Week 1-7 Flashcards
What factors influence growth and development?
Genetic, temperament,
family, nutrition,
environment, health, culture
How do genetic factors influence GD?
genetic factors are hereditary blueprints made when male speak fertilises female ovum
Both sperm and ovum contain 23 chromosomes and combine to form zygote with 46 chromosomes
Genetic material is passed in equal proportions from father and mother
How does temperament influence g and d ?
A child’s temperament will affect its behavior
•Of course outside influences impact on a developing fetus
Eg. If the mother smokes, drinks alcohol and takes illicit drugs this will have a profound effect on the baby.
..FASD Fetal alcohol syndrome is shown to have detrimental effects on the growing fetus which effects the child’s health and development throughout the lifespan.
What is a temperment?
The temperament is formed in the child’s biology
- It is a set of inborn traits which gives the child its distinctive personality
- Thomas Chess & Birch 1970 coined three temperament types
- Easy , Slow to warm up and difficult
How does family influence growth and development?
When we look at socioeconomic status we clearly see that a child whose parents are lower on the socioeconomic gradient have more health problems and likely to die earlier in life than someone who is high on this gradient
How does nutrition influence g and d?
What we eat and drink determines whether we will have a healthy life or not
Type 11 diabetes is a significant health problem across the world
If a mother has a very healthy diet eg fruit and vegetables protein and carbohydrates in balance the baby is going to born healthier and likely to keep to that style of eating
How does the environment influence g and d?
Where you live will have a significant impact on your health
We know from Aboriginal Health that people who live remotely will die 11years earlier than their Australian counterparts
IF someone lives remotely in Africa and is drinking poor quality water they are more likely to die sooner than someone who is living in a wealthy city.
How does health influence g &d
People who are born to families that have genetically induced cancers and other genetic diseases are more likely to contract those diseases than someone else who is not.
Health is also determined by environment and lifestyle
Someone born in Somalia to poor parents are likely to die earlier than someone born in UK to well off parents
How does culture influence g and d
Culture has a huge impact on growth and development.
Language is one of the many ways through which culture affects development.
Parents in different cultures also play an important role in moulding children’s behaviour and thinking patterns.
Cultural differences in interactions between adults and children also influence how a child behaves socially
Why is effective communication important
it’s critical to gathering assessment data for nursing diagnoses, to developing understandings of the person receiving care, to instructing and cooperating in care delivery, to teaching, to expressions of caring and com- fort and to collaboration with health colleagues.
What makes verbal communication more effective?
effective when the criteria of pace, intonation, simplicity, clarity, brevity, timing, relevance, adaptability and credibility
What does non verbal communication do
often reveals more about a person’s thoughts and feelings than verbal communication; it includes personal appearance, posture and gait, facial expressions and gestures.
How do you know if communication between 2 has been effective
receiver and sender accurately perceive the meaning of each other’s message.
When assessing verbal and non verbal behaviours should a nurse be aware of culture?
Yes. the nurse needs to consider cultural influences and be aware that a single non-verbal expression can indicate any of a variety of feelings and that words can have various meanings.
Factors that influence the communication process?
development, gender, culture, values and perceptions, personal space (intimate, personal, social and public distance), territoriality, roles and relationships, environment, congruence and interpersonal attitudes.
Techniques that facilitate therapeutic communication?
expressing empathy, prompting, instructing, using silence, probing—using open and closed questions, using touch, restating or paraphrasing, seeking clarification, perception checking or seeking consensual validation, offering self, providing information, encouraging, focusing, reflecting, summarising, confronting and self-disclosure.
Techniques that hinder communication
stereotyping, being defensive, testing, rejecting, false reassurance, passing judgement, arguing, patronising, agreeing and dis- agreeing, excessive questioning and giving common advice.
4 phases of therapeutic relationship?
pre- interaction phase, the introductory phase, the working phase and the termination phase; each has a specific goal and tasks, with each phase requiring specific skills of the nurse.
What to do when a patient experiences deficit in their communication?
careful nursing assessment is needed to identify the deficit and to implement appropriate nursing actions to restore nurse–patient communication.
Ways a nurse can help with communication problems?
To help people with communication problems, the nurse manipulates the environment, provides support, employs measures to enhance communication and educates the per- son and support people.
How may nurses evaluate their own communication?
• Mentor feedback is used by nurses to evaluate their own communication. Nurses can review both the process and the content of the communication and identify both communication strengths and areas for improvement.
Aim of handover?
Its aim is to hand over responsibility for the care of the person to the next nurse/shift and to ensure a safe continuity of care. Use of acronyms such as ISBAR are effective tools in promoting clear communication and maintaining care safety
What does assertive communication do
promotes care safety by minimis- ing miscommunication with colleagues. An important char- acteristic of assertive communication is the use of ‘I’ statements.
