• Oxygen Saturation
• Pain
Room and Patient Safety check:
• IV (correct solution, rate, date)
any tube should be considered part of that person’s body.
• IV
■ Verify the correct IV solution is hanging
■ Verify it is running at the prescribed rate
■ Verify the date of tubing is current
■ Trace IV tubing to Pt’s IV (make sure the tubing is going somewhere)
■ Assess all IV sites
• Note signs taped above head of bed
• Check tubes: NGT, PEG, PEJ, chest, trachs, foley, rectal, JPs
• Are Ambu bag and mask, suction canister, tubing, & yankauer (plastic hard tube) present?
• Bed in locked & lowest position, call light within reach, tray table within reach
• Bed alarm on if patient is a Fall risk
Step 3: Physical Assessment: (ask yourself…)
• Comes with experience
• Requires technical skill and clinical knowledge
to gather data.
Ask yourself:
“Is this the finding I expect from this patient?”
Preparing for a Patient Exam
• Establish a safe environment
• Warm, comfortable, quiet
• Maintain privacy
• Expose only the area being examined
• Tell the patient what you’ll be doing
• Equipment –
• Organized and within reach
• Stethoscope, VS machine, pen light, etc.
• Don appropriate personal protective equipment
(maybe turn down the TV)
Order of Physical Exam: (inspect, palp..etc BUT one is the other way) (I need an IPPA for the physical exam)
Order of assessment for most systems *
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
5. (Olfaction if appropriate, e.g wounds, drainage, breath)
*Exception: To avoid disturbing bowel sounds, the order of assessment of
the abdomen is different: We go from least invasive to most invasive:
• Inspect
• Auscultate
• Percuss
• Palpate
Order of Physical Exam
*Always inform the patient what you plan to do
1: Inspection – using your eyes to gather data (gait, physical
marks, general survey, physical appearance)
2: Palpation– using tactile sense to check temp, moisture,
mass, swelling, vibration, pulsation, presence of pain.
Start with light then move to deeper palpation (within reason).
Assess known tender areas last.
Percussion
Using fingers to tap skin with short sharp stroke to
assess underlying structures (location, size, and density of underlying
structures– air, fluid, mass)
• Stationary hand – middle finger of non-dominant hand
• Striking hand – middle finger of dominant hand
• Compare left and right sides
Auscultation
Step 4: Auscultation
Using a stethoscope to hear sounds produced by the body
There are 2 parts of the Stethoscope:
• A Diaphragm for high pitched sounds
(normal heart, lung, and bowel sounds)
• A Bell for low pitched sounds
(extra heart sounds, murmurs)
Systems Approach Exam
NEUROLOGICAL (lethargy makes me obtuse, stupid, and coma)
● LOC – awake, alert, oriented, responds to stimuli
Level of Sedation:
● Alert & Oriented? Person, Place, Time, Situation AOx0? AOx4?
● Lethargic
● Obtunded
● Stuporous
● Coma
STEP 1: INSPECTION:
● Eyes open spontaneously to name
● Spontaneous motor and verbal response
● Moves all extremities
Systems Approach - NEUROLOGICAL - how to assess if the patient is oriented (neuro isn’t a person, place, or time)
Assess if they are oriented to:
• Person - Do they know who they are?
• Place - Do they know where they are?
• Time - Do they know the date?
situation - do they know what’s going on?
motor strength grading (0 - 5 Ethan - the motor flicks, defies gravity, then resists)
Sensation intact: light touch, pain, vibration ( perform on face and each extremity)
Motor Strength grading
• 0/5: no contraction
• 1/5: muscle flicker, but no movement
• 2/5: movement possible, but not against gravity
• 3/5: movement against gravity, but not against resistance
• 4/5: movement against some resistance
• 5/5: normal strength
Integumentary Assessment
Examined when each area of the body system is being
assessed
Step 1: Inspection
• Skin color: Consistent with person’s baseline/heritage
• Abnormal findings: jaundice, cyanosis, mottling, erythema,
petechiae (dots), pallor (pale)
• For people with darker skin tones pallor can be assessed by
inspecting the mucus membrane of the mouth or the
conjunctiva ( inside the lower eyelid).
