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355 terms

Fundamentals of Nursing Finals: From ATI Concepts, Outlines and Definitions for Foundations of Nursing

Key terms, definitions, lists, concepts for ATI Fundamental Finals from Fundamentals for Nursing 7.0, Review Module
STUDY
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The Joint Commission
Sets quality standards for accreditation of health care facilities
Utilization review committee
Monitors appropriate diagnosis and treatment of hospitalized clients
Federally funded health care programs
1) Medicare - for clients 65 years or older or with permanent disabilities (premiums applied either through (a) Insurance programs - DRG; or (b) MCO (Managed Care Organizations) - enrolled clients receive a comprehensive care overseen by a primary care provider
2) Medicaid - for clients with low incomes; State determines eligibility requirements
Privately funded health care plans
a) Traditional - fee for service
b) MCO - Managed Care organization; primary care provider focuses on prevention and health promotion
c) PPO - preferred provider organization; client chooses from a list
d) EPO- exclusive provider organization; client chooses from a list within a contracted organization
e) LTC - long term care insurance; expenses not covered by Medicare
Levels of health care
a) Preventive - focus on education (immunization, stress management, seat belts)
b) Primary - emphasizes health promotion (prenatal and well baby care)
c) Secondary - diagnosis and treatment of emergency, acute illness or injury (acute inpatient care, ER)
d) Tertiary - specialized highly technical care (Oncology, burn centers)
e) Restorative - intermediate follow up care for restoring health (home health care, rehab centers)
f) Continuing health care - addresses long term or chronic health care needs (hospice, adult day care)
Interdisciplinary personnel (non-nursing)
a) clergy
b) registered dietitian
c) laboratory technician
d) occupational therapist
e) Pharmacist
f) Physical Therapist
g) Provider - MD, DO
h) Radiologic technologist
i) Respiratory therapist
j) Social worker
k) Speech Therapist
Nursing Personnel
a) RN
b) LPN/LVN
c) UAP - CNA, CMA
Expanded Nursing Roles
a) APN - advanced practice nurse ( CNS - clinical nurse specialist; CRNA - certified registered nurse anesthetist; NP - nurse practitioner; CNM - certified nurse-midwife)

b) Nurse Educator
c) Nurse Administrator
d) Nurse Researcher
ETHICS
Based on an expected behavior of a certain group in relation to what is considered right or wrong. Study of conduct and character
MORALS
Values and beliefs held by people that guide their behaviors and decision making
ETHICAL THEORY
Examines different principles, ideas, systems and philosophies used to make judgments about what is right and wrong, good or bad.
a) utilitarianism - the value of a thing is based on its use; end justifies the means
b) deontology - moral rights and duties
ETHICAL PRINCIPLES related to the treatment of clients
a) Autonomy
b) Beneficence
c) Fidelity
d) Justice
e) Nonmaleficence
AUTONOMY
Ability of client to make personal decisions even when they may not be in client's best interest
BENEFICENCE
Agreement that acre given is in the best interest of the client; taking positive actions to help others
FIDELITY
Agreement to keep one's promise to the client about care that was offered.
JUSTICE
Fair treatment in matters related to physical and psychosocial care and use of resources
NONMALEFICENCE
Avoidance of harm or pan as much as possible when giving treatments
Ethical Dilemmas
Problems about which more than once choice can be made and the choice made is influenced by the values and beliefs of decision makers.
A problem in health care is an ethical dilemma if :
a) it cannot be solved solely be a review of scientific data
b) it involves a conflict between two moral imperatives
c) the answer will have a profound effect on the situation/client
Documents used to help solve ethical dilemmas
a) ANA Code of Ethics for Nurses (2001)
b) ICN Code of Ethics for Nurses (2006)
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for LPN/LVN - Code of Ethics by NAPNES
Basic principles of Nurse's code of Ethics
a) Advocacy - support the cause of client
b) Responsibility - willingness to respect obligations
c) Accountability - ability to answer for one's actions
d) Confidentiality - protection of privacy without diminishing care
UDDA - Uniform Determination of Death Act
Document used to assist on issues regarding end-of-life and organ donor issues
FEDERAL regulations and laws that impact nursing practice
a) HIPAA - health insurance portability and accountability Act
b) ADA - Americans with Disabilities Act
c) MHPA - Mental Health Parity Act
d) PSDA - Patient self determination Act
CRIMINAL LAW
Subsection of public law and relates to the relationship of an individual with the government.
CIVIL LAW
Protects the individual rights of people. One type of civil law that relates to the provision of nursing care is TORT LAW
TORTS
a) Unintentional Torts (Negligence, Malpractice)
b) Quasi-intentional Torts (Breach of confidentiality, defamation of character)
c) Intentional Torts (Assault, Battery, False Imprisonment)
NEGLIGENCE
A nurse FAILS TO implement safety measures for a client who has been identified as at risk for falls
MALPRACTICE (Professional negligence)
A nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies.
BREACH OF CONFIDENTIALITY
A nurse releases the medical diagnosis of a client to a member of the press
DEFAMATION OF CHARACTER
A nurse tells a colleague that she believes the client has been unfaithful to her spouse
ASSAULT
The conduct of one person makes another person fearful or apprehensive (threatening to place a nasogastric tube in a client who refuses to eat)
BATTERY
Intentional and wrongful physical contact with a person that involves an injury or offensive contact (restraining a client and administering an injection against her wishes).
FALSE IMPRISONMENT
A person is confined or restrained against his will (using restraints on a competent client to prevent his leaving the health care facility)
COMPACT STATE
In relation to licensure, a nurse who resides in a compact State is allowed to practice in another compact State under a multi-State license.
PROFESSIONAL NEGLIGENCE
Failure of a person with professional training to act in a reasonable and prudent manner.
Reasonable and Prudent
Used to describe a person who has the average judgment, intelligence, foresight, and skill that would be expected of a person with similar training and experience.
FIVE ELEMENTS necessary to prove NEGLIGENCE
1. Duty to provide care as defined by standard
2. Breach of duty by failure to meet standards
3. Foreseeability to harm
4. Breach of duty has potential to cause harm (combines 2 and 3)
5. Harm occurs
Ways to AVOID being liable for NEGLIGENCE
1) Follow standards of care
2) Give competent care
3) Communicate with other health team members
4) Develop a caring rapport with clients
5) Fully document assessments, interventions and evaluations
PATIENT'S (Client's) Rights
a) Informed consent
b) Right to refuse treatment
c) Advanced directives
d) Confidentiality
e) Information security
American Hospital Association (AHA) identifies patient's rights in Health Care settings
Contained in "The Patient Care Partnership"
Informed Consent
Written and signed permission (document) for a procedure or treatment to be performed.
Elements of an Informed consent
a) Reason for treatment or procedure
b) How procedure will benefit the client
c) Risks involved if client agrees to the procedure
d) Other options available to treat the problem
Nurse's ROLE in an INFORMED CONSENT
a) WITNESS THE CLIENT's SIGNATURE
b) Ensure that informed consent has been appropriately obtained
Who CAN SIGN an INFORMED CONSENT?
a) a competent adult
b) someone who is capable of understanding the information provided.
AUTHORIZED individuals to grant consent for another person:
a) Parent of a minor
b) Legal guardian
c) Court-specified representative
d) A person with a durable Power of Attorney (POA) for health care
e) Emancipated minors (independent minors such as married minors)
Patient Self Determination Act (PSDA)
Upon admission to a Health Care facility, a client must be informed of their right to accept or refuse care.
AMA (against medical advice) form
Client must sign this document when a decision is made to leave the facility without a discharge order.
Standards of Care (Practice)
Legal parameters of practice, define and direct the level of care that should be given by a practicing nurse. They are used in malpractice lawsuits to determine if that level was maintained.
Where can the "Standards of Care" be found?
in the NURSE PRACTICE ACT of each State
SCOPE OF PRACTICE
That which belongs to the area of competence as determined by training, education and licensing requirements.
ADVANCED DIRECTIVES
Communicates a client's wishes regarding and end-of-life care should the client become unable to do so. PSDA requires that all health care facilities ask if a patient has advanced directives upon admission.
Types of ADVANCED DIRECTIVES
a) Living Will - expresses client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end of life issues

b) Durable Power of Attorney for Health Care- designates a health care proxy who is an individual authorized to make health care decisions for a client who is unable

