Lecture 1 Exam Review Flashcards
Good spirits brought health, while evil spirts bring sickness and death.
Theory of Animism
Nursing role becomes more defined and formal, deaconess made visit to sick.
Early Christian Period
In the Ancient Greek Civilization temples were what?
Medical Care Centers
In the 16th century a shift occurred from what to what?
Religious orientation to an emphasis on warfare, exploration, and expansion of knowledge.
Nursing is based on the beliefs of whom?
Florence Nightengale
These reforms changed the roles of nurses and of women in general
Social reform.
Who established the first training school for all nurses?
Florence Nightengale
Female nurses were under the control of who?
Hospital administrators and Physicians
What happened during the World War II era?
Large numbers of women worked outside the home and became more independent.
Growth of nursing and technology expanded.
In the 1950s nursing broadened in what areas?
Upgrading nursing education.
Practice in variety of healthcare settings.
Developing specific knowledge.
The conduct and publication of nursing research.
Increasing knowledge of nursing and EBP practices
What are the Nursing Aims?
Promote Health
Prevent Illness
Restore Health
Facilitate coping with death/ disability.
The 4 Blended competencies?
Cognitive
Technical
Interpersonal
Ethical/Legal
What are some roles for nurses?
Teacher
Communicator
Counselor
Leader
Researcher
Advocate
Collaborator
QSEN include what?
Patient Centered Care
Teamwork
Safety
EBP
Informatics
How can we promote health?
Identifying, analyzing, and maximizing each patient’s individual strengths as components of preventing illness, restoring health, and facilitating coping with disability or death.
What are some factors affecting health?
Genetics
Education Level
Culture
Sex
Socioeconomic status
What are some Healthy People 2030 Health Promotion Guidelines
Attain Healthy, thriving lives and wellbeing, free of preventable disease, disability, injury, and premature death.
Eliminate Health disparities.
Promote Health Development
Encourage Leadership in health settings.
How do nurses prevent illness?
By teaching and example
What are some ways to prevent illness?
Reducing the risk of illness, promoting good health habits and maintain optimal functioning.
Educational programs.
Health Assessments.
TV, Radio, or Internet Information.
Name ways in Restoring Health
Focus on the person with an illness and are considered the nurse’s responsibility.
Performing Assessments
Collaborating with other healthcare members
Planning, teaching, and carrying out rehabilitation for illness.
Ways to facilitate coping with Disability and Death
Maximizing person’s strengths and potentials
Providing end of life care.
Well Defined Body of knowledge
Strong service orientation
Code of Ethics
Professional organization that sets standards
Autonomy and Regulations
Nursing as a professional Discipline
Nursing educators have a responsibility to form the professional identities of their students. This is known as ?
Personal Formation. Graduates will acquire a professional identity with sense of belonging.
Name Professional Nursing Organizations
ICN
ANA
NLN
Specialty Practice and Special- Interest Nursing Organizations
Nursing Practice Acts
Define the legal scope of nursing practice.
Create a state board of nursing to make and enforce rules and regulations.
Defines scope of practices
Establishes criteria for the educational and licensure of nurses.
What are some guidelines for Nursing Practice?
Standards of Nursing Practice
Nurse Practice Acts and Licensure Code of Ethics and Professional Values
Nursing Process and other clinical Judgement Models
What are some NLN trends to watch?
Changing demographics and increasing diversity
Globalization
The era of educated consumers and alternative therapies
The cos of healthcare and the challenge of it.
Impact of health policy and regulation.
Growing need for interdisciplinary education.
Self Care
Nurse owes the same duties to self as to others
Include promoting health and preserve wholeness of character and integrity in professional and personal growth.
Define resilence
Individual’s aptitude for overcoming and adverse life circumstance with hopeful attitude.
Utilizing healthy internal mechanisms
Signs of fatigue in Nursing Profession
Compassion Fatigue
Burnout
Fatigue
Knowledge passed down from generation to generation
Traditional
Knowledge from an expert?
Authorative
Knowledge obtained through the scientific method.
Scientific
Theory
Group of concepts that describe a pattern of reality.
Abstract impressions organized int symbols of reality, describe objects, properties, and events and relationships among them.
Concepts
Group of concepts that follow a pattern
Conceptual Framework or model.
The act of making generalized conclusions based of specific scenarios.
Inductive Reasoning
The act of backing up a generalized statement with specific scenarios.
Deductive reasoning.
Name the common concepts of Nursing
The person
The environment
Health
Nursing
Proces that use observable and verifiable information, collected in a systematic manner to explain, describe, or predict events.
Scientific Inquiry
Goals of research
Develop explanations in theories
Improving care of people in a clinical setting
Study people and the nursing process.
Basic Research
Designed to generate and refine theory, findings are often not directly useful in practice.
Applied Research
Designed directly to influence or improve clinical practice.
Involves the concepts of basic and applied research
Quantitative
Qualitative
Conducted to gain insight by discovering meanings
Based on the belief that reality is based on perceptions for each person and change over time.
Evaluating the ethics of clinical research studies
Value
Scientific Validity
Fair subject selection
Informed consent
Respect for enrolled subjects
Reading and Critiquing Research Articles
Review elements of the article
Level of quality of evidence using a scale
Decide if the study is applicable to your practice
Define PICOT
Patent
Intervention
Comparison
Outcome of interest
Time
Problem solving technique to make clinical decisions using the best evidence available.
Evidence Based Practice
What are steps in implementing EBP?
Formulate clinical questions
Search and collect best evidence
Critically appraise the evidence
Integrate the evidence with clinical expertise and patient/ family for best decision.
Evaluate the outcomes of the practice
Systematic and continuous actions that lead to measurable improvement in health care services and health status of targeted groups.
Quality Improvement
What are the IOMs Six Outcomes for New Health for 21st Century
Safe
Effective
Efficient
Patient Centered
Timely
Equitable
Access to Healthcare
Patient Protection and Affordable Care Act
Health Insurance marketplace
Shortage of providers
Legislation to health care access
Caring for undocumented individuals
One way for affordability for patients is through what group?
DRGs
Diagnosis Related Groups
Name the levels of Health Care
Primary Health Care Common Health problems
Secondary Health Care Treatment requiring more specialized clinical expertise.