• Skin integrity: clean, intact or rash, pressure injury present,
wounds, ecchymosis, etc.
Nails
Nails Contour, shape and color
(nychia means nail)
nails Step 2: Palpate
• Warm and dry or cool, hot, diaphoretic (use back of hands)
• Skin turgor: Pinch up a fold of skin under clavicle to note any
tenting (dehydration), skin returns to original shape (normal)
• Assess for pitting edema, crepitus (oxygen gets into subcutaneous area of body - ie lung injury and if tube isn’t put right, air can get under the skin)
Capillary refill
• Press down firmly on nail bed for 3 secs and release
• Normal when blood refills ≤ 3 secs
• Blanch fat pad of finger if nails are thickened and opaque
Palpate Pulses: (gotta be equal w/ pulses)
• Compare all for equality
• Sites: radial, ulnar, brachial, femoral, popliteal, dorsalis pedis (DP)
posterior tibialis (PT)
• Carotid and femoral pulses not routinely palpated unless indicated
HEAD: (head - Am I drooping?)
always looking for symmentry
Step 1: Inspection
• Position midline
• Facial features – symmetry, moon face, edema, facial droop
• Any involuntary movements, hair pattern, lice present
head Step 2: Palpation (eyebrow, cheek bone, tears, temple)
• Skull and face for tenderness Lymph nodes: Frontal (below eyebrow) and Maxillary sinuses (below cheekbone), Ethmoid (tear canal) Sphenoid (temple area)
EYES:
Step 1: InspectionPupils
• Pupils-Pupils Equal Round Reactive to Light and Accommodation (PERRLA)
● Visual acuity/field
● Eyebrows, eyelids, sclera, conjunctiva
● Extra-occular movements –nystagmus● Ptosis (droopy eyelid)
Pupils:
● Size measured in mm
● Use a pupillometer if uncertain of size or
reaction to light
EARS:
EARS:
Step 1: Inspection
❖Gross and fine hearing, drainage (if clear, drainage can be a CNS problem)
Step 2: Palpation
❖ External ears for deformity, lesions
NOSE:
Step 1: Inspection
❖External, discharge, sinus tenderness
Step 2: Palpation – patency
MOUTH/THROAT:
STEP 1: Inspection:
❖Appearance of lips, tongue.
❖Condition of teeth and gums
❖Appearance of pharynx, tonsils, uvula, floor of mouth
❖Movement of tongue and palate
NECK:
if they have a trach, make sure it’s midline and the ties are tied.
STEP 1: Inspect – symmetry of muscles, ROM, JVD
STEP 2: Palpate - muscle strength, trachea, carotid pulse (one
at a time), thyroid for goiter
Objectives:
Objectives:
• Review components of a Health Assessment
• How to perform a Physical and Safety Assessment
• Differentiate between comprehensive, focused and
ongoing assessments
• Identify normal and some abnormal findings
• Differentiate between subjective and objective data
Thorax and Lungs
Best to assess in high fowler’s position
(make sure even, breathing, regular pattern)
Anterior Chest:
Step 1: Inspect
Color, shape, breathing pattern
Normal
• Color consistent with overall skin color
• Transverse diameter > anterioposterior diameter of chest
• Normal breathing pattern and effort
Abnormal
• Rash, ecchymosis, suspicious moles, etc.
