Health Assessment Exam 2 (4-7 Flashcards
Factors affecting safety
developmental considerations (children hazards increase as motor skills develop), lifestyle (occupation), environment (pollutants), mobility (older adults with unsteady gait), sensory perception (impacted sight/hearing)
Factors affecting safety pt 2
knowledge (awareness of safety precautions), ability to communicate (language barriers), physical health state (promote wellness while preventing accidents), psychosocial health state (stress can narrow persons attention)
Nursing assessment (safety)
identify patients at risk and unsafe situations
components of nursing assessment for pt risk and safety
nursing health history and physical examination
nursing health history analyzes (pt at risk and unsafe conditions)
Hx of falls of accidents (#1 indicator of future falls), use of assistive devices (walker), drug/EtOH abuse, family support and home environment (cluttered, lots of stairs, carpets)
physical examination (pt at risk and unsafe conditions)
assess mobility, assess communication, assess LOC, assess sensory perception, know signs of abuse/DV/neglect, assess environment
modifiable factors contributing to falls
lower body weakness, poor vision, gait/balance issues, feet problems, psychoactive meds, postural dizziness, home hazards
intrinsic factors contributing to falls
advanced age (solo is not a risk factor), PREVIOUS FALLS, muscle weakness, gait/balance problems, poor vision, orthostatic hypotension, chronic conditions, fear of falling
extrinsic factors contributing to falls
lack of handrails, poor stair design, no bathroom grab bars, dim lighting, tripping hazards, uneven/slippery surfaces, psychoactive meds, improper use of assistive devices
questions to ask patients
have you fallen in the past year? do you feel unsteady when standing or walking? do you worry about falling?
Morse fall scale
0 = no risk, <25 = low risk, 25-45 = implement standard fall prevention, 46+ = implement high-risk fall prevention
safety considerations for the older adult (characteristics)
impaired eyesight, decreased proprioception and balance, slower reflexes, impaired hearing, decreased sensitivity to touch, impaired thermoregulation, decreased flexibility/strength = weakness
fall prevention methods
patient teaching, orientation to unit (call bell, bathroom, bed alarm), use side rails, bed lowest position, bed locked, slipper socks, eliminate environmental hazards, indicate fall risk on door and in record
Fire safety
RACE
fire safety R
rescue anyone in immediate danger of the fire
fire safety A
alarm; pull the nearest fire alarm and call fire response
fire safety C
contain fire by closing all doors in the fire area
fire safety E
extinguish small fires; if not leave the area and close the door
types of restraints
physical and chemical
physical restrains can…
increase risk of falls,
negative outcomes of restraint use
falls, skin breakdown, contractures, incontinence, depression, delirium, anxiety, aspiration/respiratory difficulties, death
safe restraint use
hitch knot for quick release, tie to frame of bed or wheelchair, keep call bell within reach, reassess frequently, release every 2 hours for ROM, assess skin integrity, assess mobility, assess tightness/circulation (2 fingers)
can you apply physical restraints without an order?
yes in an emergency, but get provider order ASAP; need new order every 24 hours
definition of self-care
activities of daily living, instrumental activities of daily living, any neurological impairments that will affect ability to care for self
ADLs
BATTED; bathing, ambulating, toileting, transferring, eating, dressing
IADLs
grocery shopping, running errands, using the phone
Principles for providing hygiene
determine patient preferences, assess ability to assist (maintain highest level of function; encourage independence), assess activity tolerance, respect person space and ways of doing things
factors affecting self care
health state, developmental level, socioeconomic status, culture, personal preferences
early morning pt care
assist pt with toileting, provide measures to refresh/prepare pt for day, wash face and hands, provide oral care
partial care
patient is able to help with atleast one taks
total care
patient is unable to help at all
afternoon care
- toileting assistance, handwashing, oral care 2. straighten bed linens 3. help patient with mobility to reposition self
hours of sleep care
toileting washing oral care, back massage, change soiled bed/linens, position pt comfortably, ensure call light and other required objects in reach
Skin assessment
assess daily, use pH balanced no-rinse cleanser, mild soap, avoid hot water, avoid friction/scrubbing, use moisturizers (not between toes of diabetic)
therapeutic affects of bathing
