Week 1 Notes from NUR 230
Week 1 Notes from NUR 230 NUR 230
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This 17 page Class Notes was uploaded by Issy Notetaker on Friday August 28, 2015. The Class Notes belongs to NUR 230 at Ball State University taught by Marjorie Pyron in Fall 2015. Since its upload, it has received 94 views. For similar materials see Health Appraisal Across the Lifespan in Nursing and Health Sciences at Ball State University.
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Date Created: 08/28/15
Isabelle Yazel Chapter 1 Jarvis Books Notes add ins from clinical and lecture I highly recommend looking through the chapters of the books at all the table and extra boxes Key quotPtquot Patient O Objective S Subjective NP Nursing Process EB Evidence Based Dom Dominate Wt Weight Ht Height V Volume BP Blood Pressure RR is Respiratory Rate GH Growth Hormone NS Nervous System 0 Assessment 0 O O Begins upon initial encounter and continues until discharge Collects all date about health past present family history promotion ect Subjective What pt says Objective What is observed S and O are combined to create the Data Base Needed to make appropriate and informed judgements about each individual pt condition Begins w Diagnostic Reasoning Creates diagnosis from database and conclusions in assessment Steps 0 Attend to cues pieces of S and 0 data signs symptoms 0 Create hypothesis from diagnosis created by cues o This is tentative and can be changed 0 Gather data that is supporting to the tentative hypothesis 0 Evaluate hypothesis using all gathered data Diagnose Create list and clusters from cues Validate by repeating or asking for a second opinionhelp Look for and nd missing pieces of the puzzle Nursing Diagnosis is NOT a medical diagnosis Critical Thinking Used in the nursing process Allows for H movement through NP Use intuition the recognize patterns in a patients condition Required for correct and appropriate judgment and diagnostic reasoning Data is forever change hour by hour or day by day so critical thinking is always in play Used to determine most feasible cause and best solution Multidimensional Avid making assumptions Always double check identify abnormal and normal data and cluster Create priority setting Dynamic and ever changing First Level Emergent lifethreatening Second Level Require prompt intervention Isabelle Yazel Third Level Addressed after 1St and 2nCI level 0 Collaborative Involves multiple disciplines Identify problems and create expected outcomes and goals that are obtainable ad measurable Evaluate continuously and make sure the plan of care is continuously up to date 0 EB Assessment 0 EB Practice EBP developed due to an increase in belief that patients are to be treated with the most current techniques All policies and procedures were created tested and approved through EBP Best HCP keep up with all current EBP Developed by Archie Cochrane in 1972 Systemic approach Use of the best evidence and experience preferences and values Assessment skill create the foundation for EBP Helps nd practices that are not bene cial and nd others that are 0 Collecting 4 types of Data 0 Complete Health history past and present Physical Exam Forms Baseline Screen for pathology Helps build relationship Important for development of trust Gathered upon admission in acute care 0 FocusedProblem Centered For limitedshort term Smaller and more targeted database collected 0 One problem 0 Follow Up Evaluation at intervals after 0 Emergency Rapid urgent Quickly diagnosed Expanding Concept of Health 0 Clear def guides data collection 0 Holistic Health is determined by the mind body and spirit working together 0 Health promotion and prevention Education Vaccines Screenings Chapter 8 Cultivation of Senses Won39t use everyone on each system 0 Inspection concentrated watching Isabelle Yazel Begins at meeting comes rst Develop general survey and then individual parts Requires correct setting and tools Watching is common 0 Palpation Follows and con rms inspection Follows and con rms inspection Sense of touch 0 Use different parts of hands ngertips backs of hands ect Slow and systemic Start light then deeper If the