IM1- Exam 3 Material Flashcards
Before you begin your head-to-toe assessment what are some things you should consider?
Age group
organization of the assessment
What is the single most important neuro assessment component?
LOC–> level of consciousness
Why is the level of consciousness one of the most important components of the neuro exam?
It is often the first clue of a deteriorating condition.
When we are testing LOC what are some of the things we are looking for?
Alert: attentive, follows commands, if asleep - wakes promptly and remains attentive
lethargic: Drowsy but awakens, slow to respond
obtunded: difficult to arouse, need constant stimulation
stuporous/semi-comatose: arouses only to vigorous/noxious stimuli
comatose: no response to verbal or noxious stimuli, no movement except deep tendon reflex.
When should you start looking/testing for LOC?
The moment you walk into the patients room.
True or false: there is special testing for observing a patients LOC
False
What is cognitive awareness?
Finding out if the patient is oriented to person,place, time and event
What is cognitive awareness also known as?
Mentation
What questions can we ask to test a patient cognitive awareness?
- What is your name and DOB?
- Where are you right now?
-What year/day is it? - What has brought you to the hospital?
When asking a patient their name and date of birth you are testing that they are oriented to what?
Person
When asking a patient where they are you are testing that they are oriented to what?
Place
When asking a patient what year/day it is you are testing that they are oriented to what?
Time
Why is asking a patient what day it is not as effective as asking what year when testing their cognitive awareness?
Often times when a patient is in the hospital an extended period of time patients become confused.
When testing Cranial nerves III, IV and VI what are we testing for?
Pupil response and cardinal gaze
When we are assessing pupil responses what are things we are assessing
size and shape of pupils and compare to scale
How do we do our pen light exam when assessing pupil response?
1.Start at ear with penlight and move in toward nose
2. Note change in size and speed and reaction
3. With penlight off, move penlight close to and away from pupils
How do we do our pen light exam when assessing the cardinal gaze
- use tip of unlit penlight
- have patient follow with eyes only
- about 9-12” from face, move the end of penlight in an H motion
How can we test cranial nerve VII?
Ask the patient to smile and show teeth
Ask patient to wrinkle forehead or raise eyebrows
What could be the reason a patient is unable to wrinkle their forehead or raise there eyebrows
They have had botox
What could you detect when asking a patient to smile showing teeth?
Facial Droop
How can we have a patient test cranial nerve XII?
-Ask patient to touch the roof of mouth with tongue
- protrude tongue out of mouth
- move tongue side to side
How can we test cranial nerve Xl?
-Place hands lightly on patient shoulder
-Ask the patient to shrug shoulders
Remember– you do not need to put all your weight down just enough to have a small amount of resistance.
True or False: Testing motor function is part of both the neuro and musculoskeletal assessments?
True- Remember we will complete the motor function as part of our neuro exam
What are ways we test a patients motor function?
- hand grasp & toe wiggle (HGTW)
- Flexion and extension w/resistance
When we are testing hand grasp, toe wiggle, flexion and extension during our motor function exam we want to perform this exam bilaterally on _____ and _____
Bilateral upper extremity (BUE)) and bilateral lower extremity (BLE)
True or false: We want a patient to have a weak grip during our motor function test?
False
What are the 7 components of the Neuro assessment?
- LOC and orientation
- Pupil response and Cardinal gaze
- Smile and show teeth, raise eyebrows
- tongue to roof of mouth, out, side to side
- shoulder strength with resistance
6.HGTW
7.Flexion/extension BUE and BLE
What are the 3 normal sounds of the lungs?
- Vesicular- Periphery of the lungs
- Bronchovesicular- closer to the sternum
- Bronchial- over trachea
True or false: different areas of the lungs have different qualities of sound?
True
What are some abnormal or adventitious lung sounds?
- Crackles or rales–> can be fine or course
- Rhonchi
3.Wheezes - Pleural friction rub
Describe what a crackle or rale may sound like?
Similar to milk being poured over rice crispies
high pitch
Where are you likely to hear crackles or rales in your patient
base of the lung
What is one of the most common causes for crackles or rales in your patient?
