knowledge assessment I Flashcards
ANA focuses on four main goals of nursing
- promote health
- prevent illness
- treat human responses to health or illness
- advocate for individuals, families, communities, and populations
nursing scope and standards of practice
describes what duties RN is able to do under their license
works with nursing process to promote health and prevent illness
autonomy
a patient’s independence to make their own decisions about their care
beneficence
doing good by others
justice
treat patients in a way that is equitable and fair
nonmaleficence
do no harm
nurses are considered a ___ and a _____ of care
provider / manager
nursing communication
SBAR
SBAR
a standard form of communication that allows the nurse to give a report with the most concise and important information and to provide recommendations about interventions based on critical thinking
S (SBAR)
situation
i am…
im calling because…
i am concerned that…
(blood pressure is low/high, pulse is xx, temperature is xx, early warning score is xx)
B (SBAR)
background
patient x was admitteed on xx with … (chest infection)
they have had.. (x operation done)
pt x condition has changed within the last x min
their last set of vitals were xx
patients x normal condition is xyz
A (SBAR)
assessment
i think the problem is …
i have… (given O2/analgesia, stopped the infusion)
OR i am not sure what problem is but i am worried
R (SBAR)
recommendation
i need you to…
come and see pt in next xx min
AND
is there anything i need to do (stop fluid..)
nursing values
caring
integrity
diversity
excellence
caring
promotes health, healing, and hope
integrity
respect, dignity, and moral wholeness
diversity
affirming uniqueness and differences
excellence
cocreating and implementing transformative strategies
teaching and health promotion is influenced by
individual beliefs
cultural beliefs
perception of health and healthcare
demands in individuals life
individualizing health promotion
consider talking about their beliefs and experiences and see what they deem important to help provide better outcomes
healthy people 2030
national model for health promotion and risk reduction
goal to increase length and quality of life and eliminate health disparities
levels of intervention
primary
secondary
tertiary
primary level of intervention
strategies to prevent problems
ie. physicals, yearly blood work, immunizations
secondary level of intervention
early diagnoses of health problems-screenings
ie. CT scans, vision screenings
tertiary level of intervention
preventing complications of existing disease
ie. making sure diabetics get proper foot care, diet teachings, exercise programs
components of health assessment
- health history and physical exam
- gathering info about health status
- ID patterns and trends
- performing nursing process
health history and physical exam
gather info on health status
analyze information as data, make judgments and evaluate the outcome
think clinical judgement model of nursing
gathering information about health status
subjective questions and physical findings
physiological, sociocultural, spiritual, economic, and lifestile
ID patterns and trends
assist with guiding treatment plans to improve patient overall wellness
6 functions of clinical judgment model
- recognize cues (what matters most)
- analyze cues (what does it mean)
- prioritize hypotheses (where do i start)
- generate solutions (what can i do)
- take action (what will i do)
- evaluate outcomes (did it help?)
nursing process
- assessment
- analysis
- planning
- implementation
- evaluation
assess (nursing process)
compare health assessment of pt
data must be complete and accurate
includes subjective + objective data
subjective data
what is reported to you by the patient
- feelings, sensations, chief complaint
objective data
what you identify in the assessment (physical findings, VS, EHR info)
analysis/diagnosis (nursing process)
making judgment based on what you find in the assessment; consider what assessment findings mean
(basis for clinical decisions you will make
planning (nursing process)
determine what resources are available in order to implement the care needed for pt
- consider the pt specific outcomes and goals for shift
- plan out what interventions will be used give resources
implementation (nursing process)
put care plan into action for shift
evaluate outcomes (nursing process)
judge effectiveness of interventions used
- did they help reach the goals and monitors progress of pt in health promotion journey
clinical judgment model
combination of basic nursing process, critical thinking, and diagnostic reasoning
CJM is composed of
critical thinking and diagnostic reasoning
critical thinking
analysis and implementation of best interventions for pt given complex health scenario that is provided
- requires analysis of situation and all potential outcomes
- ensures that nurse provides complete, patient centered care that is not misguided
diagnostic reasoning
based on critical thinking
- process of data gathering in order to create hypothesis for pt care
- requires collaboration with the interprofessional team to obtain orders and implement interventions for pt
what steps of the CJM help form a hypothesis
recognizing cues and analyzing them
what steps of CJM help refine hypothesis
refining helps prioritize which in turn helps generate solutions
what steps of CJM help evaluate
eval. helps take action which helps evaluate better outcomes
types of physical assessment
comprehensive and focused
comprehensive physical assessment
- complete health hx
- physical assessment
- includes all body systems and vital signs
- similar to primary care visit
focused
- based on health issues
- health hx based on symptoms
- one to two body systems where abnormalities are found
- smaller assessment more in depth
both comprehensive and focused assessments include
subjective and objective data
Given the following case scenario, make a list of subjective data findings: J.S. is an 82y.o. patient,
comes to the clinic complaining of a dry nagging cough and shortness of breath when walking up the
stairs. She states this started about one week ago and that she just “can’t stand it any longer”. She
complains of throat pain when coughing. Upon assessment, she appears weak and frail. She has lost
15 pounds since her last visit to the office 2 months ago. She has a dry cough when she takes a deep
inhalation; lung sounds are clear to auscultation. She has a normal temperature, heart rate, blood
pressure, and oxygenation reading.
