NURS 264 Exam 1 Flashcards
What is evidence based practice?
- Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences.
- Clinical decision making = best evidence from literature review + patient’s own perspective + clinician’s experience/expertise + physical exam.
Evidence based practice barriers?
- Nurses lack research skills to evaluate quality research
- Nurses are isolated from colleagues who know how to conduct research
- Nurses lack confidence to make change
- Organizational characteristics of health care settings
- Nurses lack time to go to the library
- Institutions lack library research holdings
- Organizational support for EBP is lacking when nurses want to make change
Nursing Process (Assessment)
- The process of collecting subjective and objective (facts) data, medical history, medications, labs.
Nursing process (Diagnosis)
Clinical judgement about a persons response to an actual or potential health state
Nursing process (Planning)
Goal, interventions that are planned to be implemented to treat the issue present
Nursing Process (Implementation)
Prioritize and implement the interventions that have been planned
Nursing Process (evaluation)
Did the plan work? Should we continue? Should we modify it?
Inspection (What is it?)
- Close careful scrutiny, first of individual as a whole then of body systems
- Begins when you first meet the person with a general survey
- inspection requires, good lighting, adequate exposure, occasional use of instruments.
Palpation (What is it?)
- Palpation applies sense of touch to assess
- Texture Temperature and moisture
- Organ location
- Swelling, vibration, pulsation
- rigidity or Spasticity
- Presence of lumps or masses and tenderness
- Should be performed slowly and systematically (light to deep)
Palpation Techniques (What parts of the hand to use)
- Fingertips: best for fine tactile discrimination of skin, texture, swelling, pulsation, determining presence of lumps
- Fingers and thumb: detection of position, shape, and consistency
- Dorsa of hand and fingers, best for temperature
- Base of fingers or ulnar surface of hand: Best for vibration
Percussion (What is it?)
- Tapping persons skin with short, sharp strokes to assess underlying structures
- Used to: map location and size of organs, signal density of structure, detecting superficial abnormal mass, eliciting pain, eliciting deep tendon pain
Percussion (both hand methods)
The Stationary Hand: Hyperextend the middle finger, press with other middle finger.
The Striking Hand: Use the middle finger of dominant hand, tap on it with opposite hand.
Percussion (4 Types of Sound)
- Amplitude (loud or soft)
- Pitch (high or low)
- Quality (describe it: resonant, tympany, dull)
- Duration (length of time sound lingers)
Auscultation (What is it?)
- Stethoscope does not magnify sound but it blocks out extraneous sound
- Keep environment warm and warm the stethoscope
- Avoid listening over hairy body parts
- Never listen through clothes
Organization of assessment 4 Steps
- Inspection
- Palpation
- Percussion
- Auscultation
* however these can be rearranged depending on the order they may disturb the patient given their age
Subjective Data (Definition)
Information gathered from patient that is by their own interpretation of themselves
Objective Data (Definition)
Data obtained from assessments or other facts from medical records
4 types of database (Complete total health database)
Describes current and past health state and forms baseline to measure all future changes
4 types of database (Focused or problem centred database)
Collect mini database, smaller scope and more focused than complete database
4 types of database (Follow up database)
Status of all identified problems should be evaluated at regular and appropriate intervals
4 types of database (Emergency database)
Rapid collection of data often compiled concurrently with lifesaving measures
Priority levels (What are the three?)
- First level: Emergent, life threatening
- Second level: requiring attention to avoid further injury
- Third level: Important but not in risk of becoming worse without immediate intervention.
Process of communication (3 Parts)
- Sending: verbal communication, nonverbal communication
- Receiving: be aware of how someone may receive the message, reduce the risk of misunderstanding.
- Interpreting: the process of understanding what the patient says
Holistic health Definition
It is the interdependent functioning of mind, body, and spirit to maintain optimal health and health depends on all of these working together.
Nursing diagnosis (Definition)
Clinical Judgement about a persons response to an actual or potential health state
Risk Diagnosis (Definition)
Identified actual or potential risks from both medical and nursing assessment
Phases of the interview
Introducing the interview: asking the persons name and introducing yourself
Working phase: the data gathering phase
Closing the interview: summarize what you have gathered and offer a chance to ask any questions.
Techniques of Communication (Clarification and Confrontation)
- Clarification: summarize persons words simply and ensure you are on the right track
- Confrontation: clarifying inconsistent information
Techniques of communication (Interpretation and empathy)
- Interpretation: linking events and making association that imply cause, based on inference or conclusion
- Empathy: Names a feeling and allows its expression, allows person to feel accepted.