Fluid collection in lung
Describe the lung sound– Rhonchi
Rumble
Where are you likely to hear rhonchi and why?
Over the trachea and bronchi due to large secretions in the airway
What typically helps eliminate rhonchi lung sounds?
Having the patient cough.
Describe the lung sound– Wheezing
High pitched musical sound
Is wheezing more common during inhalation or exhalation?
Exhalation– HOWEVER in really severe cases it can be heard during inhalation
What are some common causes of wheezing?
Asthma, COPD, emphysema
Describe the lung sound: Pleural Friction Rub
Like a piece of cloth moving over a mic
Why might a patient have pleural friction rub lung sound?
They may not have fluid between the plural cavity and lung, so it is being rubbed together.
Name some abnormal respiratory patterns
- Bradypnea
2.Tachypnea - apnea-
4.Hypernea (breathing in more air than you normally do) - Kussmaul’s (fast, deep breaths that occur in response to metabolic acidosis)
- Cheyne- stokes (periodic breathing— gradual increase then decrease in breathing followed by a period of apnea)
Take this time to review pattern of auscultation (sorry guys I am too broke to pay to add pictures lol)
take this time to review pattern of auscultation
Why is there seven auscultation spots on the anterior side of the body?
Because there is another lobe on the right side.
For each area that you auscultate for breath sounds how long should you listen for?
1 inspiration and expiration
When auscultating for lung sounds should you ever go below the ribs?
No- because you have passed the lungs at that point
What are the two components of the Respiratory assessment?
- Anterior and posterior lung sounds
- Clubbing
What is the Lub of heart sounds?
Systole or S1 and is the sound associated with the closing of the mirtal/tricuspid valves
What is the Dub of hear sounds?
Diastole or S2 and is the sound associated with the closing of the aortic/pulmonic valves
Describe the pauses between the lub s1 and dub s2
There are natural pauses between s1 and s2 as well as between s2 and s1 but there should be a longer pause between s2 and s1
Lub dub counts as how many heart beats?
1
What is a good pneumonic to remember location of heart sounds?
All party till midnight—
A- aortic
P- Pulmonic
T-Tricuspid
M-Mitral
Where is the aortic heart sound located?
Right base; second intercostal space to the right of the sternal border
Where is the pulmonic heart sound located?
Left base; second intercostal space to the left of the sternal border
Where is the tricuspid heart sound located?
Left lateral sternal border; fifth intercostal space to the left of the sternal border
Where is the mitral heart sound located?
Apex; midclavicular line at the fifth intercostal space
When listening to heart sounds how many cycles are we listening two before moving to the next location?
Two
What is another name for the mitral hear sounds?
Apical pulse
What are the four pulse sites we need to know for a head to toe assessment?
- Carotid- 1 at a time, bilaterally
- Radial- bilaterally at the same time
- Apical - with a stethoscope for 2 beats
- Dorsalis Pedis- bilaterally at the same time
Why do we sometimes assess a pulse bilaterally at the same time?
We are testing for quality of pulse— is the beat happening at the same time on each side
Describe pulse quality starting with 0 and ending at 4+
0- absent- non palpable
1+ – Weak/Thready diminished, palpable
2+ — strong, normal
3+ —Full, increased
4+ — Bounding
If you ever have to use a doppler to find a pulse you want to make sure you always do what?
Document
What are the 6 components of the Cardiac Assessment
- heart sounds
- carotid pulses
- Radial pulses
- Pedal pulses
- Capillary refill
- Assess for Edema
During our cardiac assessment how do we assess the extremites?
- Capillary refill
- Edema– Swelling in the extremities
During our cardiac assessment we test capillary refill explain how we do that?
Press skin of nailbed to produce blanching, release pressure and observe time taken for color to return, should be less that 2-3 seconds, BUE and BLE
What could affect your ability to test for capillary refill?
Artificial nails/nail polish
If you can not assess the capillary refill using the nail bed how else can you assess
By using the tip of the extremity
True or false: cold can affect capillary refill?