What does non assertive communication do?
includes two types of inter- personal behaviours: submissive and aggressive.
What are some members of the interprofessional healthcare team?
Student – nursing or midwifery RN EN Midwife NP Healthcare worker Unregulated carer Patient care attendent Technician Medical personnel Pharmacist Social worker Dietitian Psychologist Podiatrist Occupational therapist Speech pathologist Counsellor physiotherapist
What is a healthcare worker
Various roles undertaken by ealthcare workers. They may function independently or in collaboration wit the interdisciplinary healthcare team. eg. Aboriginal or maori healthcare worker, physioterapy assistant or dietary assitant
What is an unregulated worker
A variety of roles exist for people who care for patients without licencing requiremmens . They may undertake activities delegated by the RN or idwife according to their competence eg. Carer, personal care assistants and AINs
What is a medical personnel
Several levels of medical personeel. Eg. Resident medical officers like interns, resident medical officers, registars, senior registars also are consultancy medical officers
What is a podiatrist
Practitioner of podiatry(chiropody) who deals with the conditions of the feet and their ailments.
What is a patient care attendant?
People employed by a facility to support the care requireents of patients. They mmay have functions that involve oving or positioning patients or equipment , attending to the personal needs of patientsor disposing of soiled equipment.
What is a technician?
People who work with specialised equipment Eg. Anaesthetic technicians and sterile supply technicians
What is an OT
Encourage rehabilitation through performing activities of daily living
Factors that can undermine inter-professional communication and collaborative practice
■ Disruptive behaviours and lack of interprofessional respect
■ Passive–aggressive behaviours exerted by health professionals who consider themselves to be disempowered
■ Feeling of ‘being taken for granted’ with work and roles not understood or valued by other team members
■ Different focus and orientation for different professions; for example, ‘care’ as opposed to ‘cure’
■ Gender differences and power differentials; for example, nursing and allied health being mainly female professions
■ Nurses (and others) unwilling to ‘rock the boat’ by challenging authority
■ The diverse and ever increasing array of health professions, specialities and subcultures, each with its own terminology and norms
■ Different professions training separately leading to misunderstandings and miscommunication.
attributes of effective team members?
■ Committedtothegoalsandvaluesoftheteam;forexam- ple, continuum of care for people discharged from the ward.
■ Effective communication skills, including team communication.
■ Enjoy working collaboratively and collectively with others.
■ Use cooperative rather than competitive approaches.
■ Willingly communicate openly with team members.
■ Listen actively to others.
■ Suspend judgment and consider the views of others with- out personal bias.
■ Trust and respect colleagues, team members and them- selves.
■ Expertise that complements team-member expertise.
■ Readiness to applaud the work of others.
Features of effective groups/ teams
Atmosphere Purpose Leadership and member participation Communication Decision making Cohesion Conflict tolerance Power Problem solving Creativity
What type of care do nurses provide?
person centered care
What forms the family structure
The individual
What does assessing family structure allow?
Assessing the family structure enables you to plan your (family centred) care
What are the different family unit designs?
Traditional family •Nuclear family •Extended family •Dual career family •Single parent family •Adolescent family •Foster family •Blended family •Intragenerational family (matriach/patriach) •Cohabitating family •Gay & lesbian family •Single adults
So what are we assessing when we are assessing families?
- Family function (or …)
- Family interaction/ communication
- Family strengths and weaknesses
- Health status of family members
•Communication styles •Child rearing styles •Health practices and health beliefs Family coping mechanisms Risk of health problems Maturity/ age/ hereditary/ ethnic/ sociological Lifestyle
•Literacy/numeracy/education standard
What is family structure?
Size and type of family
Age and genders of members
What to consider in family roles and functions during assessment?
- Family members working outside the home
- household roles and responsibilities + distribution
- sharing of child rearing responsibilities
- major decision maker and methods of decision making
What to consider about physical health status during family assessment?
- current physical health status of each member
- perceptions of own and other family members health
- preventative health practices ( Eg. Status of immunisations, oral hygiene practices)
- routine healthcare, when and why physician last seen
What to consider about interaction patterns in family assesment?
- ways of expressing affection, love, sorrow, anger and so on
- most significant family member in persons life
- openness of communication with all family members
What to consider about family values during family assessment?
- cultural and religious orientations; degree to which cultural practices are followed
- use of leisure time and whether leisure time is shared with total of family unit
- family views of education, teachers and the school system
- health values: how much emphasis is put on exersise, diet, preventative health care
What to consider about coping resources during family assessment?
- degree of emeotional support offered to one another
- availability of support persons and affiliations outside the family ( Eg. Friends, church membership)
- sources of stress
- methods of handling stressful situations and conflicting goals of family members
What is a Genogram
maps out visually gender and lines of birth descent through generations
Factors determining the impact of illness on the family?
reatening.