removes dirt/bacteria, stimulates circulation, improves joint mobility, provides assessment opportunity, provides opportunity for positive cline-nurse interaction, relaxation and comfort, sense of wellbeing
method to bathe pt
clean to dirty; one wipe for each section: 1. face, neck, chest 2. left arm 3. right arm 4. perineum 5. left leg 6. right leg 7. back 8. buttocks
hair care
shower cap with dry shampoo in it; soap and water in bed with basin below head (full shower)
oral care (unconscious)
face pt toward nurse lying on side; every 2 hours to prevent VAP, dont use toothpaste (dry brush or sponge)
oral care conscious
encourage pt to brush own teeth if possible and assist if unable to; remove dentures and brush/clean over sink
nail care
file only (no clippers), orange sticks for cuticle care, soaking to soften
ear care
cleanse pinna or auricle, no Qtips, debrox for ear irrigation
perineal care
female- front to back and cleanest to dirtiest; male- tip from center out and then down the shaft
Type of movement: bend over and touch toes
flexion
Type of movement: stretching head back towards butt
extension
Type of movement: oblique crunch to one side
lateral flexion
Type of movement: turning at the waste to see behind you
rotation
Type of movement: moving shoulders forward
forward rotation
Type of movement: pulling shoulders back
backward rotation
Type of movement: shrugging shoulders
elevation
Type of movement: pushing shoulders down
depression
Type of movement: arms out in front lifting up in front
flexion
Type of movement: pushing arms down (lat pull over)
extension
Type of movement: arms out in circular motion (from side to overhead)
abduction; moving away from body
Type of movement: crossing arms in front of body
adduction
Type of movement: twisting foot away from body
external rotation
Type of movement: turning foot toward body
internal rotation
Type of movement: curling heel to butt (hamstring curl)
flexion
Type of movement: straightening of leg (quad extension)
extension
Type of movement: curling toes to shin bone
dorsi flexion
Type of movement: pointing toes
plantar flexion
Type of movement: rolling foot at ankle inward towards body
inversion
Type of movement: rolling foot at ankle away from body
eversion
3 types of muscle
cardiac, skeletal, smooth/visceral
cardiac muscle
branched, uninucleated, involuntary movement
skeletal muscle
striated, attached to skeleton, voluntary, tubular, multinucleated
smooth/visceral
non-striated, involuntary, spindle, covers organs, uninucleated
articular structures
joint capsule, articular cartilage, synovium, synovial fluid, intra-articular ligaments
extra-articular structures
tendons, bursae, muscle, fascia, bone, nerve, overlying skin
ligaments
rope like bundles of collagen fibers; connect bone to bone
tendons
collagen fibers connecting muscle to bone
cartilage
collagen matrix
bursae
pouches of synovial fluid; cushion movement
muscle health history
joint pain, low back pain (OPQRSTI), neck pain, bone pain, mucsle/cramps/weakness
muscle physical exam
skeleton: symmetry, contour; gait: steady/unsteady; skin: color, edema
joints
where 2 bones meet
passive range of motion
patient has limitations; anchor joint with one hand and use other hand to move joint
active range of motion
patient can perform independently
factors affecting movement and alignment
overall physical health, muscular/skeletal/nervous system problems, mental health, respiratory issues, cardiac issues, negative nitrogen balance, lifestyle, environment, attitude/values
types of exercise
isotonic, isometric, isokinetic
isotonic exercise
muscle contracts and shortens + active movement ; joint angle changes
isometric exercise
muscle contraction without shortening; joint angle and muscle length do not change during contraction; no moving or bending of joints (ex:planks)
isokinetic exercise
muscle shortens with resistance applied; resistance provided at constant rate by external device
protective positions
fowlers, low/semi fowlers, high fowlers, protective prone, supine, prone, Sims, side lying/latera
fowlers position
45-60 degree angle; optimal for thoracic lung space; butt bears brunt of weight; heels, sacrum, scapulae are at risk for breakdown
low/semi fowlers
30 degrees; decreased pressure on lower back
high fowlers
90 degrees; good for eating
how often to reposition patients
every 2 hours
sims
pt lies on side, lower arm behind pt, upper arm flexed at shoulder and elbow out in front; main body weight on humerus, clavicle, ilium
side lying/lateral
lying on side; main bodyweight on lateral aspect or scapula and ilium; relieves pressure or scapulae, sacrum, heels
tredelenburg
feet higher then head
immobility consequences
decreased muscle size/tone/strength, decreased endurance/stability, bone demineralization, decreased joint mobility/flexibility, increased risk for fractures, increased risk of foot drop
decreased skin integrity d/t immobility
pressure sores (decubitus ulcers)
