week 2 : Clinical Judgment & Vital Signs Flashcards
Nurses treat disease at different levels of care
1) Primary
2) Secondary
3) Tertiary
4) Quaternary
1) ever to go to physician, entry or access to healthcare example : primary physician
2) access through primary care
example to a doctor for a dermatologist
3) a bunch of different services, coordinate effort
example : hospital
4) outside of normal rounds, randomize control trials
example : private care
making sense of a patient (what you should be thinking about)
clinical judgment
What does AAPIE stand for in clinical judgment ?
assessment
analysis
planning
implementation
evaluation
how to think like a nurse? the usual answer…..
clinical judgment
clinical judgment ….
the observed outcome of critical thinking and decision making.
this uses nursing knowledge to observe and assess presenting situations, prioritize patient concerns
clinical judgment
Nursing Process Assessment (Recognize Cues; Noticing)
1) deliberate and systematic collection of data to determine the patient past and present coping patterns
2) data collection/verification
3) subjective/objective data
4) primary vs secondary vs tertiary
from the nursing process : assessment (recognize cues; noticing) this comes directly from the patient
primary
from the nursing process: assessment (recognize cues; noticing) the source, someone else telling their condition (family member, etc)
secondary
from the nursing process: assessment (recognize cues; noticing)
from data related to how we make sense of it (in terms of prior knowledge)/past experience whats actually going on with the patient (from generic) textbooks, or manuals
tertiary
Assessment Techniques-What is the patient’s baseline?
Client Health History (Verbal)
Review of Systems
Head-to-Toe Assessment (physical assessment and observations)
Client Health History
what does
S
A
M
P
L
E
stand for
signs and symptoms
allergies
medications
past medical/history
last eat or drink
events leading up (what happened to you)
what are the vital signs?
1) blood pressure 120/80 mmhg
2) heart rate 60-100 bpm
3) respiratory rate (rr) in an adult 10-20 full inspiration and expiration
4) temperature 35.8 degrees- 37.3
5) oxygen saturation SPO2 97-99%
if its under 90= dangerous
what are the different level of care?
primary
secondary
quaternary
tertiary
what is ROS
review of systems = collect data on all body systems (use as a guide) but u can ask more details questions if its needed
In london engand Dr.pepper came in and weight himself to be 272 lbs , what would be the conversion be in kg?
123.6 kg
what is body mass index and waist-to-hip ratio used for ?
body mass index= fat, health risk
waist-to-Hip Ratio= risk for disease if they are under or over weight
what is general survey?
changes, signs of clinical distress such as physical appearance, body stricture, behaviour, mobility
what is subjective investigation?
pain, dizziness, nauseau
what is objective investigation , give examples?
fever, broken leg, high blood pressure, skin rash, etc.. u know the vibes
Subjective Investigation
Health Assessment Questions
O
P
Q
R
S
T
U
onset (first question u should ask)
precipitation (the cause )or palliation (what makes it better)
Quality (description of the pain)
Region or Radiation (referred to as pain)–> where in terms of the body
severity
time or timing ( pattern or duration)
understanding( the issue)
Physical of Assessment
I
P
P
A
O
what do they stand for?
inspection
palpation
percussion
auscultation
olfaction
what is the instruments used for inspection?
penlight
otoscope
ophthalmoscope
specula : vaginal, nasal
give examples of palpation
touch-can conform what you saw during inspection
palpating your abdomen
palpating thyroid gland
what is generally used when it comes to palpation, light palpation & deep palpation?
light palpation
what motions do you use when it comes to palpation ?
circular motions
what are the characteristics of palpation?
texture, temperature, moisture ( diaphoresis)
swelling, thickness, (^ density ), lumps or masses
presence of tenderness or pain
vibration or pulsation
what is percussion ?
tapping skin with short, sharp strokes to assess underlying structures
direct
indirect
produce vibration –> sounds
what is an artifacts?
hearing sounds, coming through (not from the patient)
for example : extra room noise, keep patient warm-prevent shivering etc.
What is Data Verification?
making sure the information you’re collecting is accurate
A nurse takes a patient’s radial pulse. They count 40 beats in one minute. What should the nurse do next, in terms of data verification?
Abnormal is it really accurate? to make sure check the other arm.
Laboratory values provide key in formation about….
homeostasis in your body
TRUE OR FALSE. laboratory values are important piece of evidence to inform out clinical judgment
true
what is the suggested prioritization framework for planning nursing care
- Life-threatening situations
2.Safety issues
3.Client priorities
4.Nurse priorities
List in order of priority :
A patient requires a bed bed bath per their nursing care plan
A patient has no pulse and is unresponsive
A patient asks to mobilize to the wheelchair to visit family
A patient has the side rails down on their bed
A patient requires a bed bed bath per their nursing care plan (4)
A patient has no pulse and is unresponsive (1)
A patient asks to mobilize to the wheelchair to visit family (3)
A patient has the side rails down on their bed (2)
name the implementation process
1) re-assess the patient
2) reviewing the existing nursing care plan
3) organizing resources and care delivery
4) anticipating and preventing complications
The Evaluation process, which determines the effectiveness of nursing care, consists of five elements
1) identifying evaluative criteria and standards
2) collecting data to determine whether the criteria or standards are met
3)interpreting and summarizing findings
4) documenting findings and any clinical judgment
5) terminating, continuing or revising the care plan
Application Exercise:
_______ are techniques a nurse uses to gather data about the patient’s current condition
The nurse uses their _______ to provide safe care.