c) Provider's Orders - Unless a DNR (do not resuscitate) or AND (allow natural death) order is written, nurse initiates CPR when client has no pulse or respiration. Written order for DNR or AND must be placed in client's medical record.
Mandatory Reporting
Nurses are mandated to report any suspicion of abuse (child or elder abuse, domestic violence) following facility policy.
Communicable disease Reporting
Nurses are also mandated to report to the proper agency (local or State health department) when client has been diagnosed with a communicable disease (e.g. tuberculosis, hepatitis A)
Client's CHART OR MEDICAL RECORD
Legal record of care: confidential, permanent and legal document that is admissible in court.
Information included in the Client's Chart
a) Assessments
b) Medication Administration
c) Treatments given and the client's responses
d) Client education
PURPOSES for MEDICAL RECORDS
a) communication
b) legal documentation
c) financial billing
d) education
e) research
f) auditing/monitoring
Purpose of reporting
Provide continuity of care
Good qualities of DOCUMENTATION
a) Factual - Subjective and Objective
b) Accurate and Concise
c) Complete and Current
d) Organized
LEGAL GUIDELINES OF a GOOD DOCUMENTATION
a) Begin entry with DATE and TIME
b) Record legible with non-erasable black ink; do not LEAVE BLANK SPACES
c) Do NOT USE Correction Fluid
d) Information inadvertently omitted may be added as "LATE ENTRY". Must include time charting was done and the time the charting reflects
e) Should reflect assessments, interventions, and evaluations performed by the person signing the entry.
f) for electronic charting, password must be PRIVATE
DOCUMENTATION FORMATS
a) Flow Charts - record and show trends in vital signs, blood glucose levels, pain level and other frequently performed assessments

b) Narrative Documentation - records information as a sequence of events

c) Charting by exception (CBE) - standardized forms that identify normal findings/values and allows selective documentation of abnormal findings.

d) Problem oriented medical records (POMR) - consists of database, problem list, care plan, and progress notes.
POMR (Problem oriented medical records)
a) SOAPIE
b) PIE
c) DAR (focus charting)
SOAPIE
S = subjective data
O = objective date
A = assessment (includes Nursing Diagnosis based on assessment)
P = Plan
I = Intervention
E = Evaluation
PIE
P = problem
I = intervention
E = evaluation
DAR (focus charting)
D = data
A = action
R = response
Change-of-shift Reports
Given at the conclusion of each shift by the nurse leaving to the nurse assuming responsibility for the client.
Transcribing Medical orders
a) Have a second nurse listen to telephone order
b) Repeat back the order given: medication name, dosage, time and route
c) Document reading back the order and presence of nurse
d) Question any order that may seem contraindicated due to a previous order or due to the client's condition
TRANSFER REPORTS SHOULD INCLUDE
CLIENT's:
a) demographic information
b) medical diagnosis
c) directives
d) most recent vital signs
e) current prescribed medication
f) allergies
g) diet and activity orders
h) special equipment
i) advanced directives
j) family involvement
Components of the Privacy Rule of HIPAA:
a) Only health care team members directly responsible for client care should be allowed access to client records.
b) Clients have the right to read and obtain a copy of their medical record, and facility policy should be followed when client requests as such.
c) No part of the client chart can be copied except for authorized exchange of documents between health care institution or health care providers.
d) Client medical records must be kept in secure area
e) EMR should be password protected
f) Health care workers should only use their own passwords
INFORMATION SECURITY PROTOCOLS
a) Logging off from computer before leaving work station
b) Never share a user ID or password with anyone
c) Never leave a client's chart or other patient document where others can access it.
d) Shred any printed or written client information used for reporting or client care after it is no longer needed.
Five RIGHTS of DELEGATION
a) Right Task
b) Right Circumstance
c) Right Person
d) Right Direction/Communication
e) Right Supervision
Nursing Process (overview)
a) Cyclical, critical thinking process that consists of five steps; variation of scientific reasoning
b) client centered, problem solving and decision making framework
c) Provides the framework throughout which the nurse can apply knowledge, experience, judgment and skills to the formulation of a nursing care plan
d) Includes five sequential but overlapping steps
e) allows nurse to integrate creative critical thinking
f) Promotes professionalism
Five steps of Nursing Process
1) Assessment/data collection
2) Diagnosis - Analysis/data collection
3) Outcome - planning
4) Implementation - intervention
5) Evaluation
Methods of Data Collection
1) Observation
2) Interviews
3) Comprehensive or focused physical examination
4) Diagnostic and laboratory reports
5) Collaboration
Two Types of DATA
a) Subjective Data - Symptoms; what patient says
b) Objective Data - Signs; what is seen in a patient
Sources of DATA
a) Primary = the CLIENT
b) Secondary = all other sources which does NOT COME FROM THE client
Nurse engages in three types of PLANNING
a) Comprehensive plan of care upon admission
b) Ongoing planning based upon new information and new assessments and new evaluations
c) Discharge planning. Begins as soon as the client is admitted
Maslow's hierarchy of needs
A framework used as a guideline to set priorities
Types of INTERVENTIONS
a) Nursing initiated/independent interventions - within Scope of Practice as identified by ANA Standards of Practice, State Nurse Practice Act and health care facility policies
b) Physician initiated/dependent interventions - the nurse initiates as a result of a physician's order
c) Collaborative intervention - the nurse carries out in collaboration with other health care team professionals.
Components of CRITICAL THINKING
a) Knowledge
b) Experience
c) Competencies
d) Attitudes
e) Intellectual and Professional Standards
Levels of Critical Thinking
a) Basic Critical thinking - results from limited knowledge and experience
b) Complex critical thinking - expresses autonomy by analyzing and examining data to determine best alternatives
c) Commitment - results from an expert level of knowledge, experience, developed intuition, and reflective flexible attitudes
Assessment/Data collection
Collect information about client's present health status to identify client's needs and to identify additional data to collect based on nurse's findings
DIAGNOSIS: Analysis/Data collection
Interpret or monitor the collected database, reach an appropriate nursing judgment about client's health status and coping mechanisms, and provide direction for nursing care
OUTCOME: Planning
Establish priorities and optimal outcomes of care than can be measured and evaluated, then select the nursing interventions to include in a client's plan of care to promote, maintain, or restore a client's health
Implementation
provide client care based on assessment data gathered, analyses done, and the plan of care developed in the previous steps of the nursing process.
Evaluation
Examine a client's response to nursing interventions and form a clinical judgment about the extent to which goals and outcomes have been met.
Attitudes of a critical thinker
1) Confidence - feels sure of abilities
2) Independence - Analyzes ideas for logical reasoning
3) Fairness - objective, nonjudgmental
4) Responsibility - practices according to standards of practice
5) Risk taking - takes calculated chances in finding better solutions to problems
6) Discipline - Develops a systematic approach to thinking
7) Perseverance - continues to work until problem is resolved
8) Creativity - using imagination to find solutions unique to client problems
9) Curiosity - requires more information about clients and problems
10) Integrity - practices truthfully and ethically
11) Humility - Acknowledges weakness
12) Standards - Model to which care is compared to determine acceptability, excellence and appropriateness
Asepsis
Absence of illness-producing micro-organisms, maintained through the use of aseptic technique with hand hygiene as the primary behavior associated with asepsis/aseptic technique.
Two types of Asepsis
a) Medical Asepsis - clean technique - reduction of micro-organisms
b) Surgical Asepsis - sterile technique - elimination of micro-organisms
Components of Hand washing
a) Soap
b) Water
c) Friction
Length of time required for hand washing
at least 15 seconds to remove transient flora and up to 2 minutes when the hands are soiled.
Iatrogenic infection
Type of HAI resulting from a diagnostic or therapeutic procudure
Signs and symptoms of generalized systemic infection
a) Fever
b) Increased pulse and respiratory rate (in response to high fever)
c) Malaise
d) Anorexia, nausea, and/or vomiting
e) Enlarged lymph nodes (repositories of waste)
HAI - Health-care Associated Infection
Formerly known as nosocomial infection, they are acquired while receiving care in a health care setting. These can come from an exogenous source (outside the client) or an endogenous source (inside the client)
Inflammation
Body's local response to injury or infection
3 Stages of the inflammatory response
I. FIRST STAGE - inflammatory response (local infection)
a) Redness from dilation of arterioles bringing blood to the area
b) Warmth of the area on palpation
c) Edema
d) Pain or tenderness
e) Loss of use of the affected part

II. SECOND STAGE - micro-organisms have been killed. Fluid accumulates and exudate appears at the site of infection
a) Serous
b) Sanguineous (contains red blood cells)
c) Purulent (contains leukocytes and bacteria)