■ The duration of the illness, which ranges from short term to long term.
■ The residual effects of the illness, including none to perma- nent disability.
■ The meaning of the illness to the family and its significance to family systems.
■ The financial impact of the illness, which is influenced by factors such as loss of income and ability of the ill member to return to work.
■ The effect of the illness on future family functioning (e.g. previous patterns may be restored or new patterns may be established).
Why are cultural considerations important in Family health assessment?
Cultural safety is effective nursing practice as judged by the person being cared for.
•NOTE that this is not just about a person’s race but gender identity/age
What are some cultural assessment considerations?
- consider and be respectful of cultural traditions and how important they are
- consider spiritual and religious rituals
- communication and language ( verbal and non verbal
- cultural health practices
- view of health and illness
- cultural family roles and definitions
Intellectual disability ettiquitte is important in family health assessment because?
Etiquette
•Offer assistance to a person with a disability if you feel it is appropriate but wait for an answer before you help.
•Treat adults like adults. Do not use gestures more suitable for children.
•Do not refer to an adult as “cute” or “adorable”.
•If someone is a wheelchair user, do not lean on their chair.
•Make appropriate physical contact with people with disabilities according to the situation, the same as anyone else.
What defines a disability
•The Disability Discrimination Act 1992 (Cth) defines disability as:
“ Total or partial loss of the person’s bodily or mental functions
•Total or partial loss of a part of the body the presence in the body of organisms causing disease or illness
•The malfunction, malformation or disfigurement of a part of the person’s body
•A disorder or malfunction that results in the person learning differently from a person without the disorder or malfunction
•A disorder, illness or disease that affects a person’s thought processes, perception of reality, emotions or judgment, or that results in disturbed behavior;
and includes disability that:
•presently exists
•previously existed but no longer exists
•may exist in the future
•is imputed to a person (meaning it is thought or implied that the person has disability but does not).
Types of disabilities
- Physical - affects a person’s mobility or dexterity
- Intellectual - affects a person’s abilities to learn
- Mental Illness - affects a person’s thinking processes
- Sensory - affects a person’s ability to hear or see
- Neurological – affects the person’s brain and central nervous system,
- Learning disability
- Physical disfigurement or
- Immunological - the presence of organisms causing disease in the body
What is a physical disability and what is the nursing relevance?
All types and degrees of physical disability
•Extend from a person with a broken arm who cannot work
•To a person with a permanent spinal injury
•To a older person with a hip fracture who cannot go home
- Nursing relevance
- Sit and listen
- Refer to resources
What is NDIS?
National Disability Insurance Scheme
•This service helps to support families and patients living with a disability
•Each service provider will register with NDIS and can deliver the services they offer to the patient
•The patient and the family are able to choose from the many service providers who they want to deliver the care
•This gives patients more control over what services they are able to have and who delivers those services
•Being a nurse in disabilities services is a very rewarding and satisfying career.
What is the nursing process?
A 5 step framework to formulate care plans to provide individualized nursing care •Assessment •Diagnosis (Nursing) •Planning •Implementation •Evaluation
•A•D•P•I•E
What is the Assessing part of the nursing process?
Collecting, organising, validating and documenting data to establish a database about the persons response to health concerns or illness and the ability to manage health care needs
Activities peformed during assessing stage of the nursing process
Establishing a database…
- obtaining health history
- conduct physical assessment
- review persons record
- review nursing literature
- consult support persons
- consult health professionals
- updates organise validate and document data
What is the diagnosing stage of the nursing process?
Analysing and synthesising data to identify the persons strengths and health problems that may be prevented or resolved by collaborative and independent nursing interventions. Developing a list of nursing and collaborative problems.
What activities are peformed during the diagnosing stage of the nursing process ?
- compare data against stabndards
- cluster or group data ( generate tentative hypotheses)
- identify gaps and inconsistencies
- determine persons strengths, risks, diagnoses and problems.
- formulate nursing diagnoses and collaborative problem statements.
- document nursing diagnoses on the care plan
What is the planning stage of the nursing process
Determining how to prevent, reduce or resolve the identified priority patient problems; how to support people’s strengths ; and how to implement nursing interventions in an organised, individualised and goal directed manner to develop an individualised care plan that specifies goals/ desired outcomes, and nursing related interventions
What activities are carried out during the planning stage of the nursing process?
- set priorities and goals/ outcomes in collaboration with the person.
- write goals/ desired outcomes
- select nursing strategies/ interventions
- consult other health professionals
- write nursing interventions and nursing care plan
- communicate care plans to relevant health care providers
What is the implementing stage of the nursing process?
Carrying out ( or delegating) and documenting the planned nursing interventions to assist the person to meet desired goals/ outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning
What activities happen during the implementing stage of the nursing process?
- reassess the person to update the database.