True
What are the two types of edemas we assess during the cardiac assessment
1.Dependent edema
2. pitting edema
Where is dependent edema most often found and on who?
Feet and ankles and older adults standing
What is the main causes for pitting Edema?
Venous insufficiency or heart failure, fluid in tissues
What areas do we assess with ROM? (range of motion)
- neck
- shoulders, upper arms & elbows
- wrists
4.hips - knees
- Ankles
When assessing a patients ROM of the neck what will we have them do?
- Move neck side to side
- chin to chest
- extension back (front to back)
When assessing ROM of the shoulders, upper arms and elbows what will we have a patient do?
- Arms out to side
- arms straight up
- touchdown.
When assessing ROM of the wrists what will we ask our patient to do?
Wrist circles
When assessing ROM of the hips, knees and ankles what will we ask our patients to do?
- Bilateral hip flexion out
- bend knees
- ankle circles
What are the 5 components of the musculoskeletal assessment?
- Neck ROM
- BUE ROM
- BLE ROM
- HGTW–done in neuro
- Flexion/extension BUE and BLE— done in neuro
During the integument specific health assessments, we will be assessing the skin from head to toe for what?
- hydration
- temp
- color
- texture
- rashes
- lesions
- cracking
During the integument specific health assessments, we will be assessing the skin from head to toe looking for changes in color. What are some of the color changes we may see? list 4 and what they are
- Pallor- Pale or ashen gray
- Erythema– redness r/t vasodilation
- Jaundice– yellow, impaired liver
- cyanosis– bluish, decreased circulation or oxygenation of blood
Other than the skin where else on the body could you look to see if a patient is jaundiced
Scalera of eye
What are some common skin characteristics that can offer clues to health status? List 4.
- Temp should be warm, consistent with room temp
- Moisture from diaphoresis or dry from dehydration
- Texture can be dry & course (elbows & Knees) or shiny with no hair (impaired peripheral circulation)
- Turgor tests elasticity of the skin related to hydration
True or false: some illness can affect our skin texture?
true
What are some factors that can affect the skin? list 7
- dampness
- dehydration
- nutrition
- Circulation
- Disease
- Jaundice
- Lifestyle
What are some normal skin changes in older adults? List 9.
- Epidermis–> becomes thinner/paler/translucent
- Subcutaneous Tissue–>offers less protection (why old people are colder)
3.Collagen & Elastin fibers–>More prone to wrinkles
- Hormones–> lack of hormones can lead to dry and thinning hair
- Vascularity –>Microcapillaries become less on surface of skin–> can lead to coolness of skin
- Hair follicles–> slower growing and diminish in numbers/activity
- Melanocytes–> what gives our skin pigment–> decreases which causes our skin pigment to become uneven and our hair to gray
- Nails–> become thicker and softer or really think and hard
- Skin growths–> Warts and liver age spots increase
What causes pitting edema?
Kidney or heart failure because it leads to excess fluid collection in the tissue
How can you determine the severity of pitting edema
Four-point scale, degree and response
With pitting edema— describe the four-point scale, degree and response for each level.
- Four-point scale: 1+
Degree: 2mm to trace
Response: Rapid response - Four-point scale: 2+
Degree: 4mm to mild
Response: 10-18 seconds - Four-point scale: 3+
Degree: 6mm to moderate
Response: 1-2 mins. - Four-point scale: 4+
Degree: 8mm to severe
Response: 2-5 Mins
When we are doing our assessment of bony prominences what are we looking at and for what?
- Hips, heels, coccyx, shoulders
- Assess for skin integrity
- Blanching red spot
What are we observing when doing our nail assessment?
- shape
- contour
- cleanliness
- neatly manicured/trimmed
What should a nail look like?
- transparent
- smooth
- Rounded
- Convex
- Hygienic
When we are assessing a patient’s hair what are we looking for
- Terminal Hair
- Vellus hair
- Quantity
- Distribution
- Texture
- Color
- Parasites
When assessing for terminal hair during the hair assessment what areas are we looking at?
Scalp, axillae, pubic and beard
What is vellus hair?