III. THIRD STAGE - damage tissue is replaced by scar tissue. Gradually new cells take on characteristics that are similar in structure and function of the old cells.
Laboratory results indicating infection
a) Leukocytes (WBC more than 10,000 ul)
b) Increases in the specific type of WBCs on differential (left shift = an increase in neutrophils)
c) Elevated erythrocyte sedimentation rate (ESR)
d) Presence of micro-organisms on culture of the specific fluid/area
COMPONENTS OF THE CHAIN OF INFECTION
a) Infectious agent - bacteria, virus, fungi, protozoa
b) Reservoir - where infectious agent grows (wound drainage, food, oxygen tubing)
c) Exit - portal of the infectious agent (skin, respiratory or GI tract)
d) Means of transmission (droplet, person to person contact, touching contaminated items)
e) Entry - portal to a susceptible host (same as Exit)
f) Host - must be susceptible to infectious agent
Infection control for immobile clients
Ensure that pulmonary hygiene (turning, coughing, deep breathing, incentive spirometry) is done every 2 hours, or as prescribed. Good pulmonary hygiene decreases the growth of micro-organisms and the development of pneumonia by preventing stasis of pulmonary excretions, stimulating ciliary movement and clearance, and expanding the lungs
Isolation guidelines
a) group of actions that include hand hygiene and the use of barrier precautions

b) applies to every client, regardless of diagnosis and must be implemented whenever contact with a potentially infectious material is anticipated

c) PPE is changed after contact with each client and between procedures with the same client if in contact with large amounts of blood and body fluids.
STANDARD PRECAUTIONS (Tier One)
a) applies to all body fluids (except sweat), nonintact skin, and mucous membranes.
b) Hand hygiene using alcohol based waterless product is recommended after contact with client, body fluids, and contaminated equipment.
c) Alcohol-based waterless antiseptic is preferred unless hands are visible dirty, because alcohol based product is more effective in removing micro-organisms.

d) Clean gloves are worn when touching body fluids, nonintact skin, mucous membranes, and contaminated equipment
e) Gloves are removed and hand hygiene performed between each client.
f) Masks, eye protection, and/or face shield are required when care may cause splashing or spraying of body fluids.

g) Hand hygiene is required after removal of the gown. A sturdy moisture-resistant bag should be used for soiled items and the bag should be tied securely in a knot at the top.
h) All equipment used for client care is to be properly cleaned, one time use should be disposed accordingly.
i) Contaminated laundry should be bagged and handled to prevent leaking or contamination of clothing or skin

j) Safety devices on all equipment/supplies must be enabled after use; sharps must be disposed of in a puncture-resistant container
k) A private room is not needed unless the client is unable to maintain appropriate hygiene practices.
TRANSMISSION PRECAUTION (Tier Two)
a) Airborne precautions are used to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis). Airborne precaution require: (1) Private room; (2) Mask, respirators for providers and visitors; N95 or HEPA (high efficiency particulate air) respirator if patient is suspected to have TB; (3) Negative pressure airflow exchange in the room of at least six exchanges per hour.

b) Droplet precautions against droplet larger than 5 mcg (streptococcal pharyngitis or pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia/sepsis, pneumonic plague). Droplet precautions require: (1) Private room or a room with other clients having the same infection; (2) Masks for providers and visitors

c) Contact precautions - protect visitors and caregivers against direct client/environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, scabies, multi-drug resistant organisms. Contact precautions require: (a) private room or room with other client with the same disease; (b) gloves and gown worn by caregivers and visitors; (c) disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag.
TRANSPORTING THE CLIENT
If movement of client to another area is not avoidable, take precautions to ensure that the environment is not contaminated. For example, a surgical mask is placed on the client with an airborne or droplet infection, and a draining wound is well covered.
Guidelines for cleaning contaminated equipment
1) Always wear gloves
2) Rinse first in cold water (hot water coagulates proteins)
3) Wash the article in hot water with soap
4) Use a brush or abrasive to clean corners
5) Rinse well in warm or hot water
6) Dry the article - considered clean at this point
7) Clean the equipment used in cleaning
8) Remove gloves and perform hand hygiene
Older Adults increased risk for falls
a) Due to decreased strength
b) Impaired mobility and balance
c) Limited endurance
d) Decreased sensory perception
Other clients with increased risk for falls
1) Those with decreased visual acuity
2) Generalized weakness
3) Gait and balance problems (CP, Injury, MS) and cognitive dysfunctions
4) Side effects of medication (orthostatic hypotension, drowsiness)
GENERAL MEASURES to PREVENT FALLS
1) Call light location and use
2) Respond to call lights in a timely manner
3) Orient client to setting
4) Place client at risk for falls close to the nursing station
5) Ensure bedside table and frequently used items are within reach
6) Maintain bed in low position
7) For clients who are sedated or unconscious, bed rails are up, bed is kept low
8) Avoid the use of full side bed rails for clients who get out of bed without assistance
9) Provide clients with nonskid footwear
10) Keep floor free from clutter with a clear path to the bathroom
11) Keep assistive devices nearby after validation of use
12) Lock wheels on beds, wheelchairs and carts
13) Use chair or bed sensors for clients at risk for getting up unattended to alert staff
SEIZURES
Sudden surge of electrical activity in the brain. May occur anytime, may be due to epilepsy, fever or a variety of medical conditions. Partial seizures are surges in one part of the brain. Generalized seizures involve entire brain.
Seizure precautions (most important)
1) Do not put anything in a client's mouth (except for status epilepticus, where an airway is needed) in the event of a seizure

2) Do not restrain a client in an event of a seizure. Lower him to the floor or bed. Protect head, remove nearby furniture, provide privacy, put client on his side with head flexed slightly forward, loose clothing to prevent injury