- determine the nurses need for assistance
- peform planned nursing interventions
- communicate what nursing actions were implemented
- document care and response to care
- give verbal report as necessary
What is the evaluating stage of the nursing process?
Measuring the degree to which goals/ outcomes have been achieved and identifying factors that positively or negatively influence goal achievement in order to determine whether to continue, modify or terminate the plan of care
What activities are done in the evaluating stage of the nursing process?
- collaborate with the person and collect data related to desired outcomes
- Judge whether goals achieved
- relate nursing actions to patient outcomes
- make decisions about problem status
- review and modify the care plan as indicated or terminate nursing care
- document achieving or outcomes and modifications of care plan
What stages of the nursing process Is critical thinking used + examples
All stages
A- making reliable observations, distinguishing relevant and irrelevant data and important from unimportant data
D- finding patterns and relationships among cues, making inferences, suspending judgement when lacking data and stating the problem
P- forming valid generalisations, transferring knowledge from one situation to another, developing evaluative criteria
I- applying knowledge to peform, interventions, testing hypotheses
E- making criterion based evaluations, deciding whether hypotheses are correct
What are the types of assessment
Initial assessment
Problem focused
Emergency
Time lapsed
What is the initial assessment?
Assessment performed within specified time after admission to establish a data base for the prob,em identification, reference and future comparison
Eg. Nursing admission assessment
What is a problem focused assessment?
Ongoing process integrated within nursing care to determine the status of a specific problem identified in an earlier assessment
Eg. Hourly assessment of a persons fluid intake and urinary output in an ICU Assessment of the persons ability to peform self care while assisting them to shower
What is an emergency assessment?
Assessment done during any physiological or psychosocial crisis of the person to identify life threatening problems or identify overlooked problems
Eg. Rapid assessment of persons airway, breathing status and circulation during cardiac arrest. Assessment of suicidal tendencies or potential for violence
What is a time lapsed assessment?
Assessment done several months after the initial assessment to compare the persons current status with the baseline data previously obtained
Eg. Reassessment of a persons functional health patterns in a home care or outpatient setting, or in a hospital at shift change
Components of a nursing health history?
- biographical data
- chief complaint/ reason for visit
- history of present illness
- family history of illness
- lifestyle
- social data
- psychological data
- patterns of healthcare
What is subjective data
Something the patient tells us
Eg. I feel weak all over when I exert myself, I’m short of breath
What is objective data
The testing you do that gives you a number or an answer.
What is subjective data
what the patient tells us eg. i feel weak all over when i exert my body, i feel short of breath
What is objective data
the testing you do that gives you a number or an answer eg. blood pressure
how can you use senses to observe clinical data
vision- overall appearance ( eg. body size general weight, posture, grooming); signs of distress/ discomfort; facial and body gestures; skin colour and lesions; abnormalities of movement; non verbal demeanor (signs of anger or anxiety); religious of cultural artefacts (eg. books, icons, candles, beads)
smell- body or breath odours
hearing- lung and heart sounds; bowel sounds; ability to initiate conversation; ability to respond when spoken to; orientation to time, person and place; thoughts and feelings about self, other and health status
touch- skin temperature and moisture; muscle strength (e.g. hand grip); pulse rate, rhythm and volume; palpatory lesions (e.g. lump, masses, nodules)
Advantages of open ended questions
- let the interviewee do the talking
- interviewer is able to listen and observe
- they are easy to answer and non threatening
- they reveal what the interviewee thinks is important
- they may reveal the interviewees lack of information, misunderstanding of words, frame of reference, prejudices or stereotypes
how to be culturally responsive in terms of personal space
- accepted distance btwn ppl in convos varies with cultural affiliation
- men usually require more space than women
- anxiety increases need for space
- direct eye contact increases need for space
- physical contact is used only if for therapeutic purpose
advantages of closed questions
- questions and answers can be controlled more effectively
- they may require less effort from the interviewee
- they may be less threatening, since they do not require explanations or justifications
- take less time
- information can be asked for sooner than it would be volunteered
disadvantages of closed questions
- they may provide too little information and require follow up questions
- they may not reveal how the interviewee feels
- they do not allow the interviewee to volunteer possibly valuable information
- they may inhibit communication and convey lack of interest by the interviewer
- the interviewer may dominate the interview with questions
how to be culturally responsive in terms of personaal space
- accepted distance btwn ppl in convos varies with cultural affiliation
- men usually require more space than women
- anxiety increases need for space
- direct eye contact increases need for space
- physical contact is used only if for therapeutic purpose
guidelines for validating assessment data
- compare subjective and objective data to verify the persons statements with your observations.