Soft tiny hairs covering the body except on palms and soles
When assessing the hair quantity what are somethings we may look for?
Alopecia (abnormal hair loss) & hirsutism (abnormal hair growth)
When assessing a patients ear what are things we are looking at? list 8
- Symmetry
- drainage
- Shape
- Hearing defects
- lesions
- Redness
- tenderness
- Odor
When assessing a patients nose what are some of the things we are looking for/at?
1.position
2.symmetry
3.Color
4. swelling
5.Deformities
6. Discharge
7. flaring
8. patency,
9. Sinus tenderness
When we inspect the patients oral cavity what are we looking at/for? list 5
1.lips
2.oral mucosa
3.teeth
4.gums/tongue
5. breath odor
When inspecting a patients throat what are we looking for/at? list 6
1.Lumps
2. ulcers
3. edema
4. white spots
5. redness
6. swollowing
When inspecting a patients throat what are we looking for/at? list 6
1.Lumps
2. ulcers
3. edema
4. white spots
5. redness
6. swallowing
When assessing a patients neck what are we looking for/at?
1.Contour & symmetry,
2. midline trachea,
3. jugular vein distention
When assessing a patients neck we will also need to palpate the neck to check for inflamed/enlarged lymph nodes… take a moment to review where to palpate using the power point from lecture
Review power point
What are the components of the integument assessment? list 9
- Inspect hair and scalp
- inspect ears
- inspect nose
- inspect mouth and throat
- inspect and palpate neck
- assess skin turgor
- inspect skin on back and bony prominences
- inspect skin of BUE and BLE
- Inspect nails
What does Elimination mean (bowel definitions)
Excretion of waste products from kidneys and intestines
What does defecation mean?
Process of elimination of waste
What does feces mean?
semisolid mass of fiber, undigested food, inorganic matter
What does incontinence mean?
Inability to control urine or feces
What does void mean (urinary definitions)
To urinate
What does micturate mean?
To urinate
What does dysuria mean?
Painful or difficult urination
What does hematuria mean?
blood in the urine
What does nocturia mean?
frequent night urination
What does polyuria mean?
Large amounts of urine
What is urine frequency?
Voiding at frequent intervals
What is urinary urgency?
The need to void all at once
What is proteinuria?
Presence of large protein in urine
What is dribbling?
Leakage of urine despite voluntary control of urination
What is retention (urinary definitions)
Accumulation of urine in bladder without the ability to completely empty
what is residual (urinary elimination definitions)
Urine remaining post void > 100ml
What are the structures of the gastrointestinal tract ? list 4
1.Upper GI tract
2. Small intestine
3.Lg intestine
4. Rectum and anus
What are some characteristics of the small intestine? list 5
- Folded, twisted and coiled tube from stomach to lg intestine
- 1” in diameter and 20’ long
- Most digestion and absorption happens here
4.CHyme travels via peristalsis - 3 segments– duodenum, jejunum, and ileum
What are the 3 segments of the small intestine?
Duodenum, jejunum and ileum
Where does most digestion and absorption occur in the body?
Small instestine
Where does most digestion and absorption happen in the body?
Small intestine
What is the measurements of the short intestine
1” in diameter and 20’ long
Of the 3 segments in the small intestine which is the largest?
Jejunum
What is chyme?
Partially digested food mixed with stomach acid
Of the 3 sections of the small intestine which is the 1st section?
Duodenum
Of the 3 sections of the small intestine which is the 2nd sections
Jejunum
Of the 3 sections of the small intestine which is the 3rd section and connects to the lg intestine?
Ileum
What is the large intestine also known as?
Colon
What are the measurements of the large intestine?
2.5” diameter and 5’6 long
What are the seven segments of the large intestine?
1.Cecum- illuem attaches to
2. ascending colon
3.transverse colon
4.descending colon
5. sigmoid colon,
6. rectum
7. Anus
What are the functions of the kidneys in terms of urinary elimination?
- Filter and regulate
- Remove waste from blood to form urine
What are the functions of the ureters in terms of urinary elimination?