area is tender of painful to touch make sure to save that spot for last 0 Percussion Aping skin in short strokes Maps location and size density detects abnormal masses re exes nee jerk when hit with a hammer Stationary hand 0 Use nger tips and keep palm off skin to avoid dulling the sound Striking Hand 0 Use dom Hand middle nger relax wrist bounce striking off stationary nger Hit portion that is most rmly held to the skin 0 Hit twice in same position Sound Production Vibration creating a note 0 More airouder longer deeper More densesofter shorter higher This is not commonly done by nurse 0 Auscultation Listening to sounds produced by body Use stethoscope Blocks external sounds Diaphragm is use more often 0 Hold rmly Bell is used more when looking for abnormalities 0 Hold lightly NEVER LISTEN THROOUGH CLOTHING Setting 0 Warm o Comfortable 0 Quiet 0 Private 0 Well Lit 0 Exam table is at height where stooping is not needed Isabelle Yazel Equipment 0 Have all laid out and ready before beginning 0 Otoscope Light into ears 0 Ophthalmoscope Internal eye Dilated use Large full spot Undilated use small spot 0 Clean Field Clean stethoscope with alcohol swab bw patients Place down to paper towels on the clean area to lay out equipment After use put into used area 0 A Safer Environment 0 Wash hands Before and After encounters w pt After contact w blood or bodily uids After contact with contaminated equipment After removing gloves lf soiled handwash 40 seconds 0 Alcohol based Effective and less damaging to hands Use 35mL and rub for 20 seconds Use mechanics of handwashing Clinical Setting 0 General Approach Consider own and pt emotional state Develop motor skills 0 Hands On Measure basics ht wt BP HR temp ect Ask irrelevant question as ice breaker Ask to change into gown or assist Clean hand in persons presence Explain each step Start at hands and continue from there 0 Develop on plan to move through ORGANIZE Write out print out plan or use agency provided ones o If linger at an area explain that it is not bc something is wrong o If asking another opinion say your assessment is incomplete and so and so needs to examine too Summarize ndings at the end 0 Developmental Competence Child varies from Adult Modify approach and spend more time on comfort 0 Infant Position 0 Parent should be present and in baby line of sight I 0 D U Isabelle Yazel Flat on padded exam table Once can sit let it 12 after feeding Warm Nude Hands and Stethoscope should be warm Soft cooing voice Lock eyes Smile Smooth moves Use paci er when able Offer toys Bright Let them touch objects used they like to explore Sequence Heart lung and abdominal rst Least distressing rst Startle re ex at end 0 Toddler Position Sitting on parentlap Prep Security object is needed 0 Blanket or toy Greet with name start w parent Slowly turn attention to child Eye contact smiling talking or accepting object is sign of readiness Have parent undress Don39t offer choices use statements 0 lam going to listen to your heart now Offer limited options 0 This or this rst Demonstrate on parent Praise when cooperative Sequence 0 Preschool Collect 0 during history 0 Note gross ne motor and gait Begin w game like assessments Start w nonthreatening areas Position 0 Prep 0 Either in parent la of on exam table w parent present Short simple explanations Let them undress themselves Isabelle Yazel Talk and explain everything Don39t allow choice 0 But offer limited option when possible Allow playing w equipment and quothelpingquot Use games Be slow patient and deliberate Give reassurance Compliment Sequence Thorax abdomen exterminates and genitals rst Assess HEENT last Head Eyes Ear Nose Throat o SchoolAge Position 0 On exam table and they decide if parent is present Prep 0 Break ice w small talk Undress themselves Demostrate Comment on how body works 0 Adolescent 0 Aging adult 0 Sequence Head to toes Position Prep Exam table w cloths on as much as possible Alone wout parent or sibling Give feedback Communicate care Appraise w wide variety in mind Focus teaching on health promotion Sequence Head to Toe Position On exam table or in supine position Sequence for minimal changes Allow resting Slowed pace