Tertiary Management of rare and complex disorders
Ways of Paying for healthcare
Out of pocket
Individual private insurance
Employer based
Government finance: Medicare DRGs
What are some strategies to reduce health care costs?
Utilizing quality improvement tools to reduce waste and improve safety.
Improving transitions across settings
Making the delivery of medical services more efficient and less costly.
Elimination unnecessary costs
Improving population health
Name some healthcare settings
Hospitals
Ambulatory Care Centers
Home Health Care
Extended Care Services
Specialized Care Centers
Healthcare for ill and dying
Name roles of nurses in Hospitals
Direct Care Providers
Manager of other members of health care team
Administrator
Nurse Practioner
Clinical Nurse Specialist
Patient Educator
In service educator
Researcher
What is the most rapidly growing area of healthcare?
Home Health
Driven by payment system of reimbursement..
Give examples of extended care facilities
Transitional subacute care
Assisted Living
SNFs
Retirment Centers
Residential Institutions for mentally and physically disabled
Specialized Care Centers and Settings
Daycare centers
Mental Health
Schools
Industry
Homeless Shelters
Parish Nursing
Name Healthcare Services for seriously Ill and Dying
Respite Care
Hospice Services
Palliative Care
Types of Healthcare Agencies
Voluntary Agencies
Support groups
Other GOVT> Agencies
Public Health Service
CDC
Public Health Facilities
WHat are some trends to watch in health care delivery?
Focus on preventive care.
Knowledgeable and engaged consumers.
Mobile Health
Racial justice and equity
NLN
What are the Nurses’ role in Health Care Reform?
Gives opportunity to help shape health care and the future.
Becoming a stronger voice in addressing health related problems in our nation.
Education in nurses is increasing.
The focus of nursing care is providing a holistic care approach.
Define ADPIE
Assessment
Diagnosis Nursing
Plan
Implementation
Evaluate
What are some guiding principles of person centered care?
All team members are considered caregivers.
Care is based on continuous healing relationships.
Patient safety is priority
Transparency is the rule in the care of the patient.
What is the clinical judgement measurement model?
CJMM has new focus that is based on the New Generation NCLEX
Includes layers from 0-4.
Layers 0-2 how clinical judgement informs clinical decisions.
Layers 3-4 expected behaviors of students in specific case scenarios
Clinical Judgment Action model aligns what?
Aligns the six cognitive operations from layer 3 of the CJMM with specific situational factors from layer 4.
Mental Model
Organized way of thinking that assists in understanding complex situations and guides assessments.
Define the Nursing Process
Assessment -Date
Diagnosis -Problem
Plan- Managing the Problem
Implementation-Putting the Plan to Action
Evaluation-Did the plan work?
Systematic and continuous collection, analysis, validation, and communication of PT data.
Assessment
Data
Reflect how health functioning is enhanced by health promotion or compromised by illness/ injury
Database
Includes all the pertinent information collected by the nurse and other health professionals
Name characteristics of nursing assessment
Purposeful
Complete
Systematic
Factual
Accurate
Relevant
Recorded in a standard manner
5 Types of Nursing Assessments
Initial
Performed by the nurse shortly after admittance to a health care facility to establish a complete database for problem identification and care planning
Focused
May be performed by the nurse during initial assessment or as routine ongoing data collection to gather data about a specific problem already identified, or to identify new or overlooked problems
Quick priority
Short, focused, prioritized assessments completed to gain the most important information needed first; Can flag existing problems and risks
Emergency
Performed by the nurse when a physiologic or psychological crisis presents to identify life-threatening problems
Time-lapsed
Performed to compare a patient’s current status to baseline data obtained earlier, reassess health status and make necessary revisions in care plan, to collect data about current health status of patient
Triage
A screening assessment to determine the extent and severity of patient problems and recommend appropriate follow-up; Can be completed on the phone or in person; Triage nurses need highly specialized nursing knowledge and clinical reasoning and judgment skills
Patient-Centered Assessment Method (PCAM)
Tool used by health care practitioners to assess patient complexity using social determinants of health; Helps ask questions to gain understanding about the patient’s health and well being, social environment, health literacy and communication skills
Ways to establish Assessment Priorities
Health Orientation
Developmental Stage
Culture
Need For Nursing
Define Objective Data
Observable and measurable data that can be detected with senses.
Subjective Data
Information perceived only by affected person.
Example: Pain, dizzy, anxious feeling etc.
Where can I get sources of Data?
PT
Family
EHR
Lab studies or diagnostic studies
Other Healthcare professionals
The skill of Nursing Observation
Determines the PT current responses
Determines the PTs current ability
Determines the PT current environment and safety
Determines the larger environment and safety
Captures and records the uniqueness of the PT. Examples include: reason for care, health habits, medications, allergies, psychosocial, etc. Obtained by interviewing the PT.
Nursing History
What is the purpose of the Nursing Physical Assessment?
Appraisal of health status
Identification of health problems
Establishment of a database for nursing interventions
What are the 4 Assessment methods?
Inspection
Palpitation
Percussion
Ausculatation
What are some problems related to Data Collection?
Inappropriate organization of a database.
Omission of data.
Failure to establish rapport.
Failure to update.
When to verify data?
When there is a discrepancy between what the person is saying and what the nurse is observing.
What are the purposes of the diagnosing step?
Identify how an individual, group, or community responds to actual health and life processes
Identify factors that contribute to health problem
Identify resources or strengths on which individual can draw to prevent or resolve problems
Diagnostic Reasoning, Clinal Reasoning and Judgement
Be familiar with lists of actual and potential problems and needs.
Trust judgement but when needed ask for help
Respect your clinical intuition
Recognize personal bias and keep an open mind.
Steps of Data Interpretation
Recognizing significant Data
Recognizing patterns or clusters
Identifying strengths or potential problems
Reaching conclusions
Partner with patient and family
Types of Nursing Diagnosis
Problem Focused
Risk
Health Promotion
Formulation of Nursing Diagnosis
Problem identifies what is unhealthy about PT
Etiology- Identifies factors maintaining the unhealthy state.
S/S
Validating Nursing Diagnosis
Is my PT database sufficient and accurate?
Significant cues?
Subjective and objective data I used t determine the existence of o the current Health problem?