3) Stay with the client and call for help
4) Administer medication as ordered
5) After seizure, explained what happened to client. Provide comfort.
6) Document thoroughly: duration, behavior, description, length, injury, aura, postictal state, and report to provider
Two types of restraints:
a) Physical
b) Chemical
Seclusions and restraints must never be used for:
a) convenience of the staff
b) punishment for the client
c) clients who are extremely physically or mentally unstable
d) clients who cannot tolerate the decreased stimulation of a seclusion room
Restraints should:
a) never interfere with treatment
b) restrict movement as little as is necessary to ensure safety
c) Fit properly
d) Be easily changed to decrease the change of injury and provide for the greatest level of dignity
A prescription for restraint should contain the following:
a) reason for restraint
b) type of restraint
c) location of the restraint
d) how long the restraint may be used
e) type of behaviors demonstrated by the client that warrant use of restraint
How often should a physician rewrite a prescription for restraint?
every 24 hours
Frequency of client assessment in regards to food. fluid, comfort and safety in relation to a restraint
every 15 to 30 minutes
Other important things to know and do about a restraint
a) Always explain the need for restraint to client
b) Obtain signed consent from client or guardian
c) Review manufacturer's instructions for correct application
d) Remove or replace restraints for good circulation
e) Pad bony prominences
f) Use quick release know to tie restraint to the bed frame
g) Ensure that restraint is loose enough to fit two fingers between device and the client
h) Never leave client unattended without restraint
Fire response in a health care setting follows this pattern
R - Rescue, protect and evacuate clients in close proximity to the fire
A - Alarm, Report the fire by setting off the alarm
C - Contain the fire by closing the doors and windows as well as turning off any sources of oxygen. Clients who are on life support are ventilated with a bag-valve mask
E - Extinguish the fire if possible using an appropriate fire extinguisher
3 Classes of fire extinguisher
Class A = paper, wood, upholstery, rags or other types of trash
Class B = flammable liquids, and gas fires
Class C = for electrical fires
to USE a FIRE EXTINGUISHER
P = pull the pin
A = aim at the base of the fire
S = squeeze the lever
S = sweep motion back and forth over the fire
Factors that contribute to a client's risk for injury
a) Age and development status
b) Mobility and balance
c) Knowledge about safety hazards
d) Sensory and Cognitive awareness
e) Communication skills
f) Home and work environment
g) Community in which the client lives
Risk factors for falls among older adults
1. Physical, cognitive and sensory changes
2. Changes in the musculoskeletal and neurological systems
3. Impaired vision and/or hearing
4. Frequent trips to the bathroom at night because of nocturia and incontinence
Places an older adult at risk for burns and other type of tissue injury
Decrease in tactile sensitivity
Modifications that can me made to improve home safety for Older Adults
1. Remove items that could cause a client to trip, such as throw rugs and carpets
2. Place electrical cords and extension cords against a wall behind furniture
3. Make sure that steps and sidewalks are in good repair
4. Place grab bars near the toilet and in the tub or shower and install a stool riser
5. Use a non-skid mat in the tub or shower
6. Place a shower chair in the shower
7. Ensure that lighting is adequate both inside and outside of the home
Some HAZARDS of SMOKING:
a) Passive smoking is the unintentional inhalation of tobacco smoke
b) Exposure to nicotine and other toxins places people at risk for numerous diseases including cancer, heart disease, and lung infections.
c) Low birth weight infants, prematurity, still births, and sudden infant death syndrome (SIDS) have been associated with maternal smoking.
d) Smoking in the presence of children is associated with the development of bronchitis, pneumonia, and middle ear infections
HAZARDS of CARBON MONOXIDE
1. Carbon monoxide is a very dangerous gas because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body.
2. Carbon monoxide cannot be seen, smelled or tasted
3. Symptoms of carbon monoxide poisoning include: nausea, vomiting, headache, weakness and unconsciousness
4. Death may occur with prolonged exposure
5. Measures to prevent Carbon Monoxide poisoning include proper ventilation when using fuel-burning devices (lawn-mowers, wood burning and gas fireplaces)
6. Gas burning furnaces, water heaters and appliances should be inspected annually.
7. Carbon monoxide detectors should be installed and inspected regularly
Hazards of FOOD POISONING
a) Food poisoning is a major cause of illness in the US
b) Most food poisoning is caused by some type of bacteria such as Escherichia coli, Listeria monocytogenes, and Salmonella
c) Most food poisoning occurs because of unsanitary food practice
d) Very young, very old, pregnant and immunocompromised individuals are at risk for complication
e) Performing hand hygiene, ensuring that meat and fish are cooled to the correct temperature, handling raw and fresh food separately to avoid cross contamination, and refrigerating perishable items prevent food poisoning.
Hazards of Bioterrorism
1. Bioterrorism is the dissemination of harmful toxins, bacteria, viruses, and pathogens for the purpose of causing illness or death
2. Anthrax, variola, Clostridium botulism, and Yersinia pestis are examples of agents used by terrorists
ERGONOMICS
Factors or qualities in an object's design and/or use that contribute to comfort, safety, efficiency and ease of use.
Good body mechanics
Positioning and moving clients to promote safety for the client as well as for health care providers
Mobility assessment
Needed before attempting to move or position a client. Begin with ROM and progress as long as client tolerates. Include balance, gait and exercise
Body Mechanics
Proper use of muscles to maintain balance, posture, and body alignment when performing a physical task. Nurses use body mechanics when providing care to clients by lifting, bending, and carrying out the activities of daily living.
Center of gravity
1) it is the center of mass
2) Weight is the quantity of matter acted on by force of gravity
3) To lift an object, the nurse must overcome the weight of the object and know the center of gravity of the object.
4) When the human body is in the upright position, the center of gravity is in the pelvis
5) When an individual moves, the center of gravity shifts
6) The closer the line of gravity is to the center of the base of support, the more stable the individual is.
7) The lower the center of gravity, bend the hips and knees
LIFTING
a. Use the major muscle groups to prevent back strain, and tighten the abdominal muscles to increase support to the back muscles

b. Distribute the weight between the large muscles of the arms and legs to decrease the strain on any one muscle group and avoid strain on smaller muscles.

c. When lifting an object from the floor, flex the hips, knees and back. Get the object to thigh level, keeping the knees bent and the back straightened. Stand up while holding the object as close as possible to the body, bringing the load to the center of gravity to increase stability and decrease back strain.