• Barrel chest (transverse diameter ≦ anterioposterior diameter) - usually w/ ppl who have COPD
• Use of accessory muscles, grunting, heaving
Barrel Chest
Barrel Chest
Assess the anterior posterior
(AP) diameter to the lateral
diameter
• Normal ratio is 1:2
• Barrel Chest is 1:1
Thorax and Lungs
don’t palpate on rib, do the intercostal
Anterior Chest:
Step 2: Palpation
• Apical pulse (also known as: apex beat, point of maximal
impulse, and apical impulse) located at the 5th intercostal
midclavicular area
• If displaced laterally, may indicate cardiomegaly
Thorax and Lungs - what is the acronym
(All patients take meds - acronym)
Step 4: Auscultate with bell & diaphragm
• High Fowler’s position (if possible)
• Apical pulse : Can best heard at 5th ICS left midclavicular
• Listent to Aortic, Pulmonic, Erbs Point, Tricuspid, Mitral
Systole – contraction of ventricles to push blood
through the aorta and the pulmonary artery
Diastole – the ventricular is relaxed and filling
● S1-– the first heart sound.
Systole “Lub sound” - The AV valves close (tricuspid, mitral)
● S2 - the second heart sound.
Diastole (“Dub sound”) Semilunar valves close (aortic,
pulmonic)
At Erbs Point - both S1 and S2 are heard well
Lungs step 1 - Best to assess in high fowler’s position
Step 1: Inspect
• Oxygen therapy-if any check for proper fit, liters of O2/FiO2, humidify)
• Work of breathing, breathing pattern; presence of accessory muscle use, dyspnea, or orthopnea
lungs step 2
• Tactile fremitus (vibration) – compare vibration while pt says 99
• Indirect measure of density of lung tissue
• Denser the tissue, stronger the vibration
• Solid mass> PNA w/consolidation > emphysema-air filled
• Thoracic excursion (expandability)
● symmetrical; normal 2-5in
● Limited excursion d/t shallow breaking
● Asymmetry d/t air obstruction, pleural effusion, pneumothorax
lungs step 3 - resonance
Percuss
• Resonance (hollow sound)- normal over lung fields
Normal lung sounds
STEP 4: Auscultate
Auscultate breath sounds comparing side to side
• (minimum 10-12 sites)
• Normal Breath sounds:
• Bronchial – Heard over larynx and trachea
• loud high pitched blowing hollow, tubular sound
• I > E (inhale and exhale probably)
Adventitious Lung Sounds (fine, of course, rhonda strides)
Crackles indicate inflammation or fluid filled lungs
Fine Crackles (rales) (better)
• popping, crackling sound
• high pitched
Coarse crackles (rales) (worse)
• Bubbling sound
• lower pitched than fine crackles
Rhonchi (even worse)
• Air passing through mucous and secretions in large airways
• May be cleared by coughing
• low pitched continuous, coarse snoring quality
Stridor (very dangerous)
• Narrowing of upper airway; Foreign body obstruction
• Harsh loud high pitched
ABDOMEN (Note the difference in order of exam, why?)
STEP 1: Inspection
(Special thing about abdomen is the order of how you listen or palpate)
• Position of umbilicus, visible hernia or pulsation, symmetry, lesions,
color of skin, presence of ecchymosis (this just means bruise), scarring
• Presence of tubes/drains/wounds
• Contour: Is it flat, rounded, distended, bulging, is there ascites?
Abdomen STEP 2: Auscultation (what is inactive?)
Listen to all 4 quadrants.
NORMAL
• Presence of sound (every 5-34 sec is normal)
• Use bell side to listen for bruit – may indicate narrowing of vessels
Hyperactive
• BS frequent in quantity, loud in quality
• ↑ gastric mobility with inflammation, anxiety, diarrhea, early bowel obstruction
• Borborygmi: rumbling or gurgling sound made by the movement of fluid and gas in the intestines
Hypoactive
• Infrequent < 5 sounds per minute
• Absent: can indicate obstruction or ileus
Absent
• Listen for >2min each quadrant before documenting absence of bowel sound
• May indicate obstruction or ileus
• Common immediate post-op
abdomen STEP 3: Percussion
(Advance practice)• Normal:
Tympany (drum like) indicates air in intestine
• Dullness suggests fluid or underlying organs like the liver & spleen
• Extremely high-pitched tympanic sounds = distention
• Extensive dullness=organ enlargement or mass
abdomen STEP 4: Palpation
STEP 4: Palpation• Start with light touch then deeper
• Palpate known tender area last
• Normal: Soft, relaxed, nontender
• Abnormal: mass, tenderness, pain, spasm (may indicate peritonitis, infection, tumors)
Genitourinary
• Foley present? Recently removed ?