Transport urine from kidney to bladder
What are the functions of the bladder in terms of urinary elimination?
Reservoir for urine until the urge develops
What are the functions of the urethra in terms of urinary elimination?
Urine travels from bladder and exits through urethral meatus
Where are the kidneys located and about how big are they?
Bilateral, posterior flanks and they are the size of fists.
True or false: Kidneys are the primary regulators of fluid and acid-base balance
True
Name some of the parts that make up the kidney?
- Nephron- functional unit of the kidney
2.glomerulus
3.bowman’s capsule - proximal convoluted tubule
- Loop of henle
- distal tubule
- collecting duct
True or false: Ureters have tubule structures that enter the bladder?
True
True or false: Urine traveling through ureters is typically not sterile?
False
How do the ureters enter the bladder and why?
Obliquely and posteriorly to prevent reflux
True or false: obstructions cause peristaltic waves and severe pain often referred to as renal colic?
True
True or false: The bladder is hollow, distensible, and muscular?
True
In men where is the bladder located?
The bladder lies against the anterior wall of the recturm
In women where is the bladder located?
The bladder rest against the anterior wall of urterus and vagina
When is the bladder considered full?
When it extends above the symphysis pubis
How many ml can fit in a normal bladder? and how much can it extend to?
500ml but can extend to 1000ml
True or false: The turbulent flow does not wash urethra free of bacteria?
False
True or false: the urethra descends through the pelvic floor muscle.
True
True or false: the contraction of pelvic floor muscles cant prevent flow or urine
Flase
True or false: the contraction of pelvic floor muscles cant prevent flow or urine
False
what is the size of womens urethra?
urethra is short (1 1/2 to 2 1/2 in) – because it is so short it is a common reason why women get UTI easier than males
What is the size of a mens urethra?
Urethra is long (8in), serves in both GU and reproductive system, three sections: prostatic, membranous and penile.
In what order do you do the abdomen assessment
- Inspection (look)- observe size, shape, contour, skin integrity
- Auscultation (listen)- bowel sounds, four quadrants– listening for normal, hypoactive hyperactive
- palpation (feel)– palpate for tenderness, pain, masses
During the assessment of the abdomen what are things you should ask about?
- Normal bowel and urine patterns
- appearance
- changes
- history of problems
During the urethral meatus and perinea area assessment what are we looking for/at?
- inspect urethral orifice for erythema, discharge, swelling or odor
- signs of infection, inflammation, or trauma
- perineal area: color, condition, presence of urine or stool
What are the components of the GI/GU assessments?
- Examinations of abdomen – look, listen, feel
- ask questions about habits
- examinations of urethral meatus and perineal area
What are the ANA standards for documentation?
- Relevant data: accurately and in a manner accessible to the interprofessional team.
- problems and issues in a manner that facilitates the determination of the expected outcomes and plan
- Expected outcomes as measurable goals.
- The plan using standardized language or recognized terminology
- Implementation and any modifications, including changes or omissions, of identified plan.
- The coordination of care
- the results of the evalution
- Nursing practice in a manner that supports quality and performance improvement initiatives
What do a patients record contain?
- Patient identification and demographic data
- informed consent for tx and procedure
- admission data
- Nursing dx or problems
- care plans
- record of nursing care tx and eval
- medical history
- medical dx
- therapeutic orders
- progress notes
- physical assessment finding
- diagnostic study findings
- patient education
- summary of operations
- discharge plan and summary.
True or false: therapeutic orders are part of a patients record
True
What are the purpose of records?
Includes
1. Communication
2. legal document
3. reimbursement compliance
4. education
5. research
6. auditing and monitoring supports compliance with standards of care.
True or false: The chart is a very persuasive witness because it is the description of the facts at the time?
True
Why is communication important to a patients record?
Allows everyone to be on the same page
True or false: Communication is multi-displinary?
true
True or false: communication is critical for continuity and risk reduction?
True
What are some of the things that we can communicate in regards to patient?
- current status/needs.
- progress
- therapies
- consultations
- education
- discharge planning
Documentation should be what?