Based on EBP and scientific knowledge?
Documentation of Diagnoses on EHR
View the PT ongoing risks and problems that others have identified and documented
Decide and document new PT problems
Facilitate communication of the PT actual problems
Use PT problems to make goals and decisions about mutual goals and PT desires
Goals of the Identification and Planning Step
Establish Priorities
Identify and write expected PT outcomes
Select EBP nursing interventions
Communicate the plan of nursing care
What does a formal care plan allow the nurse to do?
Individualize care that maximizes outcome achievement
Ste priorities
Communication between other healthcare members
Coordinate Care
Evaluate PT response
Create record for used evaluation, research, and legal reasons.
Promote Nurse Development
Standards to Apply to Outcome Identification And Planning
The Law
Specialty professional organizations
The joint comission
The Agency of Healthcare Research and Quality
Your Employer
What are the three elements of comprehensive? planning?
Initial- Developed by the nurse who performs the nursing history and assessment. Addresses each problem.
Ongoing- Carried out by nurse who interacts with patients. Keeps everything up to date.
Discharge: Carried out by nurse who works most with PT. Discharge begins on admission.
Maslow’s Hierarchy of Needs
Physiologically
Safety/ Security
Love and Belonging
Self- Esteem
Self- Actualization
How can we identify outcomes?
Deriving outcomes from nursing problems
Determine PT centered outcomes
Using cognitive, psychomotor, and affective outcomes.
Identifying cultural considerations.
Define SMART
S specific
M measurable
A achievable
R relevant
T time-bound
IOMs 6 aims to be met by healthcare include what?
Safe
Effective
PT Centered
Timely
Efficient
Equitable
Joint Comission National PT Safety Goals include?
Identify PT correctly.
Improve staff communication.
Use medicines safely
Prevent infection.
Identify PT risks.
Common Errors in writing PT Outcomes
Expressing PT outcomes as nursing intervention
Vague responses
Including more than one PT behavior
Name 3 types of nursing interventions
Nurse initiated- Autonomous action based on scientific rationale that a nurse executes to benefit the PT in a predictable way related to the nursing diagnosis and projected outcomes.
Physician Initiated- Actions initiated by a physician in response to a medical diagnosis but carried out by nurse under doctor’s orders.
Collaborative- treatments intiated by other providers and carried by a nurse.
What are some actions performed in Nurse initiated interventions?
Monitor Health status
Reduce Risks
Resolve or prevent a problem. Promote independence.
Promote optimum sense of well- being.
What are purposes of implementation?
The nursing aims
Promote Health
Prevent disease and illness.
Restore Health
Facilitate coping with altered functioning.
Scope of Practice
Ways to implement Guidelines.
Act with PT and family
Before, reassess the PT.
Approach the PT competently and caringly.
Modify care plan according to the PT. Unique and PT centered.
Check to make sure that the nursing interventions are consistent with the standards of care.
Ways to implement the Plan of Care
PT need for assistance
Promote self care
Reassess PT
Use PT whiteboard
Plan ahead
Anticipate unexpected outcomes
Ensure quality and safe care
A way to reassess the PT and reviewing the care plan?
Each nursing intervention is supported by EBP.
Consistent with standards of care and safe for the PT.
Clarify anything that is questionable.
What are some variables influencing outcome achievement?
PT variables
- Developmental stage
- Psychosocial backgrounds and culture
Nurse Variables
- Resources
- Scope of practice
- Research Findings
- Ethical Legal Guidelines
What are common reasons for noncompliance?`
Lack of family support.
Lack of understanding.
Low value attached to outcomes.
Inability to afford treatment.
Limited access to treatment.
Name the 5 rights of Delegation
Right:
Task
Circumstance
Person
Directions
Supervision and Evaluation
What is the evaluating step?
Nurse and PT measure together how well the PT has achieved the outcomes.
Nurse modifies plan by identifying factors the PT is able to achieve.
Purpose of evaluation is to allow the PT achievements direct future interactions.
What are the 5 classic elements of evaluation?
Identifying evaluating criteria and standards
Collecting Data to see if standards are met.
Interpreting and summarizing findings
Documenting judgement
Terminating, continuing, or modifying the plan
Measurable qualities, attributes or characteristics that identify skills, knowledge, or health status.
Criteria
Standards
Levels of performance accepted by and expected of nursing staff.
Established by authority, custom, or consent.
Name the 4 types of Outcomes
Cognitive
Psychomotor
Affective
Physiologic
Evaluation
Evaluative Statements
Variables Affecting Outcome Achievement
Actions based on PT response to care plan.
What are the 4 steps crucial to improving performance?
Discover a problem
Plan a strategy
Implement a change
Assess the change or plan new strategy
AACN standards for establishing and sustaining Healthy work environments
Skilled communication
True collab.
Effective Decision making
Appropriate staffing
Meaningful recognition
Authentic leadership
Name some evaluative programs
Quality assurance programs
structure evals
process evals
outcome evals
quality improvement
PT satisfaction
Peer Review
Nursing sensitive quality indicators
Bacteria, Fungi, and Viruses are
Infectious agent
Reservoir
Natural habitat of the organism
Portal of Exit
Point of escape for organism
Means of transmission
Direct contact or indirect. Contact. Airborne route.
Point at which organisms enter a new host
Portal of Entry
Susceptible Host
Must overcome resistance mounted by Host’s defense.
Name the Infection Cycle
Infectious Agent
Reservoir
Portal of Exit
Means of Transmission
Portals of Entry
Susceptible Host
Infectious Agent
Most Significant and most prevalent in hospital settings
Bacteria
Smallest microorganisms
Viruses
Fungi
Plant Like organisms present in air, soil, and water
Live on host or in a host and rely on it for nourishment
Parasites
How do we classify bacteria?
By
Shape
Response to staining
Need for oxygen
What are some factors that affect an organism’s potential to produce disease?
Number of organisms
Virulence
Competence of person’s immune system
Length of intimacy of contact between person and microbe
Endemic
Occurs with predictability in one specific region or population
Pandemic
Global outbreak of new or existing virus.
Name possible reservoirs of microbes
people
soil
water and food
animals
inanimate objects
Common Portals of exit include?