complaints of dry and nagging cough and SOB when walking up stairs
started about a week ago
“cant stand it any longer”
complaints of throat pain when coughing
Given the same scenario again, make a list of objective data findings: J.S. is an 82y.o. patient, comes
to the clinic complaining of a dry nagging cough and shortness of breath when walking up the stairs.
She states this started about one week ago and that she just “can’t stand it any longer”. She complains
of throat pain when coughing. Upon assessment, she appears weak and frail. She has lost 15 pounds
since her last visit to the office 2 months ago. She has a dry cough when she takes a deep inhalation;
lung sounds are clear to auscultation. She has a normal temperature, heart rate, blood pressure, and
oxygenation reading.
82 yo
appears weak and frail
has lost 15 pounds since last visit 2 mo ago
dry cough when taking deep breaths
lung sounds are clear to auscultation
normal temp, HR, BP, and O2 reading
emergency assessments use
ABCDE
abcde
A - airway (is airway patent, do they have neck or throat injuries
B - breathing (rate, depth, muscle use)
C - circulation (pulse rate, rhythm, skin color
D - disability (level of consciousness, pupils, movement)
E - exposure
functional assessment
functional patterns humans shar
health perception
health management
activity and exercise
nutrition and metabolism
elimination
head to toe assessment
organized system for gathering comprehensive physical data
body systems assessment
ultizes critical thinking to document and communicate assessment findings for each system
enables nurse to hypothesize system specific issues
key component to infection prevention is
hand hygeine
transmission based precautions
increased personal protective equipment based on disease
standard precaution
all waste and contact are considered infections
used w all patients
lower risk exposure
performing admin duties in nonpublic areas of healthcare members
medium risk exposure
providing care to general public who is not known to have covid, busy staff areas
high risk exposure
entering known or suspected covid 19 pt room
very high risk exposure
performing aerosol generating procedures (intubation, cough induction, bronchoscopies, some dental procedures, etc.)