- factual
- accurate
- complete
- current
- organized
What are some components of factual documentation?
- objective
- descriptive
3.subjective (quotes)
What should you never include in your documentation?
Assumptions or opinions
What should accurate documentation include?
- Exact measurements
- clear
- understandable
- standard abbreviation only
- timed, dated with signature and title
- correct spelling
Complete documentation should include?
Condition changes
-onset, duration, location, description,
precipitating factors, behaviors,,,
Communication with patient and family
True or false: do not leave blanks… use n/a…
True
Anyone reviewing the chart must be able to understand an accurate, clear and comprehensive picture of:
- Patient needs
- nurse’s interventions
- patient outcome
Should you pre-date, pre-sign or pre-chart on a patient chart?
No because this is considered illegal falsifcation of the record
Should you pre-date, pre-sign or pre-chart on a patient chart?
No because this is considered illegal falsification of the record
Documentation should be organized how?
- chronological order
- concise
- clear
- to the point
- complete sentences not needed
What terms should you avoid using?
- accidently
- apparently
- appears
- assume
- confusing
- could be
- may be
- miscalculated
- mistake
- somehow
- unintentionally
- normal
- good
- bad
What are some documentation “don’ts”?
- Don’t document a patient problem w/o charting what you did about it
- Don’t alter a patient’s record - this is a crime
- Don’t write imprecise descriptions, such as bed soaked, large amount…
- Don’ chart what someone else heard, felt or smelled unless information is critical. Use quotations and attribute remarks appropriately
- Don’t chart care ahead of time. It’s fraud.
What are some common formats of documentation?
- Narrative
- Problem- intervention- evaluation (PIE)
- SOAP/SOAPIE/SOAPIER
- DAR
What does a narrative format include?
- Written in order of patients’ experience happens.
- Provides details of patient’s care, status activities, nursing interventions, psychosocial context and response to treatment.
- charting by exception
What does a problem-intervention- evaluation (PIE) format include?
- nursing focused instead of medical focused and eliminates need for separate care plan
What does SOAP/SOAPIE/SOAPIER format include?
- Subjective data,
- Objective data,
- Assessment,
- Plan,
- Intervention,
- Evaluation,
- Revision
What does the DAR format include?
- Data
- Action
- Response
What are some types of data forms?
- Nursing admission data forms
- Discharge summary
- Flow sheets and graphic sheets
- Medication Administration records
- Kardex
What is included in flow sheets and graphic sheets?
- check list- assessment
- vital signs
- intake and outake
What is included on a patients MAR (medication administration records)
- Scheduled meds,
- unscheduled meds,
- drug allergies,
- single order medications
What is a patient Kardex?
- Not a permanent record. A summary of patient needs and care.
What are the rules as far as what you can use to write with on paper charts?
- Never use white-out
- Never use erasable ink
- Never obliterate
- Never Erase- No pencils
What and how should we write on paper charts?
- Print or script
- Blue or Black Ink
True or false the kardex is part of the patients chart ?
False
What can be on a patient’s kardex
- Patients data (name, age, martial status, religious preference, physician, family)
- Medical diagnoses: listed by priority
- Medical order (diet, IV, therapy, etc)
- Activities permitted
Describe what a flow sheet/forms look like?
Vertical or horizontal columns for recording dates and times and related assessment and intervention information: Vital signs, intake and output, assessment
What does a nurse’s progress note/narrative include
- Patient’s condition, problems and complaints
- interventions
- patient’s response to interventions.
- achievement of outcomes
- additional assessment
6 report given
-Time given- nurses’ name
- important information
True or false: It is important to note the time you received report as well as who gave you report to cover in instances where a patient might be declining close to shift change?
True
True or False: You should not share information with classmates unless in clinical conference?
True
True or false: it is okay to access medical records of other patients that you are not caring for?
False
True or false: There is no way to trace who has looked in a patients medical record
False
What are the components of good documentation?
- Who
- What
- When
- Where
- How
- Outcome
- follow-up
- Accuracy
In the “What” component of a good document what should you inclue?
- Assessment findings?