Respiratory
GI
GU tracts
Breaks in skin
Blood and tissue
What are some means of transmission?
Direct
Indirect
Droplet
Airborne
Name the stages of Infection
Incubation Period- organisms growing and multiplying
Prodromal stage- Person is most infectious, vague, and nonspecific signs of disease.
Full stage- presence of specific signs and symptoms of disease.
Convalescent- Recovery from infection.
Vasodilation increases blood flow. Histamine released causes permeability of vessels and protein rich fluid to get to the site of injury
Vascular Phase
Cellular Stage
Leukocytes/ Neutrophils consume debris; damaged cells are repaired
Inflammatory Response
Helps body Neutralize, control, or eliminate the offending agent and prepare the site for repair.
Immune Response
Humoral
Cell Mediated
Humoral Immunity
Antigen- Foreign material
Antibody- Body response to antigen
Cell Mediated
Increase in lymphocytes that destroy or react with cells that the body recognizes as harmful
Factors affecting risk for infection
Intact skin and mucous membranes
pH levels
Body’s WBCs
Age, sex, and heriditary factors
Immunization, natural, or acquired
Stress
Use of indwelling medical devices
What Lab values indicate infection?
Elevated WBC
Increase in specific types of WBCs
Elevated erthrocyte sedimentation rate
Presence of pathogen in urine, blood, sputum, or draining cultures.
What are some Outcome Identification and Planning infection control
Demonstrate Hand Hygiene
Identify signs of infection
Maintain nutritional intake
Proper disposal of soiled articles
Use appropriate cleansing and disinfecting techniques
Proper Immunizations
Demonstrate stress reduction techniques
Medical Asepsis
Clean Technique to reduce number of pathogens
Surgical Asepsis
Sterile Technique to keep area free from microbes
ex: Indwelling catheter
Transient Flora
Attache loosely on skin. Removed with relative ease
Resident Flora
Found in folds of skin, requires friction with brush to remove
What are the 7 targeted HAIs
CAUTI
SSI
CLABSI
STAPH AUREUS
MRSA
C DIFF or C DIFF infections
Name some Multi- Drug Resistant Organisms
MRSA
VRSA
VRE
CDI
Carbapenem Resistant Enterobacteriacae
Acinetobacter Baumannii
What are some factors determining use of sterilization and disinfection methods?
Nature of organisms present
Numbe of organisms present
Type of Equipment
Intended use of equipment
Available means for sterilization and disinfection
Time
Used in the care of all hospitalized PTs regardless of diagnosis
Standard Precautions:
Name some PT teaching for Medical Asepsis at home
Wash Hands before eating foods or preparing
Prepare foods at high temps
Wash Hands and cutting boards before and after meats etc
Wash raw fruits and veggies
Use Pasteurized products
Use Individual care items
What are some ways we can evaluate PT goals
Correctly use techniques
Identify health patterns and lifestyle habits
State S/S of infection
Identify unsafe situations in home environments
What are some factors affecting safety?
Developmental consideration
PT environments
Functional ability
Developmental Considerations for Neonate and Infant
Fetal considerations. Mobility. Car seats.
Developmental safety considerations for school age children
Accidents
Child abduction
Bullying
Developmental Considerations for toddler and preschooler
Poisoning
Child Abuse
Environment
Asphyxiation
Developmental Considerations for Older Adults
Falls
Motor vehicle accidents
Fire
Polypharmacy
Elder Abuse
Adolescent safety considerations include
Driving
Piercings
Substance abuse
Social Media
Sex Trafficking
Adult safety considerations include ?
Drug Use
Intimate Partner violence
What are some safety considerations for Adults?
Remind them the effects of stress on lifestyle and health
Enroll in defensive driving course
Counsel unsafe habits
Counsel domestic violence
What is the safety plan for victims of domestic violence?
Safety. Safety. Safety. Safety. Safety. Safety
Leaving a relationship.
Name some safety considerations for Older Adults
Identify safety hazards in the environment
Modify environment
Encourage vision and hearing tests
Ensure availability assistive healthcare devices
Have operational smoke detectors in place
Objective document and report any signs of elder abuse
PT environments include?
Work
Social
Home
Functional ability includes?
Mobility
Sensory Perception
Ability to communicate
Knowledge
Health includes?
Physical and Psychosocial
Ways to Assess falls risk for older adults include?
History of falls or accidents
History of falls
History of drug abuse
Obtain knowledge of family support systems and home environments
Factors that contribute to falls
Poor gait and balance
Strength issues
Visual impairment
Problems with feet
Comorbidities
Use of Medications
Orthostatic hypotension
Hazards in community
Vitamin D deficiency
Name safety improvement Strategies
Preventing Falls Targeted Solutions Tool
Falls Toolkit
Falls Prevention Training Program
Root Cause Analysis
Pt Outcomes for Safety
Identify real and potential unsafe situations
Implement safety measurements
Use available resources
Remain free of injury
Preventing falls
Using restraints in health care facilities
Physiologic Hazards Associated with Restraints
Increased risk of falls
Skin breakdown
Contractures
Depression
Delirium
Anxiety
Death
Aspiration and respiratory difficulties
Facility safety includes:
Fire safety
Alarm management
Preventing equipment and procedure related accidents
Filing a safety event report
What are some procedure related accidents?
Transferring PTs
Changing a dressing
Administering meds
Safety event reports must be completed when?
After any accident or incident in a health care setting
Describe circumstances of the incident
Completed by Nurse
Not part of the medical record
Roles of the Skeletal System in Movement
Supports soft tissue of body
Protects crucial components of the body
Furnishes surfaces for attachment
Produces blood cells
Provides storage areas for minerals and fat
Freely movable joints include:
Ball and socket
Condyloid
Gliding
Hinge
Pivot
Saddle
Longs bones include:
Upper and lower extremities
Short Bones include:
Wrist and ankle
Flat Bones
Ribs and skull bones
Irregular Bones
Spinal column and jaw
Name some joint movements
Abduction
Adduction
Extension
Flexion
Rotation
Dorsiflexion
Plantar Flexion
What are the effects of nervous system on muscle contraction?