collecting or handling specimens from known or suspected covid 19 pt
hand hygiene
must be done prior to pt contact
nails should be kept short with no polish
any open skin wounds need to be covered with bandage
PPE
gloves, masks, respirators, eye protection, gowns, foot covers
the amount of PPE needed is based on
diseases
sequence of donning ppe
1.wash hands
2. gown
3. mask or respirator
4. goggles or face shield
5. gloves
sequence of doffing ppe
- gloves (take gloved hand and from palm take glove off, then slide underneath glove and toss)
- goggles or face shield (move from back)
- gown (shimmey it off of you)
- mask or respiratory (bottom first)
- wash hands
contact precautions
- ensure patient placement in single room if available
- use ppe appropriately
- limit transport and movement
- use disposable or dedicated patient equipment
- prioritize cleaning and disinfection of room
droplet precautions
used for pt known or suspected with transsmissble pathogens from respiratory droplets
- mask pt
- appropriate pt placement
- PPE (mask upon entry)
- limit transport and movement of pt
airborne precations
known or suspected pt has pathogens transmitted by air (TB, measles, chickenpox)
- mask pt
- ensure placement in airborne infection isolation room
- restrict susceptible healthcare personnel from entering room
- use PPE (fit respirator
- limit transport
- immunize susceptible persons
assessment techniques
inspection
palpation
percussion
auscultation
inspection
observation of pt to look for abnormalities
palpation
use of hands to feel for abnormalities
percussion
use fo hands to create sounds on specific body part and listen for abnormalities
ausculation
using stethoscope to listen to air and fluid movement
it is neccessary to consider each independent patients
ability level
cultural beliefs
social beliefs
elderly, cultural variations, and health disparities
- patient may be anxious
- some pt fear disclosing info that makes them uncomfortable
- if pt has language barrier, coordinate to have a medical interpreter present
- ask pt their preferences and always perform less invasive assessment first
what is the first component of the assessment
general survey
general survey
- begins with the first encounter and continues with each interaction
- the rn makes note of general appearance, behavior, and mobility
- overall impression of pt that gives general indicator of health status
vital signs
include temperature, HR/pulse rate, respirations, o2
- nurses must interpret these with the clinical picture
- indicate physiological state and response to the different stressors on a body at given time
- allow nurse to establish a baseline and monitor trends
subjective data collection within general survey
- question pt about past medical and surgical history, medications used, family history, nutrition, and psychosocial profile
- look for risk factor related to variation in vital signs (family history, increased age, male gender, high BP, high cholesterol, smoking, diabetes, overweight, decreased activity, high-fat diet, high alc intake, elevate C reactive proteins and elevated Btype natriuretic peptide)
subjective data:teaching and health promotion
educate importance of consistent medication usage
educate on risks associated w medical history and family history
primary prevention: lifestyle modification
factor to obtain accurate VS
- establish comfortable setting
- provide privacy, ask if they want a chaperone
- perform hand hygiene prior to taking VS (cleanse equipment)
- begin general survey immediately and continue taking in cues while assessing vitals
- perform the least invasive first
- pt can be sitting or lying but legs shouldn’t be crossed, restrictive clothing removed, ask if pt has had anything to eat or drink for 30 min prior
temperature
controlled by hypothalamus
normal range of temperature
97.7-98.6 F or 36.5C-37C
fever is considered
100.4 F or above
hypothermia
low body temperature <35C or 95F
hyperthermia
high body temp >38.6C or 101.5F
pulse/heart rate
number of pulsations per minute
normal range of HR
60-100 bpm
rhythm of HR
regular (rhythmic, same interval between each beat) vs irregular (beats have different intervals, no pattern)
strength of HR
absent is rated at 0
strong is +4
normal is considered to be +2
tachycardia
high heart rate
OVER 100 bpm
bradycardia
low HR
LESS than 60 bpm
aystole
no pulse
medical emergency, code blue
apical pulse
measure at apex of heart
if pulse rhythm is deemed to be irregular the RN must auscultate the apical pulse for an entire minute to ensure the accurate pulse rate is counted
respiratory rate
one respiration comprised of a full inhale and a full exhale
tachypnea
rapid respiratory rate
GREATER than 24 respirations
bradypnea
slow respiratory rate
LESS than 12 respirations per minute
apnea
absence of breathing for more than 10 seconds
EMERGENCY
dyspnea
difficulty breathing
hyperventialtion
rapid, deep breathing
hypoventilation
slow, shallow breathing
accessory muscle use indicates distress
normal respiratory rate
12-20 respiration per minute
oxygen saturation
percent of hemoglobin that is saturated with O2 at time of measurement
pulse oximetry
noninvasive continuous oxygen saturation monitoring used in clinical settings
normal pulse oximetry
92-99% on room air, without supplemental oxygen therapy
blood pressure
force exerted on the arterial walls by the flow of blood from the heart
systolic BP
measurement at systole in heart
highest pressure against arteries