- Patient’s complaint
- care you provided
In the “What” component of a good document what should you include?
- Assessment findings?
- Patient’s complaint
- care you provided
In the “when” component of good documentation what should you include?
The time when you provided care
In the “where” component of good documentation what should you include?
- where did event take place
- where was the tx given or medication administered
In the “how” components of good documentation what should you include?
- How was tx completed
- How did the resident tolerate the procedure/tx
In the “outcome” component of good documentation what should you include?
Outcome of the procedure/tx
In the “follow- up” component of good documentation what should you include?
What type of follow-up needed (retaking bp…pain level)
In the “accuracy” component of good documentation what should you include?
Exact measurement (dont use about or approximately)
What are specific aspects of care?
- Critical diagnostic results
2.fall reduction - infection prevention
- meds and reconciliation of meds
- non-conforming patient behavior
- pain assessment and management
- Patient and family role in safety
- restraints
- skin care
- suicide
When you are documenting that you have notified a provider what should you include in the documentation?
- Include the full name of the provider
- note the exact time you notified the provider
- state the specific laboratory result, symptom, or other assessment data that you reported
- record- the provider response using exact words if possible.
- include- any orders which the provider gives. if the provider gives no orders, note this- especially if you anticipated an order.
- include- in your complete note of the event, include the patients other vital signs, relevant observations, any nursing interventions you performed
- include- the commitment for necessary follow-up by provider, such as “well visit patient at 0800”
- include- symptoms and parameters such as changes in vital signs, change in LOC, or pain that the provider defines as indicators for nurse to use in deciding to call provider again
- note- it is essential that you note your own actions to assist the patient in addition to documenting your contact with the provider
- pursue- If a provider fails to respond to a page, a telephone message or fails to order an intervention and thereby creates a risk for the patient peruse the chain-of-command and notify supervisor.
- Record all your actions
Never use ______ to describe a patient or patients behavior. Example obnoxious, belligerent, rude
Labels
Rather than using labels we should _____ a patients behavior.
Describe
If a patient refuse’s somethings what should we do?
Document patient’s refusal, reason for refusal and what you did about it.
review examples on PowerPoint on how to properly document a patient’s behavior
slide 36-37
What are the legal guidelines for recording?
- correct- corrects all errors promptly, using the correct method
- record- record all facts; do not enter personal opinions
- record- if an order was questions, record that clarification was sought
- chart- only for yourself, not for others
- Keep- your computer password secure
- Avoid- generalizations
- paper charting- begin each entry with the date/time and end with your signature and title. Do not leave blank spaces in nurse notes
write legibly in permanent black or blue ink.
True or false: Accurate documentation is the best defense in a legal claim?
True
True or false: you must describe exactly what happened to a patient and how nurse followed agency standards in your documentation for legal purposes.
True
When is the best time to chart?
If at all possible immediately following care.
What are some common mistakes leading to legal action?
- failing to record health information/drugs
- failing to record nursing actions
- failing to record meds that were given
- failing to record drug reactions/ or change in pt condition
- failing to write legibly or complete.
- failing to document discontinued/refusal medication
- Failing to notify dr. nurse, family and recording exact convo
- failing to record late entry correctly
- failing to record referrals
- failing to record pt teaching
How do you correct errors on paper charts?
- a single line through entry and initials
How do you correct errors on EMR (electronic medical record)
New entry and explain error
True or false: you should make sure you have the right chart before correcting an error.
True
How do you add a late entry on a paper chart?
- Add the entry to the first available line, and label it “late entry” to indicate that its out of sequence, according to facility policy.
- record the date and time of the entry and in the body of the entry record the date and time it should have been made
How do you add a late entry in the EMR (electronic medical record)
Change date/time and then document
According to the Texas Administrative code Title 22 of TBON all nurses should accurately and completely report and document what?
- clients status including signs and symptoms
- nursing care rendered
- admin of meds and tx
- client’s responses and
- contact with other health care team members concerning significant events regarding clients status.
When we are interviewing what are the two types of data?
- Subjective
- Objective
What are two types of sources of data?