- be sure your data consists of cues and not inferences
- double check data that are extremely abnormal
- determine the presence of factors that may interfere with accurate measurement
- use references (textbook, journals, research reports) to explain phenomena
Normal Respiratory Rate for Infants (<1 y)
30-53
Normal Respiratory Rate for Toddlers (1-2 y)
22-37
Normal Respiratory Rate for Preschoolers (3-5 y)
20-28
Normal Respiratory Rate for School-aged children (6-11 y)
18-25
Normal Respiratory Rate for Adolescent (12-15 y)
12-20
Normal respiratory rate for Adults
12 to 20 breaths per minute
What is a respiratory rate
A person’s respiratory rate is the number of breaths you take per minute. The normal respiration rate for an adult at rest is 12 to 20 breaths per minute. A respiration rate under 12 or over 25 breaths per minute while resting is considered abnormal.
Normal respiratory rates for older patients
12 to 18 breaths per minute for those living independently and 16 to 25 breaths per minute for those in long term-care.
what is Tachypnea
A respiratory rate of 20 breaths per minute (or more than 25 breaths per minute for someone in a nursing home) indicates tachypnea.
Normal Pulse Rate for Neonates (<28 d)
Awake Rate: 100-165
Sleeping Rate: 90-160
Normal Pulse Rate for Infants (1 mo-1 y)
Awake Rate: 100-150
Sleeping Rate: 90-160
Normal Pulse Rate for Toddlers (1-2 y)
Awake Rate: 70-110
Sleeping Rate: 80-120
Normal Pulse Rate for Preschoolers (3-5 y)
Awake Rate: 65-110
Sleeping Rate: 65-100
what does a lower heart rate at rest imply?
Generally, a lower heart rate at rest implies more efficient heart function and better cardiovascular fitness.
For example, a well-trained athlete might have a normal resting heart rate closer to 40 beats a minute.
Normal Pulse Rate for Adolescents (12-15 y)
Awake Rate: 55-85
Sleeping Rate: 50-90
A normal resting heart rate for adults
A normal resting heart rate for adults ranges from 60 to 100 beats a minute.
Normal Temperature Range by different Methods
Method- Normal Range (oC)
Rectal - 36.6-38
Ear- 35.8-38
Oral- 35.5-37.5
Axillary- 36.5-37.5
When should we assess vital signs
- On admission to health care facility, to obtain baseline
data and monitor patient improvement deterioration - When a person has a change in health status or report symptoms such as chest pain or feeling hot or faint
- Before, during and after surgery or an invasive procedure
- Before and/or after the administration of a medication that could affect the respiratory or cardiovascular systems
- before and after any nursing intervention that could affect the vital signs e.g. ambulating a person who has been on bed rest on when a person is receiving a blood transfusion
what happens during inspiration
- The diaphragm contracts and pulls downward while - – Inter costal muscles contract and pull upward. increases the size of the thoracic cavity and decreases the pressure inside
what happens during expiration
- The diaphragm relaxes, and the volume of the thoracic cavity decreases, while the pressure within it increases.
As a result, the lungs contract and air is forced out.
how to assess for breathlessness
- nasal flaring
- anxious flailing
- neck muscle tensing
- cyanosis (bluish discoloration of the skin)
- tracheal tug ( A downward pull of the trachea)
- use of intercostal muscles- rib retraction
- paradoxical breathing- abdomen rises
what is tachypnoea
quick, shallow breaths
what is bradypnoea
abnormally slow breathing
what is apnoea
cessation of breathing
what are the different rates of breathing
tachypnoea
bradypnoea
apnoea
terms to describe different breathing sounds
stridor- a shrill, harsh sound heard during inspiration with laryngeal obstruction
stertor- snoring or sonorous respiration, usually due to a partial obstruction of the upper airway
wheeze- continuous, high pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway.
bubbling- gurgling sounds heard as air passes through the moist secretions in the respiratory tract
what are the different breathing rhythms
cheyne strokes breathing- waxing and waning of respiration’s, from deep to very shallow breathing and temporary apnoea
terms to describe different ease and effort of breathing
dyspnoea- difficult and laboured breathing during which there is a persistent, unsatisfied need for air and person feels distressed.