cardiovascular and respiratory consequences of immobility
increased cardiac workload, risk of orthostatic hypotension, risk of thrombus formation, decreased lung expansion, decreased rate of respirations, secretion pooling, impaired gas exchange
nutrition/metabolic consequences of immobility
decreased appetite, decreased metabolic rate
GI and urinary consequences of immobility
constipation d/t decreased GI peristalsis, increased risk of urinary stasis, increased risk of renal calculi, decreased smooth muscle tone
mental status consequences of immobility
increased powerlessness, decreased sensory stimulation, decreased social interaction, altered sleep-wake cycle, increased risk for depression
why are patients risky
cant be held close to body, bulky, no handles, unpredictable
why are nurses at risk
frequency, force, position, and duration
nursing key body mechanics
wide base, feet wide knees bent back straight, utilize muscles in legs, work at proper height, face direction of movement, keep pt close to body
repositioning methods
use draw sheet, friction-reducing sheet, hoyer lift, stand aid machine, air assisted mattress
before ambulating pt
determine distance prior to standing, assess for weakness/dizziness, non-slip footwear on pt, use gait belt, stand to side and slightly behind (on pt weaker side)
ambulation with a walker
place walker directly in front of pt, stand to side and slightly behind, pt move walker forward sets it down then step toward (one leg at a time); start with weaker foot first
ambulation using cane
hold cane on stronger side, nurse on weaker side and slightly behind
cane walking steps
- advance cane, 2. advance weaker side, 3. advance stronger side, 4. advance cane
nurse education requirements of medication
actions and indications, appropriate dosage, administration guidelines, drug-drug interactions, contraindications and cautions, nursing considerations (teaching), therapeutic effects, adverse drug effects, therapeutic range
know your pt for meds
medical history (why giving med), medication history (interactions), allergies, check the MAR, diet and fluid orders, lab values
10 pt rights
right drug, right dose, right patient, right route, right time, right documentation, right reason, right assessment data, right response, right education, and right to refuse
3 checks for med administration
when pulling med out, when preparing med for administration, when at the bedside
medication pre-administration assessment
patient identification (need 2 identifiers), patient assessment (ability to swallow, relevant body system assessment, vitals)
medication documentation
document as soon as given, document reason not given if indicated, document response to med
medication pt education
purpose of med, dose of med, time of admin., potential side effects, when to discontinue med, when meds need to weaned down prior to stopping, what adverse effects to report
name of drugs
generic name (chemical name derived), trade name (advil), chemical name (FDA publication)
drug classification
pharmaceutical (MOA, chemical structure, physiological effect) and therapeutic (antipyretic, antiemetic)
drug schedules
schedule I- schedule V; most narcotics are schedule II; based on abuse potential and medical usefulness (marijuana schedule I)
components of a drug order
pt name and other identifier, date and time order written, medication name, med. dose, route of admin., frequency of admin, signature of provider
example of drug order
Tylenol 650mg PO q4h prn for john smith
types of orders
routine/standing, PRN, one time order, STAT, repeat
PRN
pro re nata; used when med is requested, required, or specifics of order are met (ex: analgesics, anti-emetics, sleep aids); professional judgement calls
dose conversions
1g = 1000mg; 1000mg = 1,000,000 mcg; 1000mcg = 1mg; 1kg = 2.2lbs; 1mL = 1g; 1000mL = 1L; 1 mL = 15gtts; 5mL = 1tsp; 15mL= 3tsp =1tbl; 30 mL = 1 fl oz; 240mL = 8 fl oz = 1cup; 16oz = 1lb
drug calculations
dose on hand/ quantity on hand = dose required/X (quantity desired)
general administration guidelines
hand hygiene before and after, open at bedside and poor into cup, prep. 1 pt at a time, never admin. a med prepared by someone else, do not allow interruptions, double check calculations, dont use unmarked or illegible containers, be aware of changes in liquid clarity and sediment, administer within +/- 1 hour of designated time
PO administration
oral, sublingual, buccal; tabs, capsules, caplets, spansules, liquids, suspension; make sure pt can swallow; remain with patient while taking meds
do not _____ medications because it will alter rate of absorption
crush
transdermal administration
used for hormones, narcotics, cardiac, nicotine; slow onset but maintain consistent serum levels; avoid touching med (wear gloves); not date & time & initials on patch; rotate sites
why is it important to rotate sites for transdermal?