Neurons conduct impulses from one part of body to another
Afferent to CNS to Efferent Neurons
Name some Postural Reflexes
Labyrinthe Sense
Proprioceptor or kinesthetic sense
Visual or optic reflexes
Name factors affecting mobility
Developmental
Physical Health
Mental Health
Lifestyle
Attitude and Values
Fatigue and Stress
Risks related to exercise
Muscle shortening and active movement
Isotonic
Muscle contraction without shortening
Isometric
Muscle contraction with resistance
Isokinetic
Effects of immobility on the body
Cardiovascular System
Resp. System
Musco skeletal System
Metabolic Processes
Skin
GI
Urinary System
Psychosocial
Health History Includes
Daily Activity Level
Endurance
Exercise and fitness
Mobility Problems
External factors affecting mobility
Physical or mental alterations
Physical Assessment for Mobility
General ease of movement
Gait/ Posture
Alignment
Joint structure
Muscle mass
Endurance
Practice of designing equipment and work tasks to confirm to the capability of the worker
Ergonnomics
Name variables that can lead to PT handeling injuries
Uncoordinated Lifts
High exertion
Awkward postures
Manual Lifting
Repetitive movements
Standing for long periods of time
Variables leading to Back Injury to Healthcare workers
Uncoordinated lifts
Manual lifting
Lifting when fatigued
Transferring PTs
Repetitive movements
Name some equipment and assistive devices
Gait Belts
Friction Reducing sheets
Transfer chairs
Powered stand and assist
Mechanical lateral assist devices
Ways to Position PTs
Pillows
Mattresses
Adjustable Beds
Bed side rails
Trapeze Bar
Types of Positions
Fowlers
Supine/ Dorsal Recumbent
Side Lying
Sims
Prone
Name the VS
T
RR
HR
BP
SpO2
Pain
When do we check or obtain VS
On admission
Based on facility policies
Any time change in PT condition
Before and after any surgical or invasive procedure
Before and after activity that may increase risk
Before administering medications that affect CV or Resp. function
What is the primary source of metabolism?
Temperature
When additional heat is required and alter metabolism what is released?
Epi and Norepi
Axillary range Temperature
35.4-36.9 C
Oral Temp.
35.9-37.5 C
Rectal/Bladder Temp
36.3- 38.1 C
Temporal Artery Temp
- 3- 38.1 C
Tympanic Temp
36.8- 38,3
Name sources of heat loss
Skin
Evaporation of Sweat
Warming and humidifying air
Eliminating urine and feces
Without fever
afebrile
With Fever
Pyrexia
Intermittent Fever Temp
Returns to normal state at least once
Regulated by SA node
Pulse
Decreases HR
Parasympathetic
Increases HR
Sympathetic
Pulse Rate
Number of contractions over a peripheral artery in a minute
Name Assessment Considerations for Pulse
Rate
Amplitude
Rhythm
Stroke Volume- Blood ejected with each heart beat
Movement of air in and out of lungs
Ventiliation
Diffusion
Exchange of oxygen and CO2 in alveoli and circulating blood
Perfusion
Exchange of oxygen and CO2 between circulating blood and tissue cells
Most powerful Resp stimulant
CO2
Rate and Depth of breathing
Changes in response to tissue demands
Controlled by medulla and pons
Activated by chemoreceptors
`Eupnea
Normal breathing. One resp/ to 4 heartbeats
Dyspnea
Difficult or labored breathing
Orthopnea
Changes in breathing when sitting or standing
Difference between Systolic and Diastolic pressure is called
Pulse Pressure
SHort Term regulation of BP is caused by
Nerve or Humoral
Heart has what to monitor CV changes?
Baroreceptors
Name some factors affecting Blood Pressure
Age
Race
Circadian Rhythm
Biologic Sex
Food Intake
Exercise
Weight
Emotional State
Body Position
Drugs/ Meds
Hypotension
Decrease in Blood pressure
Side effect of Meds
Inability of the body to maintain or return pressure back to normal
Orthostatic Hypotension
Inadequate Physio response to position changes
Occurs when rising to an erect position
Caused by dehydration, blood loss, or problems of the neurologic, CV, or endocrine systems
Pulse Oximetry
Normal 90-100
Measures Peripheral arterial oxyhemoglobin saturation of arterial blood
Actual oxygen content of hemoglobin and potential max oxygen capacity of Hemoglobin
Conduction along pathways A delta to C delta fibers
Transmission of Pain
Types of Pain
Acute
Chronic
Location
Localized
Somatic
Visceral
Cutaneous
Referred
Inhibition or modulation of pain
Modulation
Activation of pain receptors
Transduction
Pain and nociception are the same?
False
Rapid onset of pain
Acute
May be limited, intermittent, or persistent
Lasts beyond normal healing period
Periods of remission
Chronic
PQRST
P- precipitating factors
Q- quality of pain
R- radiation
S- severity
T- timing
Terms used to describe pain
Quality
Severity
Periodicity
What are some basic methods of assessing pain?
PT self report
Identify pathologic or procedures causing pain
Report from family or other members close to PT
Nonverbal behaviors
Physiologic measures
What pain assessment tools do we use?
Numeric Rating Scale
Adult nonverbal scale
Wong Baker Faces
Nursing Interventions for Pain
Establishing Trusting relationship
Manipulating the Pain
Managing Pharm measures
Ensuring ethical responsibility to relive pain
Understanding Placebo controversy
Complementary Health Approaches and Integrative Health Care
Distraction
Humor
Music
Imagery
Mindfulness
Acupuncture
Hypnosis
Biofeedback
Cutaneous Simulation
Teaching about Pain
Should include family members
Explanation about pain scales
Safety
Keep diary of pain
Diet
Types of Data
Subjective - Based on PT experiences and perceptions
Objective- Measurable and directly observed.
Health Assessment includes what?
Health History
Physical Assessment
Types of Health Assessments
Comprehensive
Ongoing partial
Focused
Emergency
What are some factors to assess during a health history?
Intake
Bio data
Reason for care
History
Family history
Functional health
How to prepare the PT for physical assessment
Consider physio and psycho needs of the PT
Explain the process
Alleviate anxiety
Explain each procedure
Lifespan considerations
Cultural considerations
PT prep
Environmental Prep
Sims
Assessment of rectum or vagina
Prone
Assessment of hip joint and posterior thorax
Lithotomy
Assessment of female genitalia and rectum
Knee Chest
Assessment of anus and rectum
Name techniques used during a Physical Assessment
Inspect
Palpate
Percussion
Auscultation
Head and Neck assessment includes ?