orthopnoea- ability to breath only in an upright/ sitting or positions
sites for taking pulse
temporal- side of head carotid- side of top of neck apical- at the apex of the heart. brachial- inside of arm at the elbow radial pulse- at the wrist femoral- inner thigh popliteal- back of the knee posterior tibial artery- near bony projection on the inside of each ankle dorsalis pedial- arch of the top of the foot between the first and second metatarsal bones
what words describe the different chest movements
intercostal retraction-in drawing between the ribs
substernal retraction- in drawing beneath the breastbone
suprasternal retraction- in drawing above the clavicles
what terms describe the different breathing secretions and coughs
haemoptysis- presence of blood in sternum
productive cough-a cough accompanied by expectorated secretions
non productive cough- dry harsh cough without secretions
sites for taking pulse
radial pulse- at the wrist, used as it is readily accessible
temporal- side of head, used when radial is not readily accessible
carotid- side of top of neck, used during cardiac arrest/ shock in adults and to determine circulation to the brain
apical- at the apex of the heart. routinely used for infants and children up to 3 yrs, to determine discrepancies with radial pulse, used in conjunction with some medications
brachial- inside of arm at the elbow, used to measure blood pressure and during cardac arrest for children
femoral- inner thigh, used in cardiac arrest and shock, used to determine circulation to a leg
popliteal- back of the knee, used to determine circulation to the lower leg
posterior tibial artery- near bony projection on the inside of each ankle, used to determine circulation to the leg
dorsalis pedial- arch of the top of the foot between the first and second metatarsal bones, used t determine circulation o the foot
Estimated ranges for body temperature during early morning / cold weather oral v rectal
below 36
Estimated normal ranges for body temperature oral v rectal
oral- 36-37.5
rectal-36-37.75
Estimated ranges for body temperature when working hard, feeling empootional or for active kids oral v rectal
oral- 37.5-38.5
rectal- 37.75-38.5
Estimated ranges for body temperature during hard exersise rectal
rectal- 38.5-40
what times of the day might oral temperature decrease
early mornings and during the night when we are asleep
advantages and disadvantages of oral temperature
advantages
- accessible, relatively inexpensive and convenient
disadvantages
- can break if bitten, inaccurate if ingested hot or cold food or has smoked, could injure mouth following oral surgery,
advantages and disadvantages of rectum
advantages
- reliable measurement
disadvantages
-inconvenient and more unpleasant, difficult for someone who cannot turn to side, could injure rectum following rectal surgery, presence of stool may affect thermometer placement- if soft the thermometer may be embedded in stool rater than against wall of rectum
advantages and disadvantages of axilla temperature measurement
advantages
- safe and non invasive
disadvantages
- thermometer must be left in place 3-5 min to obtain accurate measurement
advantages and disadvantages of ear
advantages
- readily accessible, reflects the core temperature, very fast
disadvantages
- can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far, repated measurements may vary - right and left esp if person has been lying on one side, presence of cerumen may affect the reading, impaired accuracy if not calibrated properly
advantages and disadvantages of forehead
advantages
-safe, non invasive, very fast
disadvantages
- requires electronic equipment that mmay be expensive or unavailable: variation in technique needed if the person has perspiration on the forehead
oral thermometer placement
place bulb on either side of frenulum
rectal thermometer placement
- apply clean gloves
- instruct the person to take a slow deep breath during insertion
- never force thermometer if resistance felt. insert 3.5 cm in adults
axillary thermometer placement
- pat axilla dry if very moist
- the bulb is placed in the center of the axilla
tympanic thermometer placement
- pill pinna slightly upwards and backwards,
- point probe slightly anteriorly towards eardrum,
- insert the probe slowly using circular otion until snug
temporal artery thermometer placement
- brush hair aside if covering area. with probe flush on centre of the forehead, depress the red button; keep depressed. slowly slide the probe midline across the forehead to the hair line, not down the side of the face.
- lift the probe from the forehead and touch on the neck just behind the ear lobe
- release the button
what is hypothermia
less than 36 degrees
Hypothermia involves three mechanisms: excessive heat loss, inadequate heat production by body cells and increas- ing impairment of hypothalamic thermoregulation.
what is the average body temperature
36-38 degrees
what is pyrexia
raised body temperature; fever. 38-41 degrees
what is hyperpyrexia
a very high fever. 41 degrees+
3 clinical manifestations/ phases of fever
1) Chill (or cold) phase (onset of fever)
- Increased heart rate (tachycardia)
- Increased respiratory rate (tachypnoea) and depth
- Shivering, Pale, cold skin, Complaints of feeling cold
- Cyanotic nail beds, ’Goosebumps’ on the skin, Cessation of sweating.
Plateau phase (course of fever)
- Absence of chills
- Skin that feels warm
- Photosensitivity, Glassy-eyed appearance, Tachycardia and tachypnoea, Increased thirst (polydipsia), Mild to severe dehydration
- Drowsiness, restlessness, delirium or convulsions
- Herpetic lesions of the mouth (i.e. an ulceration of the skin)
- Anorexia(persistentlossofappetite)ifthefeverisprolonged
- Malaise, lethargy, weakness and aching muscles.
Defervescence (or flush) phase (fever abatement)
- Skin that appears flushed and feels warm
- Sweating (diaphoresis)
- Decreased shivering
- Possible dehydration.
What is heat stroke
When the body’s core temperature rises above 40.58C and its internal systems start to shut down.
Heat stroke can be brought on by high environmental temperatures, strenuous physical activity or other conditions that raise a person’s body temperature.