What is a health history?
Used to collect subjective data to combine with objective data from physical exam.
Helps to provide a complete picture of patients past and present health status.
Can be used as a screening tool for detection of abnormalities.
External factors of communication (What are they)
- Ensuring Privacy
- Refuse interruptions
- Physical environment
- Dress
- Note taking (keep to a minimum)
Internal factors of communication (What are they)
- Liking others (being genuine)
- Empathy
- Ability to listen
- Self awareness
What is the purpose of Review of systems?
- Evaluate past and present state of each body system
- Assess that all pertinent data relative to each body system have been noted
- evaluate health promotion practices
Examination of different ages (What is different for each?)
- The ill person: need to alter patients position, adapt to their comfort level, perform focused assessments.
- Older adults: may not admit to pain, delay in responses, dementia does not impact pain, pain is not normal with age
- Infants: feel same the pain as adults, sometimes more sensitive, higher risk for under pain management
- Adolescents: are less likely to tell truth with parents around, do not give them a yes or no choice when assessing.
What are the 8 critical characteristics?
- Location (of pain)
- character or quality (provide descriptive terms)
- Quantity or severity (use scales to identify)
- Timing (onset Duration)
- Setting (location and associated activity)
- Aggravating or relieving factors
- Associated factors (is it related to anything else)
- Patient perception (how does it affect you?)
Functional assessments (What are the 4 and what do they assess?)
- Activity (what tasks does it inhibit)
- Sleep (how does it affect your sleep)
- Nutrition (Are you having troubles eating properly)
- Coping/Stress (does it stress you out more)
What is the biggest thing we can do to reduce the spread of infection?
Wash your hands properly
PQRSTU What do each of them stand for?
P - Provocation
Q - Quality/quantity
R - Region/radiation
S - Severity scale
T - timing (When does it happen)
U - Understanding
What age can pain rating scales be used on children?
- 4 to 5 years old
- FPS - R (facial pain scale - revised)
What behaviours signify acute pain?
- guarding, grimacing
- vocalizations such as moaning
- agitation, restlessness, stillness
- diaphoresis
- change in vital signs
What behaviours signify Chronic pain?
- Bracing, rubbing
- diminished activity
- sighing
- change in appetite
How to assess pain in infants
- the best way is with expressions and body movements
- look for changes in temperament, expression, and activity like sweating, nausea, vomiting, and change in vital signs
What 5 things are different when taking Vital signs in infants.
- Take temperature in the ear (pull down)
- Temperature may be elevated in the afternoon
- Pulse Should be counted for a minute
- Watch abdomen rise for respirations
- Check in Resp, Pulse, Temp order.
What 4 things should be remembered when taking vital signs in older adults
- Lower temperature with age
- Normal heart rate range is 50 to 95 bpm
- Breathing becomes more shallow with age
- Major arteries tend to harden with age (Systolic pressure increases, widened pulse pressure.
Normal temperature range (What is it?)
- orally it is 35.8 to 37.3
What is MAP
- Pressure forcing blood into tissues, averaged over the cardiac cycle.
What are orthostatic vital signs?
They are taken over the course of sitting and standing and measuring blood pressure and respiratory rate both times.
- Usually peoples systolic pressure is 10 less when standing vs sitting.
Orthostatic hypotension (What is it)
- occurs when a systolic BP drop of 20 (or diastolic drop of 10), and pulse increase of 20 bpm or more occur when going from supine to standing
Common mistakes relating to high blood pressure? (5 of them)
- Taking when someone has exercises
- Arm below the heart
- Crossed legs
- Cuff too narrow and lose
- Reinflating during procedure/not waiting
Common mistakes leading to low blood pressure (3 of them)
- Arm too high above heart
- Decreased inflation
- Too large cuff size
What is a normal resting heart rate
- 50 to 95 bpm
What is normal breathing rate?
- 16 to 25 Breaths/minute
What is hypopituitary dwarfism?
It is caused by deficiency in growth hormone
Achondroplasmic dwarfism (what is it?)
Genetic disorder, normal trunk size but short arms and legs
Gigantism (what is it?)
Excess growth hormone as a child
What is acromegaly?
Excess growth hormone as an adult
Anorexia nervosa (what is it?)
Mental health disorder that causes weight loss
Bulimia what is it?
Mental health disorder, binge and purge
Crushings syndrome what is it?
Excess ACTH causing weight gain
Marfan syndrome (what is it?)
A genetic connective tissue disorder where you usually grow tall but thin
Marfan syndrome (what is it?)
A genetic connective tissue disorder where you usually grow tall but thin