normal systolic
90-120 mmHg
diastolic BP
measurement at diastole in heart
lowest pressure against arteries
normal diastolic
60-80mmHg
MAP (mean arterial pressure)
average arterial pressure through one cardiac cycle
- minimum MAP of 60 mmHg needed to perfuse the vital organs
hypertension
high BP over multiple readings
must be a trend before a diagnosis is made
hypertension levels
SBP > 120
hypotension
low BP
hypotension levels
SBP <90
orthostatic hypotension
assess for drop in BP and change in HR when patient changes position (sitting from lying down)
can be caused by meds or health status
frequently seen in older population
how to assess orthostatic hypotension
check BP and HR in supine
sit patient up, wait 1-2 minutes and asses in sitting position
have patient stand and wait 1-2 minutes and assess in standing position
signs of hypotension
dizziness, lightheadedness, feeling like passing out
using BP cuff that is too small will lead to BP reading that is falsely
high
hypertnesion can only be diagnosed after multiple high BP readings are recorded. true or false
true
normal diastolic range
60-80
normal systolic range is
90-120
using BP cuff that is too large will lead to BP reading that is falsely
low
which of the following patients are at risk of experiencing orthostatic hypotension (select all)
a) 25 yo pt admitted after MV collision and high blood loss
b) 95 yo pt with history of heart failure and parkinsons disease
c) 20 yo pt with flu like symptoms and abdominal pain
d) 45 yo pt wait gallbladder removal surgery
a, b
mexican americans experience greater percentages of
being overweight and obese
considerations for older adult
general survey: appearances change with age (posture and gait are altered and pt may have decreased balance, assess for declining ability to care for self, changes in mental status)
height and weight:
thinning of vertebral discs and postural changes lead to decline, muscle shrinks and fat dis. changes
temp:
lower body temp due to changes in regulatory mechanisms and fat distribution (may not illicit fever like younger adult)
pulse:
vascular changes over time lead to changes in compensatory mechanisms, takes longer for heart to respond to hemodynamic changes in body and longer to return to normal state
respirations:
rigidity of rib cartilage, decreasing chest expansion and vital capacity, decreased volue of air inspired in each breath, increased SOB and shallow breathing
Pulse O2:
more difficult to read due to decreased perfusion, sensorts to the forehead, nose, or ear
BP:
change in body size and fat distribution makes it harder to size cuff, both numbers increase naturally, BP may drop when adult stands too quickly
in certain cultures there may be variations in
vital signs
cultural variations in general survey
note cultural differences, dress, grooming, speech, non verbal communication
- be attentive and take time
- utilize interpreter if necessary
- take note of family in room and interactions
non hispanic black adults have the
highest prevalence of high BP
priority urgent assessment
cues nurse in to call provider
when VS alter, nurse can begin interventions, follow triage assessment to determine if emergency, utilize senior nurses to assist
premature death from hypertension and heart disease is higher for
hispanics
nursing practice is dependent on an
effective nurse-patient relationship
nonverbal communication includes
physical apperance; facial expression
posture; positioning in relation to the patient
gestures; eye contact
voice tone; use of touch
verbal communicatin skills
effective interviewing
speech patterns (moderate pace and volume; clear articulation, modify for those w hearing problems)
simple clear language at normal volume for those with limited english
active listening refers to
ability to focus on patients and their perspectives
talking about difficult feelings to help patients heal
redirect interview if a patients anger cannot be diffused
restatement
content of communication
reflection
summarizing main themes of communication
elaboration (facilitation)
assists patients to more completely describe difficulties
silence
purposefully allow patients time to gather thoughts, provide accurate answers
focusing
redirecting patients to pertienent topics being dicussed
clarification
questions to ascertain patients meaning when word choice ideas are unclear
summarizing
reviewing and condensing important information into two or three most important findings
nontherapuetic resopnses
- false reassurance
- sympathy
- unwanted advice
- biased questions
- changes of subject
- distractions
- technical or overwhelming language
- interuptting
cultural differences may relate to
group or ethnicity; region
age; degree of acculturation into western society
combination of factors
you would use culturally competent communication when dealing with
those with limited english skills, or those of different gender and/or sexual orientation
phases of interview process
pre-interaction
beginning
working phase
closing phasep
pre interaction phase
compiling existing patient data, preparing for interview from existing medical records
beginning phase
introduction; state purpose for interview, ensure privacy
working phase
closed-ended or direct questions: specific information
open-ended questions: broad answers in patients own words, avoid “why” questions
closing phase
summarizing, stating most important two to three problems or patterns
- report any information that is required by law