avoid skin irritation
topical skin meds
apply with sterile swab, tongue depressor, or gloved fingers (ex: nitroglycerin)
opthalmic medications
eye drops, ointment, or disks; administer in lower conjunctival sac and apply pressure on inner canthus; do not rub eyes; where gloves and avoid touching eye with dropper
otic medications
turn head to unaffected side, ensure drops at room temp., pull up and back for adults and down in children (<3); massage tragus after admin., wait 5 minutes before admin. in other ear; wear gloves
nasal spray medications
wear gloves; have pt sit up and tilted back, agitate bottle gently, close opposite nostril and instruct pt to breath in while you compress bottle gently
rectal medications
suppositories/enema; wear gloves, place pt on left side, lubricate med; insert past internal rectal sphincter against rectal wall (will feel uptake); have pt remain on side for 5 minutes
vaginal medications
foams, jellies, liquids, creams, tablets, suppositories; don gloves; pt on back with knees flexed; perform perineal care front to back, change gloves again, insert med using applicator or gloved hand and instruct pt to stay supine for 5-10 minutes
parenteral administration routes
intramuscular (90 degrees), subcutaneous (45-90 degrees), intradermal (15 degrees)
when combining from vial and ampule…
draw from vial first
when drawing from single dose vial and multi-dose vial…
draw from multi-dose vial first
limited compatibility
can be given 15 minutes after the next one
injection guidelines
let patient control which side, position to reduce muscle tension, divert clients attention
leg site injections
pt should sit or lie down
gluteal site injections
lie on abdomen or side
rounding guidelines
dosage less than 1.0, round to nearest 100th; dosage is more than 1.0, round to nearest 10th
preventing needle stick injuries
never leave syringe at bedside, never place syringe in pocket, never cap bend or break, cannot recap contaminated needles
needle selection
use shortest length and smallest gauge; length depends on muscle mass/adipose tissue (1/4in -3in); diameter (gauge) lower number = larger diameter, gauge choice depends on viscosity of fluid
tuberculin syringes
maximum 1mL; calibrated by 1/100; 25-27 gauge and 1/4-1/2 inch needle
standard syringes
3mL or 5mL; calibrated by 0.1 and 0.2 respectively
insulin syringe
marked in units; small does use U30 and U50; U100 is most common and equates to 1 mL; non-detachable needle 28-30 gauge and 1/2-5/8 needle
intradermal injection
used for PPD or allergy testing; use tuberculin syringe; give into dermis (forearm, upper back, under scapula); 25-27 gauge, 1/4 or 1/2 inch, 5-15 degree angle; 1 mL syringe
intradermal technique
bevel up, insert at 5-15 degree, inject to form wheal or bleb, remove needle after brief delay; DO NOT MASSAGE
subcutaneous injection
45-90 degrees; small doses (max 1mL), absorbs slower than IM; use 25-30 gauge and 3/8 or 5/8 needle
subcutaneous technique
abdomen (fast and 2’’ from umbilicus), upper arms, anterior thighs, gluteal (slowest); hold pinch skin and release after needle inserted
needle length based on subcutaneous tissue
if you can grasp 1in choose longer needle and insert at 45 degrees; if you can grasp 2+in use shorter needle and insert at 90 degrees
insulin injection
only use insulin syringes, agitate syringe by rolling in hand (never shake); observe sites for lipodystrophy; abdomen best for absorption
when mixing insulin
- inject air into longer acting (opaque) without allowing needle to touch insulin 2. inject air into fast acting (clear) without allowing to touch insulin 3. draw up clear insulin 4. draw up opaque insulin
administering heparin
SC injection at 90 degree, use small gauge needle (25-28), use 5/8 -7/8 needle length, measured in 10000 U/mL, preferred site is abdomen; DO NOT RUB; pinch gently during injection
intramuscular injection
muscle layer is more vascular = absorbed faster than SC/ID, used for irritating/viscous/oily preps, use 3mL syringe, 18-25 gauge, 5/8-3in; do not give mor than 3mL in one injection; inject at 70-90 degrees; inject slowly
z tracking
recommended for all IM injections to prevent back flow; pull skin to one side, insert needle, inject med, release displaced tissue, withdraw needle
deltoid
recommended adult site (>3), vaccine admin., rapid absorption; max of 1mL; use 5/8-1.5in needle
deltoid landmarks
palpate lower edge of acromion process, 2 fingers below, upside down triangle, inject in the center
vastus lateralis
safe for everyone (toddler/infant preferred); divide anterior thigh into 3 equal parts and inject into outer middle third; use 5/8-1in; ~3mL injection
ventrogluteal
recommended site for adults; free of major blood vessels and nerves; preferred for viscous irritating fluids; use 1.5in needle; ~3mL injection
ventrogluteal landmark
palm on greater trochanter, index finger on anterior superior iliac spine, middle finger on iliac crest, inject in between middle and index fingers