d. Use assistive devices whenever possible, and seek assistance whenever it is needed.
When pushing or pulling a load
a) Widen the base of support
b) Pull objects toward the center of gravity rather then pushing away
c) If pushing, move the front foot forward, and if pulling, move the rear leg back to promote stability
d) Face the direction of movement when moving a client
e) Use own body as counterweight when pushing or pulling to make the movement easier
f) Sliding rolling and pushing require less energy than lifting and offer less risk for injury
g) Avoid the thoracic spine and bending the back while hips and knees are straight.
Guidelines to prevent injury
1) Plan ahead for activities that require lifting, transfer, or ambulation of client, and ask others to be ready to assist at the planned time
2) Be aware that the safest way to lift a client may be with the use of assistive equipment.
3) Rest between heavy activities to decrease muscle fatigue
4) Maintain good posture and exercise regularly to increase strength in arms, legs, back, and abdominal muscles, so these activities will require less energy.
5) Use smooth movements when lifting and moving clients to prevent injury through sudden or jerky muscle movements.
6) When standing for long periods of time, flex the hip and knee through use of a foot rest. When sitting for long periods of time, keep the knees slightly higher than the hips.
7) Avoid repetitive movements of the hands, wrists, and shoulders. Take a break every 15 to 20 minutes to flex and stretch joints and muscles.
8) Maintain good posture (head and neck in straight line with the pelvis) to avoid neck flexion and hunched shoulders, which can cause impingement of nerves in the neck.
9) Avoid twisting the spine or bending at the waist (flexion) to minimize the risk for injury.
SEMI-FOWLER'S POSTION
1) Used to prevent regurgitation of tube feedings and aspiration in clients with difficulty swallowing
2) Supine with head of the bed elevated approximately 30 degrees and knees slightly elevated about 15 degrees
FOWLER'S POSITION
1) Used during procedures such as NG tube insertion and suctioning. Also for better chest expansion and ventilation, as well as better dependent drainage after abdominal surgeries
2) Supine with head of bed elevated about 45 degrees, and knees slightly elevated about 15 degrees.
HIGH-FOWLER'S POSITION
1) Promotes lung expansion by lowering the diaphragm and is used for clients experiencing severe dyspnea
2) Supine with head of bed elevated slightly 90 degrees and knees may or may not be elevated
SUPINE OR DORSAL RECUMBENT
1) Ideal for patients with lower back problems
2) Lies on back with head and shoulders elevated on a pillow. Forearms may be placed on pillows or placed at side. A foot support prevents foot drop and maintains proper alignment.
PRONE POSITION
1) Promotes drainage from the mouth for clients following throat or oral surgery, but inhibits chest expansion
2) Flat on abdomen with head to one side
LATERAL OR SIDE-LYING POSITION
1) This is a good sleeping position, but the client must be turned regularly to prevent development of pressure ulcers on the dependent areas. A 30 degree lateral position is recommended for clients at risk for pressure ulcers.
2) Client lies on side with most of his weight on the dependent hip and shoulder. Arms should be flexed in front of the body. A pillow is placed under his head and neck, the upper arm, and under the leg and thigh to maintain body alignment
SIM'S OR SEMI-PRONE POSITION
1) This is a comfortable sleeping position for many clients, and it promotes oral drainage.
2) Client is on his side halfway between lateral and prone positions. (Weight is on the anterior ileum, humerus and clavicle. Lower arm is behind the client while the upper arm is in front. Both legs are flexed, but the upper leg is flexed at a greater angle than the lower leg at the hip as well as the knee.
OTRHOPNEIC POSITION
1) This position allows for chest expansion and is especially beneficial to clients with CPOD
2) Sits in the bed or at the bedside. Pillow is placed on the over-bed table, which is placed across the client's lap. Client rests his arms on the over-bed table .
TRENDELENBURG POSITION
1) Used during postural drainage, facilitates venous return
2) Entire bed is tilted with the foot of the bed lower than the head of the bed.
REVERSE TRENDELENBURG POSITION
1) Promotes gastric emptying and prevents esophageal reflux
2) Entire bed is tilted with the foot of the bed lower than the head of the bed.
DISASTER
Mass casualty or intra-facility event that overwhelms or interrupts at least temporarily the normal flow of services of a hospital.
TWO TYPES OF DISASTER
a) INTERNAL EMERGENCIES - loss of electric power, severe damage or casualties within the facility
b) EXTERNAL EMERGENCIES - hurricanes, floods, volcano eruptions, terrorist acts, building collapse, safety and hazardous materials.
Categories of Triage
The principles of triage should be followed in health care institutions involved in a mass casualty event. Categories are separated in relation to their potential for survival, and treatment is allocated accordingly
1. Class I (Emergent Category) - Highest priority is give to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized
2. Class II (Urgent Category)
Inhalational Anthrax
SIGNS AND SYMPTOMS: sore throat, fever, muscle aches, severe dyspnea, meningitis, shock
TREATMENT PREVENTION: IV ciprofloxacin (Cipro)
Botulism
SIGNS AND SYMPTOMS: difficulty swallowing, progressive weakness, nausea, vomiting, and abdominal cramps, difficult breathing
TREATMENT PREVENTION: Airway management, antitoxin, elimination of toxin
Smallpox
SIGNS AND SYMPTOMS: High fever, fatigue, severe headache, rash (starts centrally and spreads outward) that turns to pus-filled lesions, vomiting, delirium, excessive bleeding
TREATMENT PREVENTION: No CURE,
SUPPORTIVE CARE: hydration, pain medication, antipyretics
PREVENTION: Vaccine
Ebola
SIGNS AND SYMPTOMS: Sore throat, headache, high temperature, nausea, vomiting, diarrhea, internal and external bleeding, shock
TREATMENT PREVENTION: No Cure
SUPPORTIVE CARE: Minimize invasive procedure
PREVENTION: Vaccine
Color CODE Designation for Emergencies
Newborn abduction: PINK
Mass Casualty incident: BLUE
Fire: RED
Chemical spill:ORANGE
Tornado: GRAY
Risk factor Assessment
1) Genetics
2) Gender
3) Physiologic
4) Environmental factors
5) Lifestyle-risk behaviors
6) Age
7) Frequency
Routine Physical
FEMALE: Start at age 20, every 1 to 3 years, beginning at 40 annually
MALE: Starting at age 20, every 5 years; beginning at 40 annually
Dental assessments
FEMALE and MALE: Every 6 months
Blood Pressure
FEMALE and MALE: Starting at age 20, each routine health care visit, minimum of every 2 years
Body Mass Index
FEMALE and MALE: Starting at age 20, each routine health care visit
Blood cholesterol
FEMALE and MALE: Starting at age 20, minimum of every 5 years
Blood Glucose
FEMALE and MALE: Starting at age 45, a minimum of every 3 years
Colorectal Screening
FEMALE and MALE: Fecal occult blood test annually starting at age 50; and flexible sigmoidoscopy every 5 years; or colonoscopy every 10 years; or double contrast barium enema every 5 years
Colonoscopy
FEMALE and MALE: Starting at age 50, every 1 to 10 years, depending on test used by provider
Pap test
FEMALE: Starting at age 21 (or earlier if sexually active), annually or every 2 years; After age 30, every 1 to 3 years, depending on test used by provider, and at provider's discretion.
Clinical Breast Exam
FEMALE: Starting at age 20, 3 years; Starting at age 40, yearly
Mammogram
FEMALE: Starting at age 40, yearly
Clinical Testicular Exam
MALE: Starting at age 20, every year
Prostate Specific Antigen (PSA) Test and digital rectal exam
MALE: Starting at age 50, as indicated by the provider
PRIMARY PREVENTION
Addresses needs of healthy clients to promote health and prevent disease with specific protections (immunization programs, child car seat education, nutrition and fitness activities, health education in schools)
SECONDARY PREVENTION
Focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent a worsening health status (communicable disease screening and case finding, early detection and treatment of diabetes, exercise programs for older adult clients who are frail)
TERTIARY PREVENTION
Aims to prevent the long term consequences of a chronic illness or disability and to support optimal functioning (prevention of pressure ulcers as a complication of spinal cord injury, promoting independence for the client who has traumatic brain injury)
Domains of learning
a) Cognitive - obtaining new information, being able to apply the information, and able to evaluate the information.
b) Affective - involves feelings, beliefs and ideals.
c) Psychomotor - learning how to complete a physical activity or motor skill
FACTORS THAT ENHANCE LEARNING
1) Perceived benefit
2) Cognitive and physical ability
3) Health and cultural beliefs
4) Active participation
5) Age/educational level-appropriate methods
BARRIERS TO LEARNING
a) Fear, anxiety, depression
b) Physical discomfort, pain, fatigue
c) Environmental distractions
d) Health and cultural beliefs
e) Sensory and perceptual deficits
f) Psychomotor deficits
INFANT (Birth to 1 year)
Physical development
2 - 3 months: posterior fontanel closes
12-18 months: anterior fontanel closes
first 6 months: gains about 150 to 210 g of weight per month
4- 6 months: weight doubles
End of year 1: Triples weight
Infant (Birth to 1 year) Dentition
6-8 teeth erupts at the end of 1 year.
Solving teething pain of an infant (0 to 1 yr)
Cold teething rings, OTC gels, or acetaminophen (Tylenol) and/or ibuprofen (Advil). IBUPROFEN SHOULD ONLY BE GIVEN TO CHILDREN OVER 6 MONTHS.
INFANT (0 - 12 months) GROSS MOTOR SKILLS
1 mo: demonstrates head lag
2 mo: lifts head off mattress
3 mo: raises head and shoulders off mattress
4 mo: rolls from back to side
5 mo: rolls from front to back
6 mo: rolls from back to front
7 mo: BEARS FULL WEIGHT ON FEET
8 mo: SITS UNSUPPORTED
9 mo: Pulls up to a standing position
10 mo: Changes from prone to sitting position
11 mo: Walks while holding on to something
12 mo: Sits down from a standing position without assistance
INFANT (0 - 12 months) FINE MOTOR SKILLS
1 mo: has a present grasp reflex
2 mo: holds hands in an open position
3 mo: no longer has a grasp reflex; keeps hands loosely open
4 mo: places objects in mouth
5 mo: uses palmar grasp dominantly
6 mo: holds bottle
7 mo: moves object from hand to hand
8 mo: begins using pincer grasp
9 mo: has a crude pincer grasp
10 mo: grasps rattle by its handle
11 mo: can place objects into a container
12 mo: tries to build a two-block tower without success
Piaget's Sensorimotor Stage (birth to 24 months)
1) Separation - when infants learn to separate themselves from other objects in the environment
2) Object permanence - at about 9 months, the process by which an infant knows that the object still exists when it is hidden from view
3) Mental representation in the recognition of symbols
ERICKSON's "Trust versus Mistrust" (Infant's psychosocial development)
1) Infants trust that their feeding, comfort and caring needs will be met.
2) Social development is initially influenced by infant's reflexive behavior which includes attachment, separation, recognition, anxiety and stranger fear.
3) SEPARATION ANXIETY develops between 4 and 8 months of age. Stranger fear becomes evident between 6 to 8 months, when children are less likely to accept strangers.
4) Engages in solitary play
Immunizations for the Infant (0 - 12 months)
Birth - Hep B (Hepatitis B)
2 months - DTap (Diphtheria and tetanus toxoids and pertussis); RV (rotavirus vaccine); IPV (inactivated poliovirus); Hib (haemphilus influenzae type B); pneumococcal vaccine (PCV) and Hep B
4 months - Dtap, RV, IPV, HiB, PVC
6 months - Dtap, IPV (6 to 18 months), PVC, Hep B (6 to 12 months), RotaTeq (alternative for R, requires 3 doses completed by 32 weeks)
6 to 12 months - Seasonal influenza vaccination yearly. The trivalent inactivated influenza vaccine (TIV) is available as an IM injection
NUTRITION for INFANTS (0 to 12 months old)
1) Breastfeeding is recommended for the first 6 months of life
2) Iron-fortified is an acceptable alternative to breast milk. Cow's milk is not recommended
3) Solids can be introduced between 4 and 6 months
4) Iron fortified rice cereal should be offered first.
5) New food should be introduced one at a time over a 5 to 7 day period. Observe allergies. Vegetables or fruits are first started between 6 and 8 months. Then meat can be added.
6) Milk, eggs, wheat, citrus fruits, peanuts, peanut butter and honey should be delayed until the first year of life.
7) By 9 months, table food that are chopped, cooked and unseasoned are appropriate
8) Iron-enriched food after 6 months
TODDLER (1 TO 3 YEARS)
Physical Growth
1) 18 months - anterior fontanel closes
2) 24 months - should weigh 4 times his birth weight
3) Height - grows by 7.5 cm (3 in.) per year
Toddler (1 to 3 years) - Cognitive Development
Piaget - Preoperational
1. Concept of object permanence fully developed
2. Have and demonstrate memories of events that relate to them
3. Domestic mimicry is evident
4. Preoperational thought does not allow toddlers to understand other viewpoints, but it does allow them to symbolize objects and people in order to imitate activities seen previously.
Toddler (1 to 3 years) - Psychosocial Development
Erikson - Autonomy versus shame and doubt
1. Independence is paramount for the toddler who is attempting to do everything for himself.
2. Separation anxiety continues to occur when a parent leaves the child.
3. Engages in parallel play
Toddler (1 to 3 years) - Moral Development
1. Closely associated with cognitive development
2. Toddlers are unable to see another's perspective; they can only view things from their point of view.
3. The toddler's punishment and obedience orientation begins with a sense that good behavior is rewarded and bad behavior is punished.
Preschooler (3 to 6 years) - Physical Growth
The preschooler's body evolves away from the characteristically unsteady wide stance and protruding abdomen of the toddler to the more graceful, posturally erect, and sturdy physicality of this age group
Preschoolers (3 to 6 years) - Cognitive Development
Piaget - Still in preoperational phase of cognitive development. They participate in preconceptual thought (2 to 4 years old) and intuitive thought (from 4 to 7 years of age).
Preschoolers make judgment based on visual appearances. Misconceptions in thinking during this age include:
a) Artificialism - everything is made by humans
b) Animism - inanimate objects are alive
c) Imminent justice - a universal code exists that determines law and order.
*Intuitive thought - preschoolers can classify information and can become aware of cause and effect relationship.
Preschoolers (3 to 6 years) - Psychosocial
Erikson - Initiative versus Guilt
The preschooler may take on many new experiences despite not having all of the physical abilities necessary to be successful at everything. Guild may occur when children are unable to accomplish a task and believed they have misbehaved. Guiding preschoolers to attempt activities within their capabilities while setting limits is appropriate .

