comprehensive - head to toe, detailed assessment of 1 or more body systems not directly involved in present problem, admission or initial assessment at healthcare facility

focused - quick assessment that focuses on 1 or more body systems that are focused on care, done at beginning of shift

emergency - focused on ABC, performed mostly in acute setting (ED, ICU)

assessment - gathering data: records, interview and physical examination

analysis - identify & prioritize nursing diagnosis

planning & implementation - set goals and outcomes of care; perform nursing interventions

evaluation - determine if goals and outcomes are met

as a patient - privacy and adequate draping, room temperature should be comfortable, warm blankets if needed

as a nurse - soundproof room w/ adequate lighting, easy to maneuver examination table, equipment arranged for easy use

High Fowler's (80-90°); Fowler's (45-60°), Semi Fowler's (15-30°)

Trendelenburg: reverse (lower extremities lower than the head); modified (only the lower extremities above the heart)

methods of examining

inspection

use sense of sight w/ lighted equipment; use throught the physical examination; pay attention to details(color, size, shape, position, symmetry)

methods of examining

palpation

use sense of touch

types- light and deep

use sensitive parts of hand to detect different characteristics

method of examining

percussion

use sense of hearing, sound is produced by fingertip tapping through body tissues

types - direct and indirect

methods of examining

auscultation

use sense of hearing, by listening to sounds produced w/in the body, aided or unaided

types - direct and indirect

methods of examining

olfaction

use sense of smell, be familiar w/ body odors

general appearance & behavior

vital signs

height and weight

BMI (wt in lbs x (ht in inches x 2) x 703)

skin

color

ivory to light pink, brown or olive skin

pallor (unusual paleness) - easy to observe in the face, buccal mucosa, conjunctivae, nail beds; for dark individual, skin becomes yellowish brown/ashen grey

cyanosis (bluish discoloration) - observe in lips, nail beds, conjunctivae, palms; for darker individual, assess on areas w/ less pigmentation

vitiligo (loss of pigmentation)

jaundice (yellowish tinge))

erythema (redness)

skin

moisture

wet, oily to dry skin

hyperhidrosis (excessive perspiration)

bromhidrosis (foul-smelling perspiration)

skin

temperature

use dorsal surface of the hand

stage 1 pressure ulcer (skin is warmth, erythema is non-blanching)

skin

texture

smooth, soft and flexible

older individual, skin is wrinkled and leather

skin

vascularity

compare PAD vs CVI (chronic venous insufficiency) in term's of pt's limb skin color and changes

compare hematoma, ecchymosis, purpura and petechiae

skin

turgor

grasp a fold of skin on the back of the forearm or sternal area w/ fingertips and release

normally, skin lifts easily and snaps back immediately, while poor skin turgor, skin stays pinched (late sign of dehydration)

normal - instant recoil, no dehydration

delay - 2 seconds, some dehydration

prolong - > 2 seconds, severe dehydration

skin

edema

fluid buildup in the tissues, direct trauma or venous return impairment

to assess pitting edema, press area firmly w/ the thumb for several seconds and release

+1 - 2mm

+2 - 4mm

+3 - 6mm

+4 - 8mm

skin

lesions

primary lesions -

secondary lesions - scar, keloid, crust, fissure, ulcer, erosion, excoriation, lichenification

Asymmetry - unevenness

Border - irregularity

Color - black to bluish brown

Diameter - greater than the size of a pencil eraser (> 6mm)

Evolution - mole changing in size, shape or color

nail blanch test (capillary refill) - apply gentle, firm, quick pressure w/ thumb to the nail bed, release and observe for the returnof pink color (perfusion)

clubbing - change in angle (>180) between the nail and nail base, normally 160 (hypoxia)

Capillary refill:

< 2 seconds - brisk (normal)

> 4 seconds - sluggish

palpate the cranial bones - note for any deformities

inspect facial features - note and asymmetry by comparing one side to the other

inspect the scalp - separate the hair into 3 areas w/ a comb and inspect the scalp for any lesions

Olfactory (Sensory): smell

ask pt to identify different aromas in each nostril such as coffee or vanilla

Optic (Sensory): visual acuity & visual fields

use Snellen chart or ask patient to read printed material while wearing glasses

[image]