Use physical touch Agingmore life stress Diminished hearing and vision shouldn39t be mistaken for confusion Sequence lll Person Head to Toe Isabelle Yazel Collect data on illness to resolve rst then move on to further assessment Chapter 9 o 0 Data 0 Study of whole person 0 Begins at rst encounter Before beginning asking questions make sure pt is comfortable and ask if they need anything restroom food drink 0 General Survey Consider 0 Use AIDET Acknowledge Lets them know you are focused on them and eye contact is VERY important Identify 2 Duration Explain Thank Can be adjusted to circumstance and what is being said it doesn39t have to be in that order Before entering room check the PO chart and ask other nurses who have worked w pt about pt and con rm w them that it is indeed Mr James Include the orientation 0 Note if alter and responsive w eyes open Think of it as a customer service introduction Done at every interaction Taken VERY seriously 0 Appearance Age Ask DOB when determining orientation x3 ex Hi my name is can you state your full name DOB Where you are What day is it Sex Abnormal Delayed or early puberty Consciousness Alert and oriented Responsive Confused Drowsy Skin Color Even lntact Markings Healing properly Make notes Pallor Jaundice Lesion Face Symmetric movements lmmobile Drooping Overall Distress Calm CardiacRespiratory signs Pain Hygiene Clean Unclean and why homeless or u for several days 0 Structure Stature normal for age and sex Excessively short or tall Nutrition Wt Build Cachetic Obsese Cushing symptoms of obesity 0 State if measure wt and ht or stated Isabelle Yazel BMI is now more relevant and important to obtain Symmetry Unilateral atrophy Location Posture Stooped Straight 0 Rigid Stiff or tense Position Relaxed Tripod Sits straight and reuses to lie down Fetal Position Build Arm span and body length proportions Elongated arm span Deformities Missing webbed or shortened o Mobility Gait Foot placement Walk Balance Arm swing Wide base Dragging Dif culty startingstopping ROM Full Smooth Coordinated Limited Paralysis Jerky o Behavio r Expression Eye contact Appropriate expressions At rest 0 Flat Depressed Mood and affect Comfortable and coop Hostile Crying Speech Clear Dysphagia Speech Pattern Fluent Even Extremes of few of many Dress Climate appropriate Culturally appropriate 0 Too large Small Odd for climate Hygiene Clean Groomed Odor or alcohol scent Unkempt Measurement 0 Wt Standard scale remove excess clothing and shoes in Kg and Lbs Unexplained loss Gain 0 Ht Wall mounted device extended head piece w top of head shoeless 0 BMI Optimal Healthy Wt for Ht Healthy is 1925 lt185 underweight 25299 overweight 30349 obese 1 35399 obese 2 40 extreme o Waist Circumference Excessive increase risk factors standing locate hip bone tape parallel to oor at level of iliac crest snug but not pinching end of normal expiration gt35 in F and gt40 in M increases risks when BNI is 2535 Vital Signs Isabelle Yazel 0 Temp 372 C or 99F normal in resting is 37C and range of 358373 C and rectal are 45 C higher Hypothalamus becomes compromised during CNS disorders Hyperthermia Hypothermia Normal range is in uence by daily cycle menstruation exercise and age Oral is most convenient and easy site 0 Oral Procedure Don t place in front of tongue but in sublingual pockets instruct to keep lips closed leave until signal or 34 minutes afebrile or 8 minutes febrile wait 15 minutes if eaten or drank Explain to move tongue close mouth and not bite Rectal procedure Most accurate more invasive wear gloves and insert lubricated probe 23 cm into rectum toward umbilicus DON T LET GO Tympanic Membrane Procedure Same blood supply from hypothalamus noninvasive quick Place in ear canal and aim beam at membrane for 23 seconds 0 Common for children under 5 Temporal Artery Noninvasive Slide probe cross forehead and press behind ear takes multiple readings and gives the average 6 seconds 0 104 F is 40C 986F is 37 C 95F is 35C 0 Read instructions on different models Wipe w alcohol before and after use 0 Make sure to remove cover 0 Look for drainage or swelling in area of reading 0 Pulse Force of blood through arteries creates a pulse use pads