Parallel play shifts to associative play during these years. Play is not highly organized, but cooperation does exist between children.
Preschoolers (3 to 6 years) - Moral Development
Continue in the good-bad orientation of the toddler but begins to understand behaviors in terms of what is socially acceptable.
Preschoolers (3 to 6 years) - Health Promotion
Vision screening is routinely done in the preschool population as part of the pre-kindergarten physical exam. Visual impairments such as myopia and amblyopia can be detected and treated before poor visual acuity impairs the learning environment.
School age Child (6 to 12 years) - Physical changes
1) Changes related to puberty begin to appear in females
2) Enlargement of testicles with changes in the scrotum for males
3) Appearance of pubic hair
4) Permanent Teeth Erupt
5) Visual acuity improves to 20/20
School age Child (6 to 12 years) - Cognitive Development
Piaget - Described as concrete operations
1) Sees weight and volume as unchanging
2) Understands simple analogies
3) Understands the concept of time (days, seasons)
4) Classifies more complex information
5) Understands various emotions people experience
6) Becomes self-motivated
7) Able to solve problems
8) Understands that a word may have other meanings.
School age Child (6 to 12 years) - Psychosocial Development
Erikson - industry versus inferiority
a. Sense of industry is achieved through advances in learning
b. Motivated by tasks that increase self-worth
c. Fear of ridicule by peers and teachers over school-related issues are common. Some children manifest nervous behaviors to deal with the stress such as nail biting
School age Child (6 to 12 years) - Social Development
1) Peer groups play an important part in social development. However, peer pressure begins to take effect.
2) Friendships begin to form between same gender peers. This is the time period when clubs and best friends are popular
3) Children at this age prefer the company of same gender companions
School age Child (6 to 12 years) - Health Screenings
School-age children should be screened for scoliosis by examining for a lateral curvature of the spine before and during growth spurts. Screening may take place at school or a doctor's clinic.
School age Child (6 to 12 years) - Nutrition
Obesity is an increasing concern of this age group that predisposes them to low self-esteem, diabetes, heart disease, and high blood pressure.
Adolescent (12 to 20 years) - Physical Development
a) The final 20% to 25% of height is achieved during puberty
b) Girls may cease to grow about 3 to 2.5 years after onset of menarche
c) Boys tend to stop growing at around 18 to 20 years old
Adolescent (12 to 20 years) - Cognitive Development
Piaget - Formal Operations
a) Capable of thinking as an adult
b) Able to think abstractly and can deal with principles
c) Able to evaluate the quality of one's thinking
d) Future oriented
e) Makes decisions through logical operations
Adolescent (12 to 20 years) - Psychosocial Development
Erikson - Identity versus Role Confusion
a) Adolescent develops a sense of personal identity influenced by family expectations.
b) Group identity - adolescent may be a part of a peer group that influences behavior.
c) Health perception - may view themselves as invincible to bad outcomes of risky behavior
Adolescent (12 to 20 years) - Nutrition
Rapid growth and high metabolism require increases in quality nutrients. Nutrients that tend to be deficient during this stage of life are iron, calcium, and Vitamin A and C.
Young Adult (20 to 35 years) - Physical Development
1. Growth has concluded at around age 20.
2. Cardiac output efficiency and Physical senses peak
3. Muscles function optimally at ages 25 to 30
4. Metabolic rate decreases 2% to 4% every decade after age 20.
5. Libido is high for men
6. Libido for women peaks during the later part of this stage
7. Time for childbearing is optimal
Young Adult (20 to 35 years) - Cognitive Development
Piaget - Formal Operations
a) The young adult years are optimal time for education, formal and informal
b) Critical thinking improves
c) Memory peaks in the 20's
d) Increased ability for creative thought
e) Values/norms of friends (social groups) are relevant
Young Adult (20 to 35 years) - Psychosocial Development
Erikson - Intimacy versus Isolation
1. Young adults may take on more adult commitments and responsibilities
2. Young adults may make occupational choices characterized by high goals, dreams, and exploration and experimentation
Middle Adult (35 to 65 years) - Physical Development
Middle adults typically decrease in:
a. skin turgor and moisture, large intestine muscle tone
b. subcutaneous fat, gastric sensations
c. melanin in hair (graying), estrogen/testosterone
d. hair, glucose tolerance
e. visual acuity
f. auditory acuity, respiratory vital capacity
g. sense of taste, ,vessel elasticity
h. skeletal muscle mass, height, calcium bone density
Middle Adult (35 to 65 years) - Cognitive Development
Piaget - Formal Operations
1) Reaction time/speed of performance slows slightly
2) Memory is intact
3) Crystallized intelligence remains stored knowledge
4) Fluid intelligence declines slightly
Middle Adult (35 to 65 years) - Psychosocial Development
Erikson - Generativity versus stagnation
Older Adult (65 years and older) - Physical Development
1) Decrease in almost everything
2) Prostate hypertrophy in men
3) Decline in estrogen/testosterone production
4) Decreased sensitivity of tissue cells to insulin
5) Atrophy of breast tissue in women
Older Adult (65 years and older) - Cognitive Development
Piaget - Formal operations
Slowed neurotransmission, impaired vascular circulation, disease states, poor nutrition, and structural brain changes can result in the following cognitive disorders:
a) Delirium - often first symptom of infection (UTI) in older adults
b) Dementia - Chronic, progressive and possible with an unknown cause (Alzheimer's)
c) Depression - Chronic, acute, or gradual onset (at least 6 weeks)
Older Adult (65 years and older) -
Psychosocial Development
Erikson - Integrity versus Despair
Older Adult (65 years and older) - Nutrition
Metabolic rates and activity decline as individuals age; therefore, total caloric intake should decrease to maintain a healthy weight. With the reduction of total calorie intake, it becomes even more important that calories consumed be of good nutritional value.
THERAPEUTIC COMMUNICATION TECHNIQUES
1) ACTIVE LISTENING - Shows clients that they have your undivided attention
2) OPEN-ENDED QUESTIONS - Used initially to encourage clients to tell their story in their own way. Ask questions in a language that a client can understand
3) CLARIFYING - Questioning clients about specific details in greater depth or directing them toward relevant parts of the history.
4) SUMMARIZING - Validates the accuracy of the story.
Therapeutic Communication
Helps nurses develop a rapport with clients. The techniques encourage a trusting relationship, whereby clients feel comfortable telling their stories. Nurses introduce the purpose of the interview, gather information and then conclude the interview by summarizing the findings.
Components of the health history
1) Demographic information
2) Source of history
3) Chief concern
4) History of present illness
5) Past health history and current health status
6) Family history
7) Social history
8) Health promotion behaviors
Review of systems
Ascertains information about the functioning of all body systems.
1) Integumentary
2) Head and neck
3) Eyes
4) Ears, nose, mouth and throat
5) Breasts
6) Respiratory
7) Cardiovascular
8) Gastrointestinal
9) Genitourinary
10) Musculoskeletal
11) Neurological
12) Mental Health
13) Endocrine
14) Allergic/immunologic
Normal Order of Physical Assessment
1) Inspect
2) Palpate
3) Percuss
4) Auscultate
Assessment order of the abdomen
1) Inspect
2) Auscultate
3) Percuss
4) Palpate
Inspection
1. First step of assessment, first interaction
2. Uses penlight, otoscope, ophthalmoscope
3. Involves the sense of vision, smell and hearing
Palpation
1. Touching to determine the size, consistency, texture, temperature, location, and tenderness of an organ or body part. Palpate tender areas last.
2. Light palpation (less than 1 cm) required for most body surfaces.
3. Deeper palpation is used to assess abdominal organs or masses
Part of the hands used for different sensations
1. dorsal surface - most sensitive to temperature