Identify risk factors changes in vision and hearing
History of trauma
Thyroid Gland and Lymph nodes
Inspection and palpitation
Respiratory Assessment
Identify Risk Factors
Chest Expansion
Name some Lung sounds
Bronchial
Bronchovesicular
Vesicular
Wheeze
Rhonchi
Crackles
Stridor
Friction Rub
What are some common thorax and lung variations in Older adults?
Increased AP chest diameter
Increased in spine curve. (kyphosis)
Decreased expansion
Use of accessory muscles to exhale
CV Assessment
Identify Risk Factors
Inspection, palpitation, and auscultation
Heart Sounds, Pulses, and CArotids
Cardiovascular Variations in Older Adults
Difficult to palpate apical pulse
Difficult to palpate distal arteries
Varicosities
Increased BP
Widening Pulse Pressure
Name the order for Abdominal Assessment
Inspection
Auscultation
Percussion
Palpatation
Abdominal VAriations in older adults include:
Decreased in bowel sounds and abdominal tone
Fat accumulation in abdomen and hips
Musculoskeletal Assessment
Identify Risk Factors
ex: Trauma
History of pain
Frequency and type of exercise
Diet
Smoking
Inspection and palpation
Neurological Assessment
Identify risk factors
Health History
Mental Status
Memory
Cognitive abilities
Cranial Nerve Function
Motor and Sensory Relexes
Ways to Assess Mental Status
LOC
GCS
Memory
Language
What are the purposes of documentation of health history and physical assessment?
Identify actual and potential problems
Plan care
Evaluate PT response
Integrative Health
Refers to the combination of complementary health and conventional health approaches in a coordinated way
Treatment of symptoms and diseases using drugs, radiation, or surgery
Allopathic Medicine
Theory and philosophy that focuses on connections and interactions between parts of the whole
Holism
Practice built on a holistic philosophy and healing the whole person
Holistic Nursing
Integrative Health Care
Combination of allopathic and complementary and alternative modalities.
Allopathic Medicine
Illness occurs in either the mind or body
Health is absence of disease
Main cause are pathogens
Empahsis is on disease and high technology
Holism
Focuses on connections of parts of the whole
Body is a dynamic whole
Name some Complementary Health Practices
Mind Body
ex: Relaxation Meditation
Qi Gong
Acupuncture
Yoga
Ayurveda
Hygiene Assessment
Hair Nails Feet
Skin
Cultural considerations
developmental levels
Oral Hygiene
Visual
Hearing
Assessing the Skin
Incorporate with all body systems
Use good lighting
Symmetry
Identify variables known to cause skin problems
Name the structure and function of the skin
Epidermis - Waterproof layer with no blood vessels
Dermis- Made of collagen made of nerves, hair follicles, glands, and blood vesels
Subcutaneous- Anchors skin layers to underlying tissues
Protection
Body Temperature
Psychosocial
Vitamin D Production
Absorption
Elimination
Name some factors affecting the skin
Very thin or obese people
Fluid loss in illness causes skin breakdown
Diseases such as eczema may cause lesions that require care
Jaundice- Yellow color of skin
As the person ages
Maturation of epidermal cells prolonged leading to thin skin
Decreased collagen = decreased elasticity= risk for tissue damage
Name some principles of Wound Healing
Intact Skin is 1st line of defense
Normal healing is promoted when the wound is free of foreign material
Response of wound is more effective with proper nutrition
Local Factors Affecting Wound Care
Pressure
Desccation- Dehydration
Maceration- Overhydration
Trauma
Edema
Infection
Infection
Biofilm
Necrosis
Systemic Factors Affecting Wound Healing
Age
Circulation and Oxygenation
Nutritional Status
Wound Etiology
Health Status
Immunosuppression
Medication Use
Adherence to Treatment of Pain
Factors Affecting Pressure Injury Development
Aging Skin
Chronic Illnesses
Immobility
Malnutrition
Fecal and Urinary Incontinence
ALOC
Spinal and Brain Injuries
Friction/ Shearing forces
Microclimate
Stage 1 Pressure Injury
Nonblanchable red intact skin
Stage 2 Pressure
Partial Thickness skin loss with exposed dermis
Stage 3 Pressure
Full thickness skin loss not involving the underlying fascia.
Stage 4 Pressure
Full thickness skin and tissue loss
Unstageable Pressure
Obscured full thickness skin and tissue loss
Deep Tissue Pressure Injury
Persistent Non blanchable purple or red discoloration
Ways to prevent Pressure Injuries
Assess at risk PTs daily
Cleanse skin routinely
Maintain higher humidity
Proper positioning
Nutritional supplements
Improve mobility and activity
What are some factors affecting the response to Hot/ Cold therapies?
Method and Duration
Degree of heat and cold applied
PT age and condition
Amount of body surfaced covered by application
Effects of Applying Heat
Dilates peripheral blood vessels
Increase tissue metabolism
Reduces blood viscosity and muscle tension
Helps relieve pain
Effecrs of Applying Cold
Contricts blood vessels
Reduces Muscle spasms
Promotes comfort
Assessment of Oral Cavity
Lips
Buccal
Color of gums
teeth
tongue
hard/soft palates
Oropharynx
Ways of administering oral hygiene
Moistening mouth
Cleaning mouth
Caring for dentures
Toothbrushing and flossing
Using Mouthwashes
Early Morning Care includes
Assist Pt with toileting
Provide comfort measures
Wash face and hands
Provide mouth care
After morning breakfast nurse completes:
Toileting
Oral care
Bathing
Back massage
Special Skin measure
Hair
Dressing
Refreshing Bed
Tidying bedside
Afternoon Care
Ensure PT comfort after lunch:
Offer toileting
Straighten bed linens
Help PT with mobility
HS Care
Offer assistance with toileting, washing, and oral care
Change bed if soiled
Ensure call light and objects in reach
Position comfortably
PRN Care
Offer hygiene as needed
Oral care when needed
Change bed linens as needed
Bath Time does what?