of ngertips along radius If regular count for 30 sec and multiply by 2 if irregular count for the whole minute ZERO is the FIRST PULSE MET Rate Normal is 5095 beatsminute Varies w age and is more rapid in childhood and infancy lt50 is bradycardia 0 gt95 tachycardia o Occurs w fever and infections 0 Many medications affect HR Rhythm Regular even tempo Sinus Arrhythmia is common in children varies w respiratory cycle Force Force pulse shows strength of Stroke V 0 3 is Full and bounding 2 Normal 0 1 Weak and thread 0 Indicates decreased stroke V Isabelle Yazel 0 Absent 0 Respirations Relaxed regular automatic and quiet DON T MENTION YOU ARE COUNTING maintain position from counting pulse No talking yawning or other vocal alterations may occur or counting will have to restart Norm is 1220 per MINUTE gt20 is considered tachypnea Count for 30 sec unless abnormality then for minute if hard time seeing place hand on chest More rapid in children Report if labored shallow or deep 0 BP Force of blood pushing against vessel wall Make sure pt isn39t talking Measure BP cuff using 40 and 80 markers Bladder is 80 marker Use 1 or 2 step procedure Arm should be at heart level Start after age 3 Systolic Max pressure felt Normal is 120 o If gt140 hypertension may be present a lt100 is low Diastolic Elastic recoil or resting Normal is 80 o gtthan 90 is Hypertension o lt60 is low Pulse pressure is SystolicDiastolic Mean Arterial Pressure MAP pressure forcing blood into tissuescardiac cycle Varies w 0 Age rises w age Sex Race African Americas are usually higher Diurnal Rhythm Daily cycle Wt higher in obese Exercise Increases during Emotion rises in fear anger and pain Stress increases BP Level Determined by 0 Cardiac Output more pumping higher BP 0 Peripheral Vascular Resistance Vasoconstriction increases BP 0 Many drugs to treat critically ill affect this 0 V of blood Increase V increase BP 0 Increased w transfusions Viscosity increase increase BP Elasticity increase increase BP Cuff must rest at zero or readings will be wrong 0 Sizes range from 6extra large 0 Too narrowfalse high Isabelle Yazel Procedure Comfortable and relaxed person sitting or lying w bare arm support heart level 0 2 measurements 2 minutes apart 0 Verify in both arms on initial admin differences more than 10 mmHg indicate obstruction Locate brachial artery and palpate and wrap above and in ate until pulse is lost 0 Prevents missing auscultatory gap No sound for 3040 mmHg during de ating and is abnormal Systolic is clear tapping and diastolic to no sound De ate quickly and completely then wit 1530 sec place diaphragm and in ate de ate 2 mmHg per heartbeat 0 Record phases IV and V along with Systolic Table in book 0 Hypotension is low and Hypertension is high BP Orthostatic Vital Signs 0 Take when V depletion known to have hypertension reports fainting or syncope Have person rest supine for 23 minutes and take baseline pulse and BP then repeat when sitting and then standing Orth Hypotension 0 Drop in sys of 20mmHg or increase in pulse of 20 0 Record BP as even numbers and Pule rate and rhythm Thigh Pressure 0 Compare high arm BP w Thigh 0 Checks for coartation of aorta thigh pressure is lower than arm Thigh BP is usually higher than arm 0 Wrap cuff on lower third of thigh centered over popliteal artery 0 Pulse Oximetry If less than 90 on room air sup 02 may be needed 9599 is normal Document what type of air room sup Or other is used Remove nail polish or fake nails Hands should be warm to prevent false reading Takes HR but manual is more accurate 0 Developmental Competence 0 Infants and Children General Survey 0 Appearance Structure and gait are noted as the same as adult Isabelle Yazel 0 Children learning to walk have a wide gait and posture is protruding abdomen 0 Behavior 0 Note response to stimuli and alertness Bonding O Interactions w parents 0 Abuse Avoids eye contact no separation anxiety parent is disgusted Measurements Wt platform type balance scale 0 Nearest 10 g for infant and 100g for toddler 0 Age 23 upright scale 0 Length Measure supine until age 2 0 Head plate to foot plate and repeat 0 Measure 2 using ruler mounted scale and measure to nearest 1mm 0 Healthy