Symptoms and treatment of Heatstroke
very high body temperature ■ red, hot and dry skin ■ dry swollen tongue ■ rapid pulse, shallow, rapid breathing ■ throbbing headache ■ confusion or ‘strange’ behaviour ■ nausea ■ possible loss of consciousness
heat stroke is a life threatening emergency that requires immediate medical treatment to prevent brain damage, organ failure or death.
What is heat stress
Heat stress occurs when the body becomes dehydrated and is unable to cool itself enough to maintain a healthy temperature. If left untreated, this can lead to heat stroke, which is a life-threatening medical emergency
Children and infants with fever: acute management
- Axillary measurement of temperature is recommended for routine clinical use, but staff should be aware that axillary temperatures are up to 1oC lower than rectal temperatures.
- All febrile neonates should have a full septic work-up and be admitted for parenteral antibiotics.
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Nursing interventions for adults with fever
Monitor vital signs.
■ Assess skin colour and temperature.
■ Monitor white blood cell count, haematocrit value and other pertinent laboratory reports for indications of infec- tion or dehydration.
■ Remove excess blankets when the person feels warm, but provide extra warmth when the person feels chilled.
■ Provide adequate nutrition and fluids (e.g. 2500–3000 mL per day) to meet the increased metabolic demands and prevent dehydration.
■ Measure fluid intake and output.
■ Reduce physical activity to limit heat production, especially
during the defervescent phase.
■ Administer antipyretics (medications that may reduce the signs and symptoms of fever, such as pain, discomfort and elevated body temperature) only as indicated or ordered. This intervention should be considered on the basis of maintaining the person’s level of comfort rather than simply reducing an elevated body temperature.
■ Provide oral hygiene to keep the mucous membranes moist.
■ Provide dry clothing and bed linen.
Danger of being inside a locked motor vehicle
Locked motor vehicles are potential death traps, particularly during summer. The temperature inside a motor vehicle during the Australian summer can be 30–408C higher than the outside temperature. Therefore, on a 358C day the temperature inside a motor vehicle can be 65–758C.
Clinical manifestations of hypothermia
■ Decreased body temperature and decreased pulse and res- piration rates. ■ Severe shivering (initially). ■ Feelings of cold and chills. ■ Pale, cool, waxy skin. ■ Frostbite (nose, fingers, toes). ■ Hypotension. ■ Decreased urinary output (oliguria). ■ Lack of muscle coordination. ■ Disorientation. ■ Drowsiness progressing to coma.
Nursing interventions for people with hypothermia
Provide a warm environment.
■ Remove wet clothing and provide dry clothing.
■ Apply warm blankets (a space blanket may also be used).
■ Keep limbs close to body.
■ Cover the person’s scalp with a cap or beanie.
■ Supply warm oral or intravenous fluids.
■ Apply warming pads.
clinical manifestations during heat exhaustion
Moderately increased temperature (38.3–38.98C)
Paleness
Nausea and/or vomiting
Dizziness Fainting
what is data collection
Data collection is the systematic gathering of data about a patient’s health status.
Why do we collect data on the patient?
..
data collection basic process
process is basically the same:
Patient is admitted
The nurse introduces self
Asks questions to complete paperwork (subjective data)
Conducts vital signs/assesses patient (objective data)
Documents and communicates information (as required)
What does a pulse oximeter measure?
A pulse oximeter measures the percentage of haemoglobin saturated with oxygen. A normal result is 95% to 100%.
may be placed on the finger, toe, nose, earlobe or forehead
Factors affecting body temperature include
age, diurnal variations, exercise, hormones, stress and environmental temperatures.
Four common types of fever are
intermittent, remittent, relapsing and constant.
What happens during a fever
During a fever, the set point of the hypothalamic thermostat changes suddenly from the normal level to a higher than normal level, but several hours elapse before the core tem- perature reaches the new set point.
what is documentataion
documentation is anything written or printed relating to the patient
Ability to document & communicate competently is a competency requirement of a nurse
Nursing documentation is a permanent part of a patient’s records.
You are accountable for what you write (or neglect to write)!
why is documentation important
Patient care is collaborative and multi team focused so accurate communication through documentation is essential
Documentation reflects the quality of care you are giving (or not giving)
We live in a litigious society, Documentation (medical and nursing records/”notes”) can be the single most important piece of evidence in legal action. Any of your “notes” could be called for years later in court
Why is knowing about growth and development important to you as a nurse?
Allows appropriate assessment & care planning
The more you know about psychology and theories and the human mind and body the more knowledge you’ll have as a nurse when carrying out an appropriate assessment and plan your care for that person. Individuals are individuals.
- gives us a framework to ‘organise’ humans
- gives us what we can see and how we can track it
- provides us a sound basis for any reactional actions
What does growth relate to in theories of g & d?