______ provides the health care team with an overview of clinical manifestations the patient is experiencing
____ is when the nurse performs additional assessments
_______ is a technique/tool used to assess a specific clinical manifestations (e.g pain)
- IPPA
2.Clinical judgment
3.ROS
4.OPQRSTU
5.Data Verification
Put the statements in the right category
- collect data
-organize data
- validate data
- document data
-analyze data, identify health problems ,risks, and strengths
-formulate diagnostic statements
-collect data related to outcomes
-complete data with outcomes
-relate nursing actions to patient goals/outcomes
-draw conclusions about problems status
-continue, modify, or end the patient’s care plan
-reassess the patient
-determine the nurse’s need for assistance
-implement nursing interventions
-supervise delegated care
-document nursing activities
-prioritize problems and diagnoses
formulate goals and designed health outcomes
-identify nursing interventations
assessment
- collect data
- organize data
- validate data
- document data
Nursing diagnosis/analysis
- analyze data
- identify health problems, risks , and strengths
- formulate diagnostic statements
Planning
-prioritize problems and diagnoses
-formulate goals and designed health outcomes
- identify nursing interventions
Implementation
- reassess the patient
- determine the nurse’s need for assistance
- implement nursing interventions
- supervise delegated care
- document nursing activities
Evaluation
- collect data related to outcomes
- complete data with outcomes
- relate nursing actions to patient goals/outcomes
- draw conclusions about problem status
- continue, modify, or end the patient’s care plan
What are the five vital signs?
Blood pressure
Respiration rate
temperature
oxygen saturation
pulse
Thermoregulation & Interrelated concepts (list the categories)
infection
intracranial regulation
nutrition
fluid and electrolytes
tissue integrity
perfusion
pulse reflects what?
systole, contractility, and stroke volume
where on the body can you take temperature?
rectum, tympanic (ear), temporal (forehead), oral (mouth), axilla
what is a normal temperature?
Hypothermia
Normal temperature
Hyperthermia
Hypothermia- <35.8
Normal temperature- 35.8-37.3
Hyperthermia - >38.5
What is the normal pulse rate for ..
- adult
- newborn
- infant
normal adult- 60-100 bpm
newborn - 70-190
infant - 80- 160
bradycardia bpm
<60 (less than 60)
tachycardia
> 100 ( more than 100)
what is conditioned athlete bpm
50-100 bpm
pulse strength scale
4+
3+
2+
1
0
full, bounding
strong
weak
thready
absent
what is the basic documentation when getting the pulse of the patient?
what is additional document when getting the pulse of the patient
rate + location
additional document: regularity (rhythm) + strength (force)
name the following :
normal sinus rhythm
regularly irregular
irregular
60-100 bpm
30 sec P
60sec P/HR
60sec HR
what is pulse deficit ?
pulse deficit is when the heart rate is higher than the pulse rate
how long do you count a pulse for ?
30 seconds regular
60 seconds irregular
what do you think could be the cause of the following?
an absent pulse
a week pulse
a strong, bounding pulse
a thready pulse
an absent pulse can indicate the heart stopped
a weak pulse - not strong, consistency there, poor percfussion (can cause by dehydration)
a strong bounding pulse can indicate someone running on a treadmill and exercising
a thready pulse - u can feel it but not consistent, coming in and out
formula for blood pressure:
CO x SV
When to take a blood pressure?
5 min rest, 3 measures 2 min apart, discard first and average second and third measure
true or false.
Measure in both arms ( may be 5-10 mmHg diff) take higher reading
true
True or false.
When taking a blood pressure if arms differ more than 20mmHg may need to continue to do both
true
What does auscultatory gap mean?
abnormal, more common with hypertension
the first sound you hear when taking a blood pressure manually is…?
systolic pressure
the silence you hear when taking a blood pressure manually is ….?
diastolic pressure
are any of these common error in blood pressure measurement ?
waiting 1-2 min between measures with cuff fully deflated
halting during inflation
the first one is not an error but accurate, you should wait 1-2 min
this is a common error
true or false. Electronic accurate “ 2’ mmHg (132/42) while manual only accurate to every “1” mmHg (131/43)
false, it is the other way around electronic is accurate “1” mmHg (131/43) while manual only accurate to every “2” mmHg (132/42).
hypotension: low BP
typically it is less than 95/60
hypertension ranges from …?
> 140/90
4:1 ratio pulse respiratory rate, what does that mean?
for every 4 heartbeats, there should be 1 breath
What is bradypnea? what is tachypnea?
bradypnea -less then 10 per min, slow
tachypnea - more then 20 per min, fast
what is the effort or depth of breathing? what is the rhythm of breathing?
decreased: ex. hypoventilation
normal: easy chest rise and fall
increase: for ex. hyperventilation
rhythm:
normal, even and regular
irregular
how do you count respirations?
watch of feel the patient’s chest rise and fall
Oxygen Saturation
normal range: 97-99%
critical: less then 90%
measured by pulse oximetry, O2 Sats SpO2
In Client Health History , can SAMPLE be approach?
yes it can be approach
Pallor
unhealthy pale colour
hypercapnia
high level of carbon dioxide
diaphoresis
sweating
diurnal cycle
variations in the day/night cycle, affects temperature
pyrexia
essentially fever
febrile
showing the symptoms of fever
hypoxia
not enough oxygen levels in the tissue level to maintain homeostasis