Cleanse skin
Helps relax a person
Promotes circulation
Stimulates respirations
Helps improve self image
Strengthens nurse to PT relationship
Perineal and Vaginal Care
Cleanse with soap and water
Assess
Perform in a dignified manner according to procedures
Care of Eyes
Clean from inner to outer
Use artificial tear solution or NS if blink reflex is absent every 4 hours
Care for glasses or contacts
Ear and Nose Care
Perform hearing aid teaching
Wash ears with wash cloth
Clean nose by having PT blow nose
Remove crusted secretions by applying a warm compress
Providing Hair Care
Identify PT usual hair and scalp care
History of hair or scalp problems
Treat any infestations
Groom and shampoo
Care for beards
Use electric razor for PT on anticoags
Nail and Foot Care
Assess Nail for color and shape
Check for History of health related problems
Soak nails and feet and assist with cleaning
Massage feet to promote comfort and relaxation
Provide diabetic foot care if needed
How to ensure bed safety
Bed in lowest position
Safe for PT
Bed controls are working
Call light in reach
Side rails raised
Wheels are locked
PT Outcome Achievement
Level of PT participation in hygiene
Elimination of factors affecting PT’s hygiene
Changes related to specific skin problems and independent PT management of prescribed treatment program
Rest
Refers to a condition in which the body is in a decreased state of activity
Define Sleep
Sleep is a state of rest accompanied by altered consciousness and relative inactivity.
Stages of Sleep
Stages 1 to 4
Contains NREM and REM
What happens in REM?
Everything in body increase except skeletal tone and DTRs.
A person passes through consecutively through 4 stages of sleep
True. Then the pattern is reversed.
What are the effects of ineffective sleep?
May affect normal growth.
May increase obesity.
Lowers Leptin levels and increases Ghrelin
Name factors affecting sleep
Activity/ Exercise
Dietary Habits
Smoking
Stress
Medication effects
Sleep Disorders
OSA
Obstructive Sleep Apnea
Characterized by at least 5 or more of the following
The absence of breathing
Diminished breathing
Respiratory effort related arousals
Subjective nocturnal Resp disturbances
Gasping for air
Observed apnea and other disorders
RLS
Restless Leg Syndrome also known as Willis Ekbom disease in middle aged and older adults. 15%
Can’t lie still and report unpleasant creeping
Non Pharm treatments
How to obtain Sleep History
Nature of problem
Cause of problem
Related Signs and Symptoms
When the problem began
How it affects everyday living
Severity of the problem
How the PT is coping with the problem
Screening Tools to Assess Sleep Disturbances
Sleep Diary
Sleepiness Scale
Stop Bang Questionaire
What are some nursing interventions to promote sleep?
Prepare a restful environment
Bedtime rituals
Appropriate snacks and beverages
Promote relaxation and comfort
Use meds
Teach about rest
Schedule care to avoid disturbances
Six Classes of Nutrients
Nutrients that Supply energy
Carbs, lipids, and Proteins
Nutrients that regulate Body processes
Vitamins, Minerals, and Water
Energy Balance
Derived from food. From lipids, carbs, and proteins
BMR
Energy required to fuel involuntary activities of the body at rest after 12 hours. Energy needed to sustain metabolic activities.
Increase BMR: Stress, infection, fever, emotional stress, extreme temps
Decrease BMR:
Aging, Fasting, and sleep
BMI
Ratio of Kg to HT
Estimate body fat
Provides estimation to relative risk for diseases
May be inaccurate for some groups
Vitamins Fat Soluble
A D E K
Absorbed through intestinal wall into bloodstream
Vitamins
Organic compounds needed in small amounts
Minerals
Organic elements found in all body tissues and fluids
Macrominerals
Calcium, potassium, phosphorus, sulfur, sodium chloride, magnesium
Microminerals
Iron, zinc, manganese, copper, fluoride, molybdenum, selenium, iodine
Water
Two Thirds is intracellular fluid
One third is ECF
Provides fluid medium necessary for all chemical reactions
Acts as a solvent and aids digestion, absorption, circulation, and excretion.
Factors affecting nutritional intake
Medications
Religion
Culture
Decreased = Anorexia
Increased= Obesity
Nursing Interventions for Nutrition
Teaching nutritional information
Monitoring nutritional status
Stimulate appetite
Assist with eating
Providing oral nutrition
Providing long term support
Types of Diet
Therapeutic
Consistent Carb
Fat or sodium restricted
High or Low Fiber
Renal
Modified
Clear liquid
Pureed
Mechanically altered
Short Term Nutritional Support
Use NG or NI route
Confirm placement
Measurement correctly
CO2 monitoring
Long Term Nutritional Support
Enterostomal tube is created
Comatose preferred route is
Gastrostomy
Placement of the tube can be done by the surgeon or gastroenterologist via PEG or surgically opened
True
Enteral vs Parenteral Feeding
Highly concentrated hypertonic solutions that contains amino acids, carbs, and lipids
Given through Central line
PPN vs TPN
Micturition
Process of emptying the bladder
Detrusor muscle contracts, internal sphincter relaxes and urine enters the posterior urethra.
Muscles or perineum and external sphincter relax
Muscle of abdominal wall contracts slightly
Diaphragm lowers and urination occurs
Diseases associated with Renal
DM
Gout
UTI
Hypertension
Polycystic Kidney Disease
Direutics
Prevent reabsorption of water and certain electrolytes in tubules
Cholinergic
Stimulate contraction of detrusor muscles
Analgesics
Supress CNS and neural reflex
Medications that affect Urine
Anticoags- red
Direutics- yellow
Pyridium- orange
Antidepressant- Blue
Levodopa- brown
Nursing History
Usual Patterns of urinary elimination
Recent changes in urinary elimination
Aids to eliminate
Present or past occurrence
Presence or urinary diversion
Physical Assessment of Urinary Functioning
Kidneys - Palpitation done by advanced practitioner
Urinary Bladder - Palpate and bladder scanner
Urethral Orifice- Signs for infection, discharge, or odor.
Skin- Assess color, texture
Urine -Assess for color, ordor, and temperature.