Growth relates to physical changes & size increases
◦Measured quantitatively/ objective data BUT important to think critically
What does development relate to in g & d
Development relates to the capacity & skill progression
◦Relates to adaption to environment
◦Behavioural aspect of growth
What are some principles of g and d
◦(normally) all follow similar pattern
◦Influenced by maturation/environment/genetics
◦Sequence predictable though individual
◦Certain stages more critical
◦Development starts of simply, becomes more complex
Factors influencing G and D
◦Genetic ◦Temperament ◦Family ◦Nutrition ◦Environment ◦Health ◦Culture
G and D Theories
Biophysical
◦Gesell thought that we have a genetic time table. And though nurture and experience may give children a slight advantage in reaching milestones, the timetable is inborn. Genetic makeup tells you how quickly your going to develop and these milestones will occur anyway in your development
Psychosocial
◦Personality development
◦Very many (Eg. Freud/Erikson)
Cognitive
◦Thinking/reasoning/language development
◦Piaget thought that the brain develops and children’s experience expands and they move through 5 broad stages
Five major phases: • Sensorimotor, Preconceptual, Intuitive, Concrete operations, Formal operations
Behaviourism
◦Learning is affected by negative or positive reinforcement
◦Skinner thought that learnt and retained more quickly through consistent, positive reinforcement.
Social learning theory
-Individuals learn through observation and the behaviour of others
-Bandura thought that Individual learns through imitation and practice; self-regulation, self-efficacy
are important
Ecological
- Views the child as interacting with the environment at different levels or systems:
• Microsystem, Mesosystem, Exosystem, Macrosystem, Chronosystem
Moral theory
Spiritual theory
-Life meaning theory
What may affect psychosocial development
Self concept
What is ACE
Adverse childhood events
The ACE study= “Adverse Childhood Exposure”
This study was carried out in the late 1980s by
Dr’s Vincent Feletti and Robert Anda by the center of Disease control
It was looking at childhood experience and its impact on health
It was completed on 17000 middle class Americans
Looked at
Category of childhood exposure (Psychological, Physical, Sexual), Household Dysfunction
(Substance Abuse, Mental Illness, Mother treated violently , Criminal Behaviour in household )
Believe that you had to have at least four of the ACEs to have an impact on your health.
How ACE impacts your health
4+ ACEs more likely to develop... IHD/ heart attack Any Cancer Stroke COPD Diabetes The more ACE the person had the more likely to suffer from one of the above health problem
Can intergenerational trauma be inherited
Maybe, 2nd generational holocaust survivors do inherent the gene of trauma but it’s still very controversial
What are the 7 components of wellness
Physical Social Emotional Intellectual Spiritual Occupational ( safe work environment/ free from bullying) Environmental
We have to be well in all of these areas in order to say that we are well
What is holism
(Greek) - holos - “whole”
Holistic – meaning the “whole”
Holistic nursing (care) – nursing (caring) for the whole person
When you look at you patients what components of wellness are you looking at
Physical Spiritual Emotional Social Economic Psyche
The whole patient
What may a back pain patient be suffering from? Other that the back pain
Role play issues Lack of understanding Spiritual distress Sexual issues Partner/carer issues Constipation Body image issues All these different aspects can affect a person’s health/disease worsen or sustain it. A person’s inner beliefs and convictions are powerful resources for healing & wellness
How can you as a nurse help in all areas of wellness
physical - Essential nursing care/presence
Spiritual- Presence/praying/meditating/
referring/respecting
emotional- Presence/touch/listening
Social- Listening/presence/referring
economic- Listening/referring
Psyche- Listening/touch/presence/referring
What are the Health & Wellness Models
Clinical model
The narrowest interpretation of health occurs in the clinical model. People are viewed as physiological systems with related functions and health is identified by the absence of signs and symptoms of disease or injury.
The 4+ Model of Wellness
consists of the four domains of the inner self—physical, spiritual, emotional and intellectual—plus the elements of the outer systems (environment, culture, nutrition, safety and many other elements).
Variables that affect health & wellness
Biological
-Genetics/gender/age/developmental level
Psychological
- Mind-body interaction
- Self-concept
Cognitive (intellectual)
- Lifestyle (risky behaviours)
- Spiritual
External
- environment/standard of living/
- culture/family/social support
What are some health beliefs models
Locus of control- concept from social learning theory that nurses can use to determine whether individuals are likely to take action regarding health; that is, whether peo- ple believe that their health status is under their own or oth- ers’ control. People who believe that they have a major influence on their own health status—that health is largely self-determined—are called internals.
R and B Health Belief model- is based on the assumption that health-related action depends on the simultaneous occur- rence of three factors: (1) sufficient motivation to make health issues be viewed as important, (2) belief that one is vulnerable to a serious health problem or its consequences, and (3) belief that following a particular health recommenda- tion would be beneficial.