growth is continuous but uneven o Abnormal lf fall below 5th percentile or above 95th percentile w no genetic explanation large diff bw wt and ht percentile stopped or unsteady and failure to show normal growth 0 Head Circumference Vitals O O 0 Measured birth and each well child visit until 2 and annually up to 6 Measure aligned w eyebrows 2 cm larger than chest circumference Same frequency and purpose as adult 0 Temp 0 Pulse 0 O O O Tympanic or temporal Axillary can be affected by brown fat producing extra heat Oral should be used once the cild is able to hold mouth closed upon instruction 56 years Rectal should be avoided if at all possible insert only 25 cm 3cm can cause a rupture usually registers slightly higher Fevers are commonly higher in children Palpate of auscultate apical in children 2 and under Count for full minute Respirations O O O 0 Watch abdomen move more diaphragmatic Sleeping is more accurate Count for a full minute Tachyapnea or rapid RR is gt60 resmin in up to 2 months and gt50 for 2 months 12 month 0 Aging Adult Isabelle Yazel 0 Measure annually at least Use pediatric endpiece for stethoscope 0 Hypertension is BP in the 90th and above percentiles General Survey Appearance 805 and up sharper and more angular Posture general exion Gait wider base Measurement Wt Decreases fat distributed on abdomen and lost on face and extremities Ht Shorter trunk and longer looking extremities shrinking of vertebrae Vital Signs Temp Less likely to have fever greater risk for hypothermia Pulse normal range but more irregular Respirations Decreased V and increased RR BP Increases w age Additional Techniques 0 Sp02 Pulse oximeter is noninvasive sensor attaches to nger like a close pin or taped to toe Measure light absorbed by the Hemaglobin oxygenated and un Hb02 and Hb Normal is gt 95 Make sure pulse reading matches pulse taken 0 Electronic Vital Sign Monitor Used when frequent measurements are needed esp BP Don t use when low BP or conditions affect HR Always validate and don39t use w high risk patients 0 Doppler Techniques Sound varies in pitch Higher the shorter distance traveled Used to locate peripheral pulse sites Augments Korotkoff sounds Procedure Apply gel to probe Turn on Touch probe to skin Sound indicates location ln ate cuff until sound disappears and 20 mmHg more Slowly de ate and mark systolic and diastolic Culture and Genetics 0 General Appearance Isabelle Yazel Vary among ethnicity and race as well as geographical area Japanese men in HA are taller than those in Japan Obesity 23 of adults in US are Abnormal Findings in Body Height and Proportion o Hypopituitary Dwar sm Retarded growth in 3rCI percentile de ciency in GH 0 Gigantism Excessive GH by ant Pituitary in childhood 0 Acromegaly Hyperpituitarism Excessive GH secretion in adulthood o Achondroplastic Dawr sm conversion of cartilage to bone normal trunck w short extremities o Anorexia Nervosa Mental Health disorder severe weight loss 0 Endogenous Obesity Cushing Syndrome Excessive production of ACTH weight gain and edema o Marfan Syndrome Inherited connective tissue disorder Abnormal Findings in BP 0 Hypotension 0 Hypertension 0 Classi cation and FollowUP of BP in 18 Normal Systolic lt120 and Diastolic lt80 Prehypertension 120139 and 8099 Stage 1 Hyper 140159 and 9099 Stage 2 Hyper gt160 and gt 100 0 Cardiovascular Risk Strati cation in Pt w Hypertension 0 Lifestyle Modi cations Chapter 10 0 Structure and Function 0 Nociceptive and Neuropathic processing 0 Neuroanatomic Pathway Nociceptors are pain nerve endings Carry signals via A6 Short term sharp pain and C fibers aching and longer lasting 0 Enter via post Nerve roots in dorsal horn Nociceptive Pain Transduction Release Substance P and other chemicals that transmit the pain message that terminates on dorsal horn Transmission Move from spinal cord to brain through thalamus to higher cortical areas Perception conscious awareness of the sensation limbic system and somatosensory Isabelle Yazel Modulation Block pain impulse and produce analgesic effect Neuropathic Pain Often perceived long after a wound has healed Caused by lesion or disease of somatosensory NS Nerve cells are altered causing