Oculomotor (Motor): pupil constriction & dilation; extraocular eye movement (PERRLA)

assess directions of movement; measure pupil reaction to light and accomodation

Trochlear (Motor): upward & downward movement of eyeball

Assess directions of gaze

Trigeminal (Sensory & Motor): sensory nerve to skin of face; motor nerve to muscles of jaw

lightly touch cornea w/ wisp of cotton. Assess corneal reflex. Measure sensation of light pain and touch across skin of face; palpate temple as pt clenches teeth, observe chewing

Abducens (Motor): lateral movement of eyeballs

assess directions of gaze

Facial (Motor and Sensory): Facial expression & taste

Look for asymmetry as patient smiles, frowns, puff out cheeks, and raises and lower eyebrows; have pt identify salty or sweet taste on front of tongue

Auditory (Sensory): hearing and equilibrium

Assess ability to hear spoken word

Glossopharyngeal (Sensory & Motor): taste & ability to swallow and speak

ask patient to identify sweet or sour taste on back of tongue; use tongue blade to elicit gag reflex, have person swallow

Vagus (Sensory and Motor): sensation of pharynx and behind ear; movement of vocal cords

Ask patient to say "Ah." Observe movement of palate and pharynx; assess speech for hoarseness

Spinal accessory (Motor): movement of head and shoulders

ask pt to shrug shoulders and turn head aganist passive resistance

Hypoglossal (Motor): position of tongue

Ask pt to stick out tongue to midline and move it from side to side

The thorax

posterior, lateral and anterior

Inspect - for skin and symmetry as pt takes deep breath

Palpate - for tenderness, bulging, retraction & crepitus; evaluate for tactile fremitus

Systole (S1) - closure of the mitral and tricuspid valve causing the 1st heart sound

Diastole (S2) - closure of the aortic and pulmonic valve causing the 2nd heart sound (during which coronary arteries are perfused)

Inspect - breast size & symmetry; observe for masses, retraction, dimpling or flattening

Palpation - have pt sit w/ arms extended & muscle relaxed, palpate lymph nodes along the axillary area as well as the upper & lower clavicular ridges

Palpation - lying supine, palpate the entire breast using the finger pads

inspection - position supine w/ knees bend, check for contour and skin; look for pulsation; ask pt to cough and inspect for hernia

auscultation - using the diaphragm of the stethoscope, begin in the RUQ continuing clockwise, listen for bowel sounds in each quadrant for at least 2 mins; using the bell, auscultate 1 inch above the umbilicus (aorta); 1 inch to each side (renal arteries); 1 inch down (iliac arteries) and then another 2 inches down (femoral artery)

light palpation - using one hand, palpate entire abdomen while watching pt's reaction for any tenderness

deep palpation - advanced skill (dominant hand over non-dominant hand, palpate and watch for pts reaction)

process where healthcare provider continually strives to work effectively w/ individuals, families, and communities

integration of knowledge, attitudes and skills that enhance cross-cultural communication & foster meaningful, respectful interactions

cultural awareness - one biases, prejudices, assumptions

cultural knowledge - gaining sensitivity & respect for differences

cultural skills - skills in communication, cultural assessment, culturally competent care

cultural encounter - cross-cultural interactions, gaining in depth understanding of other cultures

increase pt satisfaction

increase adherence to treatment plan

identify health risks

improve relationships

increase satisfaction for providers

minimize health disparities

overall health of americans has improved

lacking PCP: 30% of hispanics; 20% of African Americans; 16% caucasian

53% of hispanics w/ ESL report communication problems w/ PCP, vs. 26% non ESL

health of minority groups has declined

the way in which a cultural view understands or explains the world and parts of the world

an insider or native perspective (patient)

an outsider perspective (Nurse)

a group of people who share values and ways of thinking

give up ethnice identity to enter dominant culture

adapting to a new culture, affiliation w/ the dominate culture

awareness of self & connection to a higher being

B - belief system

E - ethics or values

L - lifestyle

I - involvement in a spiritual community

E - education

F - future events

be compassionate

listen effectively

identify pt strengths and resources

draw up personal faith and hope

don't express opinions

avoid false assumptions

a personal belief about the worth you hold for an idea, a custom, or an object....systems of ethics usually grow from shared values