2. ulnar surface and base of fingers - sensitive to vibration
3. fingertips - sensitive to pulsation, position, texture, size and consistency
4.fingers and thumb - used to grab an organ or mass.
Percussion
Involves tapping body parts with fingers, fists, or small instruments to evaluate size, location, tenderness, and presence or absence of fluid or air in body organs, and to detect any abnormalities
Techniques for percussion
a) Direct percussion - involves striking the body to elicit sounds
b) Indirect percussion - involves placing a hand flatly on the body, as the striking surface for sound production
c) First percussion - used to assess for tenderness over the kidneys, liver and gallbladder.
Auscultation
1. Used to listen to sounds produced by the body. Some sounds are loud enough to be heard unaided, but most sounds require a stethoscope or a Doppler technique.
2. The DIAPHRAGM of the stethoscope is used to listen to high-pitched sounds (normal heart sounds, bowel sounds, breath sounds)
3. The BELL is used to listen to low pitched sounds (abnormal heart sounds, bruit). The bell should be placed lightly on the body part being examined.
General SURVEY
A written summary of the impression of the client's overall health. The nurse gathers this information from the first encounter with the client and continues to make observations throughout the assessment process.
a) Physical appearance
b) Body structure
c) Mobility
d) Behavior
e) Vital signs
Vital Signs
Measurement of the body's most basic functions. Provide health care staff with information that they need. In most facilities, pain and oxygen saturation are also considered vital signs and may also be measured depending on the reason the client needs health.
Temperature
1) Reflects balance between heat produced and heat lost.
2) Disease or trauma of the hypothalamus or spinal cord will alter temperature control.
3) The rectum, tympanic membrane and urinary bladder are core temperature measurement sites
Pulse
Measurement of heart rate and rhythm. Pulse corresponds to the bounding of blood flowing through various points in the circulatory system.
PARASYMPATHETIC NS - lowers the heart rate
SYMPATHETIC NS - raises the heart rate
Respiration
Body's mechanism for exchanging oxygen and carbon dioxide between the atmosphere and the cells of the body which is accomplished through breathing and recorded as the number of breaths per minute
Blood Pressure
Reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relaxation (diastole) of the heart.
SYSTOLIC - occurs during the VENTRICULAR SYSTOLE of the heart, when ventricles force blood into the aorta, and represents the maximum amount of pressure exerted on the arteries.
DIASTOLIC - occurs during VENTRICULAR DIASTOLE of the heart, when the ventricles relax and exert minimal pressure against arterial walls, and represents the minimum amount of pressure exerted on the arteries.
Temperature Ranges
1) Oral - 96.8 to 100.4 F (36 to 38 C). Average is 98.6 F (37 C)
2) Rectal - 0.9 F (0.5 C) higher than oral temperature
3) Axillary and Tympanic - usually 0.9 F (0.5 C) lower than oral temperatures
4) Temporal are close to rectal, but they are nearly 1 F (0.5 C) higher than oral and 2 F (1 C) higher than axillary temperatures.
Heat production of the body
Results from:
a) increases in basal metabolic rate,
b) muscle activity
c) thyroxine output
d) sympathetic stimulation (increases heat production)
Heat loss from the body
Occurs through
a) Conduction - Transfer of heat from body to another surface (body immersed in cold water)
b) Convection - Dispersion of heat by air currents (wind blowing across exposes skin)
c) Evaporation - Dispersion of heat through water vapor (sweating and diaphoresis)
d) Radiation - Transfer of heat from one object to another object without contact between them (heat loss from the body to a cold room)
Temperature of newborns, older adults and hormonal changes
1. Newborns have a large surface-to-mass ratio; therefore they lose heat rapidly to the environment. Newborn Temperatures should be at 97.7 F and 99.5 F (36.5 C - 37.5 C)
2. Older adults loss of subcutaneous fat results in lower body temperatures. Their average temperature is 96.8 F (36 C). They are most likely to be affected by extreme environmental changes (heat stroke, hypothermia). It takes long for body temperature to register due to changes in temperature regulation.
3. Temperature rises with ovulation and menses. With menopause, body temperature may increase by up to 4 C (7.2 F)
Temperature: Exercise, illness and food or fluid intake
a) Exercise and dehydration can lead to hyperthermia
b) Illness and injury associated with inflammation can elevate temperature.
c) Food or fluid and SMOKING can interfere with accurate temperature readings. Wait for 20 to 30 minutes before measuring temperature.
Oral temperature technique
a) Please under the tongue in the posterior sublingual pocket lateral to the center of the lower jaw
b) Hold until sound is heard. If mercury, hold for 3 minutes
c) DO not use glass, mercury filled device for small children or patients who are confused.
d) AGE specific - preferred method for children 4 years old and older
e) May not be appropriate for clients who breath through their mouth or have trauma to face or mouth.
Rectal temperature technique
1. Provide privacy
2. Assist client to SIM'S POSITION with upper leg flexed.
3. Ask client to breath slowly, relax when placing a lubricated thermometer (with a rectal probe) to the anus in the direction of the umbilicus (1 and 1/2 inch for the adult or 3.5 cm) . With resistance, remove immediately.
4. Do not use in clients with bleeding disorders or have rectal disorders.
5. Age specific. More accurate that axillary. Do NOT USE FOR INFANTS 3 months or younger. Use axillary temperature initially
6. Rectal site is used as a second measurement if temperature is above 99 F or 37.2 C
7. Stool in rectum can cause inaccurate readings
Tympanic temperature technique
1) Pull the ear up and back for adult. Pull ear down and back for child younger than 3 years old
2) Place thermometer snugly in the outer ear canal.
3) Do not use for infants 3 months or younger. Axillary is preferred.
4) Excess earwax can affect accuracy of reading
AXILLARY thermometer
American Academy of Pediatrics recommend this use for infants 3 months old or younger (inaccurate reading)
Complications on Temperature
a) Fever is not harmful unless it exceeds 102.2 F or 39 C
b) Hyperthermia is abnormally elevated temperature
c) Hypothermia is below 35 C or 95 F.
Interventions for Hyperthermia (more than 102 F)
1. Obtain specimen for blood cultures if ordered.
2. Assess/monitor WBC, sedimentation rates and electrolytes as ordered.
3. Administer antibiotics if prescribed, only after obtaining specimens for blood culture
4. Provide fluids and rest
5. Provide antipyretic, Aspirin, acetaminophen (Tylenol), ibuprofen (Advil).
6. Aspirin is not recommended for children and adolescents ho may have a viral illness (influenza, chickenpox) because of the risk of REYE'S SYNDROME.
7. Pediatric antipyretic dosage depends on weight.
8. Prevent shivering as this increases energy demand.
9. Offer blankets during chills and remove then when patient feels warm. Cooling blanket may be offered.
10. Provide oral hygiene, dry clothing and linens
11. Keep head covered.
12 Maintain environment at 70 to 80 F or 21 and 27 C
Interventions for Hypothermia (below 95 F)
a) Provide warm environmental temperature, heated humidified oxygen, warming blanket, warmed IV fluids
b) Provide cardiac monitoring
c) Have emergency resuscitation equipment on standby
Physiology of the PULSEE
1. Rate - number of times per minute pulse is heard or felt
2. Rhythm - regularity at which each impulse is felt. A premature or late heartbeat can result in an irregular interval in which impulses are felt or heart and can indicate abnormal electrical activity of the heart.
3. Strength (amplitude) - Should be the same from beat to beat and can be graded on a scale from 0 to 4.
Amplitude (strength) scale of the PULSE
0 = absent, unable to palpate
1+ = diminished, weaker than expected
2+ = brisk, expected
3+ = increased
4+ = full volume, bounding
Range of Adult Pulse
60 to 100 / min at rest
Abnormal pulse rates
1. Tachycardia - rate above 100 / min
2. Bradycardia - rate below 60 / min
3. Dysrhythmias - irregular heart rhythm noted as irregular RADIAL pulse