increases sensitivity Sources of Pain Visceral Larger internal organs 0 Dull squeezing cramping Somatic Musculoskeletal tissuessurface of body Deep Somatic Blood vessels joins ect Cutaneous Skin surface Referred Felt in one site but from another Types of Pain Acute Chronic 6 months Breakthrough Pain Spike in pain Incident Pain predictable w certain movements Selfreport is the only reliable indicator for pain 0 Developmental Competence Infants and adults have the same pain capacity Preterms are more sensitive Aging Adult Common but normal in aging Those with dementia and Alzheimer39s do feel pain but may process it differently 0 Culture and Genetics No clear link bw pain and genetics Disparities related to pain do occur and are more present in minority groups In uenced by cultural social emotional and spiritual concerns 0 S Data 0 ALWAYS SUBJECTIVE Initial Pain Assessment Ask with a variety of words so they don39t just report one type of pain Ask to tell every place that pain is occurring bc it can be more localized or multiple sites When it started what person was doing and duration Ask what it feels like using variety of words tells is nociceptor or neuropathic Identify current intensity Does anything make it better or worse to determine treatment and effectiveness of treatments Isabelle Yazel Identify the degree to which the pain is affecting life by assessing its effect on activities of daily living 0 Are the responses to this pain normal to responses to other pains What does the pt think the pain is caused by and what it means to them 0 Pain Assessment Tools Upon entering room each time ask pain assessment on scale of 010 and use SOLDCART SOLDCART works well w many other assessments SScale 0Onset LLocation DDuration CCharacteristics note type and give examples of pain AAggravators RRelievers TTime Ask to rate and evaluate all pain sites Reassess after interventions Overall pain assessment tools are useful for chronic pain and some acute pain Initial Pain Assessment 0 Answer 8 questions about the location duration quality intensity and aggravatingrelieving factors Brief Pain Inventory 0 Rate pain in last 24 hours using 010 scale w concern for in uences on areas of life Short Form McGill Pain Questionnaire Asks patient to rank descriptors based on intensity Painrating Scales Re ect pain intensity indicate base and changes Numeric Rating Scales Choose rating for each pain site Verbal Descriptor Scale Visual Analogue Scale mark on line from no pain to worst imaginable 0 Tools for Infants and Children Rating scales are introduced around age 45 0 0 Data SOLDCART 0 Prep Consider whether is acute or chronic Try to reduce or eliminate pain with pharmacological or non pharmacological intervention 0 Equipment Tape measure Tongue Blade Peanht o Joints Note size an contour measure for comparison check ROM observe posture Swelling and in ammation slumped posture Isabelle Yazel o Muscles and Skin Inspect for color swelling masses test for ability to perceive sensation and press ends of broken tongue blade and have patient identify as dull or sharp Bruising leasion wounds absent pain sensation o Abdomen Observe for contour and Symmetry note areas of referred pain Swelling bulging in ammation 0 Nonverbal Behaviors of Pain Wide variety and in uenced by wide variety Acute Pain Behaviors Guarding moaning stillness or restlessness vitals changes Chronic Attempt to hide pain bracing rubbing Developmental Competency 0 Infants Limited information on assessment of chronic pain CRIES post op in neo and preterms and FLACC nonverbal under3 0 Aging Adult NOT NORMAL but prevalent Gain trust during assessment bc some will hide pain in fear of cost and dependency Observe for changes in activities of daily living Use PAINAD 4 indicates need for pain management Abnormal Findings 0 Peripheral Neuropathy PN Systemic damage to the nerves in the periphery causing pain that isn39t brought on by the stimulation of nerves 0 ChemotherapyInduced PN After chemo 0 Complex Regional Pain Syndrome CRPSRe exive Sympathetic Dystrophy RSD Chronic and progressive in extremities Light touches can create severe pain
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