primary data sources
individual patient
secondary data sources
charts and information from family members
all other sources of information
types of health history
emergency, focused, comprehensive
emergency health hx
gather information about immediate problem
focused
gather information about current situation
comprehensive
gather all medical info about pt
components of health hx
- demographic data
- reason for seeking care
- history or present illness (OLDCARTS)
- past health hx
- current meds
- allergies
- family history
- review of systems (ROS)
- functional capabilities
- social, cultural, spiritual assessment
- mental health assessment
- neglect, abuse, and violence assessment
- sexual history
oldcarts
onset, location duration
characteristic
alleviating or aggravating factors
radiating or relieving factors
timing
severity
infants and children in health assessment
parents, legal guardians, or other adult reps. may bring child so validate roles of people bringing in children
older adults
establish roles of others at interview
possible sensory deficits
more complex health hx
lifestyle choices affecting health
focus interview on patient
challenging situations
- hearing impairment
- low consciousness
- cognitive impairment
- mental illness
- anxiety
- crying
- anger
- substance abuse
- sexual agression
purpose of medical record
legal document used in civil or criminal courts for evidence, communication and care planning, quality assurance, education, research, and financial reimbursement
sentinel event
an unexpected occurrence involving death or serious physiological or psychological injury
almost 3/4s of all serious often life-threatening errors in healthcare involve failures in
communication
quality assurance
audit (internal or TJC)
financial reimbursement
medicare, medicaid, workers comp
components of patients medical record
nursing admission assessment
H&P by PHP
advanced directive or power of attorney
PHPs orders
care plan or clinical pathway
flow sheets (vitals, I&Os, routine assessments)
focused assessment sheets
MAR
lab test and results
progress notes
consults
discharge summary
EMR
software programs allow entry of assessment data quickly
interfaces with pharmacy; direct computer charting of medication administration
computerized provider order of entry (CPOE)
direct entry of all orders by healthcare providers to lab, pharmacy, and nursing personel
all entries are legible, timed and dated
automated clinical surveillance tools
priority urgent assessment
- respiratory rate below 8 or higher than 28 breath per/min
- acute change in oxygen sat below 90%
- threatened airway
- change in systolic blood pressure below 90 mm Hg or diastolic blood pressure above 110 mmHg
- new chest pain; signs of myocardial infarction
- cold, cyanotic, or pulseless extremities
- confusion, agitation, delirium
- unexplained lethargy or acute altered mental status
- difficulty speaking or signs of acute stroke
- seizures
- changes in pupillary response
- temp greater than 39 degrees C or 102.2 F
- uncontrolled pain
- acute change in urine output (less than 50 mL over 4 hrs)
- acute bleeding
- suspect sepsis
Health Insurance Portability and Accountability Act (HIPPA)
- keep clients health information private
- applies to computerized and written medical records; any information pertaining to health status or care received
- severe penalties for violations
documentation must be
accurate and complete
accuracy and completeness
must persicely reflect assessment data
subjective data: clients exact words whenever possible
correct medical terms
legally accepted abbreviation use
proper format for noting record corrections
handwritten entries must be legible
logical organization
systemic grouping of information
timeliness
follow agencies policies
avoid batch charting
point of care documentation
enables up to date assessment information to make clinical decisions
conciseness
avoid lengthy sentences use sentence fragments
nursing admission assessment (nursing history and physical)
- obtain baseline data
- timeline depends on facility
- provides comprehensive information about clients physical, physiological, functional, social, and spiritual abilities
- forms basis for individualized plan of care
STEP
status of client team members
environment
progress toward goal
narrative notes
unstructured paragraph based on time
SOAP(IE)
subjective;objective;analysis; plan; interventions; evaluation
PIE notes
problem
interventions
evaluation
DAR notes
data
action
response
charting by exception
- predetermined standards and norms to record only significant assessment data
- nurse checks box if client meets norms
- any abnormal assessment findings require additional documentation
discharge note
indicates client’s status, received necessary education, discharge instructions, condition, and time of discharge
home care documentation
OASIS: Outcome and Assessment Information Set (federally mandated for medicare or medicaid reimbursement)
long-term care documentation
resident assessment instrument (RAI)
includes: minimum data set, triggers, resident assessment, protocols, utilization guidelines
very comprehensive and labor intensive assessment tool
written handoff sumary
- transfer of care for a patient
- I PASS the BATON
hand off summary minimizes
potential errors from lack of information, agencies often provide specific assessments on written transfer summary in addition to verbal report
I PASS the BATON
introduction
patient