Measuring Output- Continent PT, Incontinent PT, Indwelling catheter
Routine Urinalysis-
Clean catch or midstream
Sterile Specimen
Urinary Diversion
24 Hour Specimen
Measuring Urine Output
Ask the PT to void into the bedpan or bathroom or urinal
Put on gloves
Read at eye level in proper device
Document and record
Discard urine unless specimen is needed
Ways to promote urinary elimination
Maintaining regular voiding habits
Promoting fluid intake
Strengthens muscle tone
Assisting with toileting
Planned PT goals for Urinary
Fluid and electrolyte balance
Empty bladder regularly
Ease of voiding
Maintain skin integrity
Equal input and output
PTs risk for UTIs
Sexually active people with female genetalia
Postmenopausal
PT with indwelling catheter
People with DM
Older adults
Transient
Appears suddenly and lasts 6 months or less
Mixed
Urine loss with features of two or more types of incontinence
Overflo
Overdistention and overflow of bladder
Functional is caused by outside factors.
True.
Reflex
Emptying bladder without sensation of need to void
Total
Continuous unpredictable loss of urine
Stress
Involuntary loss of urine related to an increase of abdominal pressure.
Urine Collection Devices
External
Internal
Absorbent Products
Consider functional disability, type and severity, gender, PT preference
Process of Peristalsis
Under control of nervous system
Contractions occur every 3to12 minutes
Mass Peristalsis sweeps occur 1-4 times in a 24 hour period
1/3rd to 1/2 is exerted in stool within 24 hours
Name some variables influencing Bowel Elimination
Developmental considerations
Daily Patterns
Food and Fluid
Actvity and muscle tone
Lifestyle
Psychological Variables
Pathologic conditions
Meds
Surgery and Anesthesia
Older Adult and BM
Constipation is chronic
Diarhhea or fecal incontenence may result from physiologic or lifestyle changes
Sequence for abdominal assessment
Inspect
Auscl
Percussion
Palpatation
Physical Assessment of Anus and Rectum
Inspection and palpatation
Lesions, ulcers, and fissures
Ask PT to bear down as having a BM
Inspect perineal area.
Stool Collection
Medical A sceptic technique
Hand hygiene
Wear disposable gloves
Do not contaminate
Label and transport accordingly
Stool Characteristics
Volume
Color
Odor
Consistency
Shape
Constituents
Bowel Habits
Timing Positioning
Privacy
Hygiene
Nutrition
Exercise
Direct Visualization Studies :
EGD
Colonoscopy
Sigmoidoscopy
Wireless Video Capsule
Indirect Visualization Studies
UGI
Small Bowle Series
Barium Enema
Abd. Ultrasound
MRI
CT scan of Abd.
PT Outcomes for normal BMs
Soft and formed w/out discomfort
Able to explain the relationship between BM and dietary fiber, fluid intake, and exercise.
Skin integrity and notify HCP if anything of stool changes
Name Individuals at High Risk for Constipation
PT on bedrest or immobility
PT taking constipating meds
PT with reduced fluids
PT that is depressed
PT with CNS diease or local lesions that cause pain while defecating
Nursing Measures for PT with Diarrhea
Answer Immediately
Remove cause
Risk for impaction hold antidiarrheal meds
Give special care to anus region
Ways to Prevent Food Poisoning
Take item refrigerate immediately
Wash hands and surfaces
Use separate cutting boards
Wash all fruits and Veggies
Never use raw eggs Do not eat seafood raw or undercooked
Use food thermometer
Keep food hot after cooking
Methods of emptying the colon of feces
Enemas - Cleansing and retention
Hypertonic large and small volumes
Rectal Suppositories
Oral intestinal Lavage
Digital removal
Managing Bowel Incontinence
Note when it likely to occur
Keep the skin Clean and Dry
Change bed and clothing
Bowel training programs
Indwelling rectal tube
External anal pouch —————
Bowel Training Programs
Manipulate factors within PT control
Plan bowel program w PT and family
Set regular time for BM
Monitor
Ensure privacy and adequate fluid and diet
Stimulate BMs
Alternatives
NG tubes
Ostomies
Functions of Water in the Body
Transporting nutrients and wastes from cells
Facilitating cellular metabolism
Acting as solvent
Maintains body temperature
Acting as tissue lubricant
ICF
70% fluid in cells
ECF
intravascular and interstitial
30%
Fluid Loss
Kidneys- Urine
Intestinal- Feces
Skin- Perspiration
Insensible water loss
Hypovolemia
Deficiency in amount of water and electrolytes in ECF with near normal limits
Interstitial to plasma shift
Movement of fluid from space surrounding cells to blood
Sodium
Controls and regulates volume of body fluids
Potassium
Chief regulator of cellular enzyme activity and water content
Calcium
Nerve impulse
Blood clotting
Muscle contraction
b12
Magnesium
Metabolism of carbs and proteins
Vital actions of enzymes
Chloride
Maintains osmotic pressure in blood and produces HCI
BICARB
Body’s primary buffer system
Phosphate
Involved in important chemical reactions in the body, cell division, and hereditary traits
Osmolarity of Solutions
Isotonic- Same concentration as plasma
Hypo- Lesser than plasma
Hyper- Greater than plasma
Capillary Filtration
Passage of fluid through permeable membrane from high to low pressure
ACID
Substance containing hydrogen ions that can be liberated or released
Base
Substance that traps Hydrogen ions
Acidosis
Excess Hydrogen ions
Alkalosis
Loss of hydrogen ions
RF for Imbalances
Patho of acute or chronic illnesses
Abnormal losses of body fluids
Burns
Trauma
Surgery Therapies that disrupt fluid imbalances
Physical Assessment
Skin and tongue turgor
Moisture of oral cavity
Tearing and salivation
Appearance and Temp of skin
Facial Appearance
Edema
VS
Expected Outcomes
Maintain appropriate fluid intake and output balance
Urine specific gravity 1.010- 1.035
Imbalance occurs:
Report relief of symptoms
Exhibit S/S of restored balance
Identify S/S of recurrence
Implementation of Electrolyte Imbalances
Preventing them
Developing diet plan
Modifying Fluid intake
Administering Meds
Administering IV fluid therapy
Nurses Role In Diagnostic Procedures
Assist before, during, and after
Complete Testing
Witness PT consent
Schedule Test
Prepare the PT physically and emotionally
Provide care and teaching after the test
Dispose used equipment
Transport specimens