- Primary
- Secondary
What are some types of diagnotisc tests?
- laboratory
- radiologic studies
- skin tests
- pulmonary function tests
- endo exams
What are the methods of data collection?
- Interview
- nursing health history
- physical examinations
- diagnostic and lab results
What are the 3 phases of interviews?
- orientation phase
- working phase
- termination phase
What are some types of physical assessments?
- comprehensive
- focused
- system specific
- ongoing
— All head assessments are considered HEAD to TOE.
What are some elements of assessments
- History– which includes a baseline history or problem- based history
- examination– which includes vital signs, inspection, auscultation and palpation
With the process and physical aspect of the health assessments what all is included in this?
- Assessment
- interview
- physical assessment
- Nursing diagnosis
- planning
- based on assessment data
- evaluation
- establishes nursing accountability
What are some techniques for assessments?
- inspection
- palpation
3.percussion - auscultation
- olfaction
What are some guidelines for a visual assessment?
- good lighting
- expose all of part to be examined; drape or cover parts not being examined drape or cover parts not being examined for privacy
- use additional lighting/devices for some areas of the body; eyes ears, throat
When we are inspecting our patients what are we observing for?
- color
- shape/symmetry
- movement
- position
What palpation technique should we use??
Bimanual/manual technique
True or false: we should use the dorsum of our hand to assess temp for a more accurate read?
True
True or false: light palpation is 1cm or 1/2 depth
True
What is deep palpation?
4cm or 2 in depth
When we palpate we are assessing what?
- texture
- resistance
- resilience
- mobility
- temperature
- thickness
- shape
- moisture
What is direct percussion?
Applied directly to body
What is indirect percussion?
applied through another surface
What are some characteristic of sound during auscultation?
- frequency
- loudness
- quality
- duration
in terms of auscultation what does frequency mean?
number of oscillations per second generated by a vibrating object
In terms of auscultation what does loudness mean?
amplitude of a sound wave
In terms of auscultation what does quality mean?
descriptive
In terms of auscultation what does duration mean?
Length of time that sounds last
What is the bell of the stethoscope used to hear?
Bell best for low pitched sounds— vascular & some heart sounds
What is the diaphragm of the stethoscope used to hear?
high pitched sounds – bowel sounds and some abnormal lung sounds
What is our olfactory used for?
To detect abnormal vs normal smell
What should you do to prepare for your assessment?
- gather all necessary equipment
- introduce self
- explain the procedure
- use gloves if necessary
- wash hands before and after any contact with patient
- clean stethoscope head and blood pressure cuffs between patients
- make patient comfortable and allow for privacy
What are some special considerations for the aged during the assessment?
- Recognize physical/sensory limitations
- may need to adjust position
- may need to allow more time (fatigue)
- May need allow more space
- recognize normal changes of aging vs. abnormal
While performing the assessment what all are we looking at?
- Health history typically taken prior to exam
- begin with general survey to include:
- race/gender
-age
- body type
-posture
- signs of distress
-substance abuse
-speech
- movement/gait
- hygiene and grooming/ dress
-affect/mood
-patient abuse
What are some signs of abuse
- inconsistency between injury and statement
- bruises, lacerations, burns and bites
- x-ray show fractures in various stages of healing
- behavior issues; insomnia, anxiety, isolation
When testing LOC what is considered alert
Attentive, follows commands, if asleep wakes promptly and remains attentive
When testing LOC what is considered lethargic?
Drowsy but awakens, slow to respond
When testing LOC what is considered obtunded?
Difficult to arouse, needs constant stimulation
When testing LOC what is considered stuporous/semi comatose?
Arouses only to vigourious/noxious stimuli, may only withdraw from pain.
When testing LOC what is considered stuporous/semi comatose?
arouses only to vigorous/noxious stimuli, may only withdraw from pain
When testing LOC what is considered comatose?
No response to verbal or noxious stimuli, no movement except due to deep tendon reflex.
When auscultating posterior lung sounds when do you start asking your patients to take deep breaths?
On breath sounds 7, 8, 9, 10