assessment
situation
safety
background
actions
timing
ownership
next
verbal handoff summary
transition of care
national pt safety goals
handoff reporting
call outs
reporting
occurs at handoffs, during pt rounds, during pt and family care conferences, when calling or texting provider to report a change in status or produce requested information
potential barriers to reporting
- lack of structured format and standard and policies for communication
- uncertainty about who is responsible and should be contact
- power differences
- poor clinical decision making regarding what needs to be reported
- different communication styles
qualities of effective reporting
organized, complete, accurate, concise, respectful
nonverbal communication
difference in communication styles between nurses and providers
SBAR model
situation
background
assessment
recommendation/request
reporting to PHP
face to face, telephone, text, fax
ensure contacting correct provider
phone and urgent communication (have pt info available for reference, document call, CPOE allows remote computer access for entering orders when off-site)
“read back”
cultural competency is the dynamic process of
acquiring ability to provide effective, safe, and quality care that meets social, cultural, and linguistic needs to pts
benefits of cultural assessment and competency
reduction in healthcare disparities, enhancing patients’ trust in healthcare system, cultural safety
culture
socially transmitted behavioral patterns, beliefs, values, customs, life ways, and arts that guide worldview and decision making
culture is learned first in
family, then school, community and other groups
characteristics of culture
nationality, arce, skin, color, gender, age, religious affiliation, educational status, occupation, sexual orientation, etc
aim of cultural assessment
gain knowledge about patients cultural beliefs and practices
compare needs of specific person with general themes
identify similarities and differences among cultural beliefs
generate holistic picture to develop nursing care plan
cultural variables
cultural values and beliefs
religions, personal philosophy of life, spiritual beliefs
educational and economic background
relationships with family and peers
views on and use of technology
politics
patients legal status
attributes for nurses during cultural assessment
- genuine interest in pt’s culture and personal experience
- active listening and awareness of meanings behind patients verbal communication
- nonverbal communication
- acknowledgment that the nurses own beliefs and prejudices might create barriers to providing culturally sensitive care
subjective data collection
complete assessment isn’t always possible so nurse must determine which questions are most relevant based on patients specific healthcare encounter, symptoms, and care planning needs
implementing cultural assessment in practice
- assess patients beliefs on healthcare
- pt will not comply with POC inconsistent with cultural beliefs and values
- determine what kind of language assistance may be needed
- provide environment for confidentiality and comfort
- nurse must remain nonjudgmental
cultural health beliefs and practices
- food and nutrition
- pregnancy and childbirth
- beliefs and expressions of pain
- during death and grieving
- spirituality and religious beliefs
social determinants of health
- economic stability
- education access and quality
- healthcare access and quality
- neighborhood and built environment
- social and community context
social environment contributes to
health disparities among most important determinants of health throughout life
social assessment
patterns of health and illness
need understanding on how patient will handle illness, comply or not with careplan, follow up w physician appointments or other therapies
most common factors of social assessment
marital status
smoking
drug and alcohol use
ability to afford medications
access to transportation
time for appointments
community
social unit or group of people with something in common
assessment of community
ID resources, constraints, high-priority health concerns
variables within community
gender, age, ethnicity, race, marital status, housing, employment status, education
making clinical decisions
prioritize hypothesis and take action
analyzing changing findings: progress notes
interprofessional collaboration with spiritual care
plan the care
evaluating outcomes
christian
- baptism
- different beliefs about birth control, artificial insemination, individual choice of conception
muslim
combination of conventional biomedical treatments with spiritual nourishment consisting of daily prayers and reading or listening to Quaran
bed faced toward mecca
jewish
jewish holidays and rituals
some pray 3x a day and need prayer items
many visitors
hindu
pray, sing, recite scriptures, and repeat the names of deities at home or in other places
shrines
sacred writings and objects
jehovah’s witness
used of blood products or animal products to sustain life may not be congruent with Jehovah’s Witness beliefs
primary building blocks
formal institutions in the area, such as local businesses, schools, libraries, parks, and police, and fire stations
secondary building blocks
agencies designed to serve the community with outside overarching corporations that manage and operate these agencies
communities primary care clinic
potential building blocks
programs and services outside community such as politicians and corporations