• Check urine for color, clarity, sediments
• Pain with urination?
• If urine output is less than expected, perform a bladder scan
• Check genitals for edema, lesions, discharge
Musculoskeletal
Musculoskeletal
Back/Spine
STEP 1: Inspection
• ROM of spine
• Normal Curvatures of spine
• Normal forward curve of cervical
spine and lumbar spine
• Normal backward curve of
thoracic spine and sacral spine
Objective Data
Objective
• Information you can gather using your senses. It is either a
measurement or an observation.
• Information gathered during your head to toe exam is objective data
• VS, lab results, diagnostic imaging
Subjective data
Information from the patient’s perspective including feelings,
perceptions, concerns, Pmhx, family hx
Subjective data:
• My chest hurts
• I have been having diarrhea for 3 days
• I have a family hx of ovarian CA
• I feel bloated
• My pain is 10 out of 10
pupils
size measured in mm, use a pulillometer if uncertain
• Preventable Adverse Event (preventing the turn)
reasonable and prudent person would not carry out that error. failing to turn patient every 2 hours.
• Sentinel Event (sentinelly severe)
so severe that it can cause death or severe harm, permanent severe harm or temporary severe harm
• Never Event
events that should never happen, several ppl failing to turn patient and getting pressure ulcer, surgery on wrong limb. not monitoring patient who is at fall risk
vital signs - pain (PQRST D)
Frequency depends on unit
policy and pt status
P Provoking Factors
What factors precipitating the pain
Q Quality
Description of pain
R Region and Radiation
S Severity on a pain scale
T Time
How long
neurological - levels of sedation (sedation is LO in SC)
● Lethargic
● Obtunded
● Stuporous
● Coma
pulse grades
Pulse Grading:
• 0 absent (check with doppler)
• 1+ diminished/ weak
• 2+ normal
• 3+ increased
• 4+ bounding
• Clubbing
chronic hypoxia. Ex: pt with COPD: angle >160 degrees
• Koilonychia (nail) (Tu is koil)
spoon nail/ concave- iron deficient anemia, syphilis
• Paronychia
inflammation at side or base of nail
• Onychomycosis (0ynchi has fungus)
fungal infection
when does urine output require attention? (the numbers)
Urine output <30 or <240 mL/8 hours
• Borborygmi (rumble in bora bora)
rumbling or gurgling sound made by the movement of fluid and gas in the intestines
abdomen ausclatation - normal Presence of sound is every…
5-34 sec is normal
pain assessment - PQRST
P = provoking factors - what factors precipitate pain
Q=Quality - description of pain
R=region or radiation
S=severity on a pain scale
T = how long has it been present? what makes it better or worse?
3 parts of glasgow coma scale (glasgow is an emv - start w/ eyes)
eye, motor, and verbal
pulse grades 0 - 4
0 - absent (use doppler)
1 +- weak/diminished
2 + - normal
3 + - increases
4 + - bounding
when checking pulse, where should the arm be?
heart level
Accommodation - eyes (your glasses will accommodate your eyes)
how the eye looks at something far away, pupil wider when looking at something far away
Tactile fremitus (lungs) (your fremitus is vibrating)
means vibration
kyphosis (ky has kyphosis)
hunchback
• If measuring abdominal girth, do so at the
umbilicus
• Peristaltic waves indicates (during stomach exam)
intestinal obstruction
• Pulsation may indicate (during stomach exam)
aortic aneurysm
● Lethargic
drowsy, sleeps most of the time, woken by gentle shaking
● Obtunded (obtuse shake)
difficult to wake; woken by vigorous shake
● Stuporous (stupor)
cannot be aroused; responds to pain only
● Coma
no response at all, complete unconscious
when to use a doppler for pulse?
edema or vascular disease