a judgement about behavior

refers to the consideration of standards of conduct or the study of philosophical ideals of right and wrong behavior

a set of ethical principles that all members of a profession generally accept

ensures that you are able to distinguish between your personal values andthose of...other participants and allows you to become a more open listener

arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursure the right course of action

s/s: nightmares, insomnia, anorexia

accountability - the ability to answer for you actions

responsibility - the execution of nursing duties, e.g. medication administration

respect for confidentiality - no disclosure of personal health information (PHI)

competency - the specific knowledge and skill necessary to perform tasks

judgment - the ability to form an opinion and draw sound conclusions

collegiality - cooperative interaction w/ others; sharing of power

veracity - the telling of truth

advocacy - promotion of patient decision making

giving pts the information they need to make decisions and then supporting those decisions...[and it is to] clearly state a pt's point of view to other healthcare providers

respect a pt's right to determine a course of action

the principle of fairness; the fair distribution of resources

the agreement to keep promises

promotion of good; taking positive actions to help others

to do no harm; continually consider the potential for harm

the study of ethics w/in the field of healthcare...increasingly, the term clinical ethics is replacing the term bioethics

exists when the right thing to do is not clearor when members of the healthcare team cannot agree on the right thing

actions are right if based on 'right-making' characteristics (it is right if autonomy is respected)

the greatest good for the greatest number of people

it is right to routinely ask how ethical decisions will affect women (with fetal surgery how is the fetus and the women affected)

by paying attention to relationships and stories the right decisions will be made (no reliance upon universal principles)

bill of rights

ensures fairness

right to considerate and respectful care

right to current information and treatment

right to be involved in healthcare decisions

bill of rights

promotes autonomy

right to all records being maintained in a confidential manner

right to be informed of hospital policies and procedures

removal of debris from a wound

separation of surgical incision

dry, non-vital surface crust that results from tissue injury, usually black or brown

remove the viscera from the abdominal cavity

superficial skin injury caused by abrasion, scratching or burn

an abnormal passage from an internal organ to the body surface or between two internal organs

soft, pink, fleshy tissue that forms during the healing process

softening and breaking down of skin resulting from prolonged exposure to moisture

non-vital tissue, usually tan, grey or green in color

cell regeneration

wound repair - primary and secondary intention

phases of healing - inflammation(or defensive); proliferation; maturation

healing when wound margins are well approximated

new connective tissue replaces epithelium

wound edges are poorly approximated

healing takes place from the base upward and from the edges inward

phases of healing

inflammation

occurs from the time of injury to three days

characterized by hemostasis (slowing of bleeding) and inflammation

clotting cascade is initiated, & white blood cells mobilize to defend and protect the area from bacterial infection

vasodilation & serous exudate facilitate the removal of debris & provision of nutrients to injured tissue

phases of healing

proliferation

lasts from day 2 until the area is healed

includes neoangiogenesis (new blood vessel) and collagen formation

granulation tissue is a pale pink to beefy red, glistening, and has a rough surface due to blood vessels and collagen deposits

phases of healing

maceration

involves remodeling (scar formation) after wound closure

may take years

scar changes from red to purple/pink to white, from bumpy to flat

by cause - surgical or non-surgical

acute or chronic

by depth - superficial; partial thickness; full thickness

red, yellow, black

superficial - involves only epidermis

partial thickness - extends into the dermis

full thickness - extends into subcutaneous tissue

red - containing granulating tissue

yellow - containing slough

black - containg necrotic tissue

a wound may have 2 or 3 colors

hemorrhage

infection

dehiscence

evisceration

fistula

loss of body part

a localized injury to the skin or unerlying tissue usually over a bony prominence caused by pressure

stage 1: intact skin w/ non-blanchable redness

stage 2: partial thickness skin loss: shallow open ulcer w/ a red-pink wound bed

stage 3: full thickness skin loss: subcutaneous tissue is visible

stage 4: full thickness skin loss w/ exposed bone, tendon or muscle

unstageable: full thickness skin loss in which the base of the ulcer is covered by slough or eschar

separation of the epidermis from lower skin layers

do not "pop"

cover w/ thin film to prevent pt from picking at blister