4. PULSE DEFICIT - apical rate faster than the radial rate. With dysrhythmias, heart rate may contract ineffectively, resulting in a beat heard with the APICAL SITE WITH NOT PULSATION felt at the radial pulse point
Pulse Rates and Age
a) Infants - 120 to 160 / minute. Gradually decreases as child grows older.
b) Average pulse for a 12 to 14 is 80 to 90 / min.
c) Older adults may be weak due to poor circulation; more difficult to palpate
FACTORS LEADING TO TACHYCARDIA
1. Exercise and Fever
2. Medication - epinephrine, levothyroxine (Synthroid), beta2 - andrenergic agonists (albuterol [Proventil])
3. Change positions from lying to sitting or standing
4. Acute pain
5. Hyperthyroidism
6. Anemia, hypoxemia
7. Stress, anxiety and fear
8. Hypovolemia, shock and
FACTORS LEADING TO BRADYCARDIA
1. Long term physical fitness
2. Hypothermia
3. Medications - Digoxin (Lanoxin), beta-blockers (propranolol [Inderal]), calcium channel blockers (verapamil [Calan])
Location of the RADIAL PULSE
Located on the thumb-side of the forearm of the wrist.
a) Place index and middle finger of one hand gently but firmly over the pulse. Assess pulsation for rate, rhythm, amplitude and quality.
b) If regular, count 30 seconds and multiply by 2. If irregular count for a full minute, then compare with Apical pulse
Location of APICAL PULSE
1) Fifth intercostal space at the left midclavicular line. Use this SITE for assessing heart rate of INFANT, RAPID RATES (FASTER THAN 100/min), irregular rhythms, and rates prior to the administration of cardiac medication.
2) Place stethoscope on the chest at the fifth intercostal space at the left midclavicular line. Always count an apical pulse for 1 minute.
RESPIRATION: Physiologic Responses
Chemoreceptors in the carotid arteries and the aorta primarily monitor Carbon Dioxide (CO2) levels of the blood. If Carbon Dioxide rises, the respiratory rate rids the body of excess CO2. For clients with COPD, a low oxygen level becomes the primary respiratory drive.
Process of respiration
a. VENTILATION - exchange of Oxygen and carbon dioxide in the lungs. Measure ventilation with the respiratory rate, rhythm, and depth
b. DIFFUSION - exchange of Oxygen and Carbon Dioxide between the alveoli and the red blood cells. Measure diffusion with pulse oximetry.
c. PERFUSION - Flow of blood to and from the pulmonary capillaries. Measure perfusion with pulse oximetry.
ACCURATE ASSESSMENT OF RESPIRATION
Involves observing the rate, the depth and rhythm of chest wall movement during inspiration and expiration. DO NOT INFORM CLIENT that you are measuring respirations.
a) Rate - full inspirations and expirations in 1 minute. Observe number of times chest rises and falls. Expected range for adults is 12 to 20 breathes / min.
b) Depth - chest wall expansion with each breath. Altered breaths are deep or shallow.
c) Rhythm - breathing intervals. A regular rhythm with an occasional sigh is expected in adults
PULSE OXIMETRY
Noninvasive, indirect measurement of the oxygen saturation (SaO2) of the blood. Range is 95% to 100% although some acceptable levels are at 91% to 100%. Some illness states may even allow for SaO2 at 85% to 89%. Less than 85% is not normal.
FACTORS OF RESPIRATION
1. Age: decreases with age. Newborns have rates of 30 to 60 / minute. School age children have rates of 20 to 30 / minute.
2. Gender: Men are diaphragmatic breathers and abdominal movements are more noticeable.
Women use more thoracic muscles, chest muscle movements are more pronounced when they breathe.
3. PAIN in the chest wall: May decrease depth of respiration. At the onset of ACUTE pain, respiration rate increases but stabilizes over time.
4. ANXIETY - increases rate and depth of respiration
5. SMOKING - causes resting rate of respiration to increase.
6. BODY POSITION - upright positions allow chest wall to expand more fully.
7. Medications such as opioid, sedatives, bronchodilators, and general anesthetics decrease the respiratory rate and depth. Respiratory depression can be a serious adverse effect. Amphetamines and cocaine increase rate and depth.
8. Neurological injury to the brainstem decreases respiratory rate and rhythm.
9. Illnesses affecting the shape of the chest wall, changing the patency of passages, impairing muscle function, and diminish respiratory effort. The use of accessory muscles and respiratory rate increases.
10. Impaired oxygen-carrying capacity of the blood that occurs with anemia or at high altitudes results in increases in the respiratory rate and alterations in rhythm to compensate.
Respiration assessment
Count a regular rate for 30 seconds and multiply by 2. Count the rate for 1 minute if irregular, faster than 20 / min or slower than 12 / min. Note depth (shallow, normal or deep) and rhythm (regular or irregular)
Complications of Respiratory Intervention
Hypoxemia - SaO2 below 90%
1. confirm sensor probe is working
2. correlate pulse rate on the oximeter with radial or apical pulse
3. confirm O2 delivery system is functioning and client is receiving required O2.
4. Place client on Fowler or semi-Fowler for ventilation
5. Encourage deep breathing.
6. Suction if needed and as ordered
7. Assess for hypoxemia, tachypnea, tachycardia, restlessness, anxiety, cyanosis
9. check for hyperthermia
10. assess vital signs, stay with patient to decrease anxiety
BLOOD PRESSURE: Physiological responses
The principal determinants of blood pressure are CARDIAC OUTPUT (CO) and SYSTEMIC VASCULAR RESISTANCE (SVR)
BP = CO x SVR
CARDIAC OUTPUT is determined by:
1. Hear rate
2. Contractility
3. Blood Volume
4. Venous Return
* Increase in any of these, increase CO and BP
*Decrease in any of these, decrease CO and BP
SYSTEMIC VASCULAR RESISTANCE
Systemic peripheral vascular resistance (SVR) is determined by the AMOUNT OF CONSTRICTION OR DILATION OF THE ARTERIES
* Increase in SVR, increase BP
* Decrease in SVR, decrease BP
Blood Pressure Classification
Systolic = SBP
Diastolic = DBP
1.Normal is less than 120 (systolic) and less than 80 (diastolic)
2. PREHYPERTENSION is 120-139 (systolic) and 80 to 89 (diastolic)
3. STAGE 1 HYPERTENSION is 140-159 (systolic) and 90 to 99 (diastolic)
4. STAGE 2 HYPERTENSION is more than 160 (systolic) and more than 100 (diastolic)
When is a diagnosis of hypertension done?
A diagnosis of hypertension is made if the readings are elevated on at least three separate occasions.
PULSE PRESSURE
Difference between systolic and diastolic readings
HYPOTENSION
A BP that is below the normal (systolic is less than 90 mm Hg) and can be a result of fluid depletion, heart failure or vasodilation
POSTURAL [ORTHOSTATIC] HYPOTENSION
A BP that falls when a client changes position from lying to sitting or standing. The client is experiencing orthostatic hypotension if the SBP decreases more than 20 mmHg and the DPH decreases more than 10 mmHg with a 10% to 20% increase in heart rate. It may result from various causes
1. peripheral vasodilation
2. medication side effects
3. fluid depletion
4. anemia
5. prolonged bed rest.
BLOOD PRESSURE AND AGE
a) Infants have a low BP that gradually increases with age
b) Older children and teenagers vary BP based on body size. Larger children have higher BP
c) Adult BP tends to increase with age
d) Older adults may have a slightly elevated SBP due to decreased elasticity of blood vessels.
Other FACTORS that AFFECT BLOOD PRESSUR
1. Circadian rhythm - BP usually lowest in the early morning hour and peak during the later part of the afternoon or evening.
2. Stress associated with fear, emotional strain, and ACUTE PAIN can increase BP.
3. Ethnicity - African Americans have a higher incidence of hypertension in general and at earlier ages.
4. GENDER - adolescent to middle-age men have higher BP's than their female counterparts. Postmenopausal women have higher BP's than their male counterpart.
5. Medications such as opiates, antihypertensive, and cardiac medication can lower BP. Cocaine, smoking, cold medications, oral contraceptives, and antidepressants can raise BP.
6. Exercise can decrease BP; obesity can increase BP
Equipment for Blood Pressure assessment
Sphygmomanometer with a pressure manometer (aneroid or mercury) and an appropriately sized cuff. The width of the cuff should be more than 40% of the arm circumference at the point where the cuff is wrapped. The bladder (inside the cuff) should surround 80% of the arm circumference of an adult and the whole arm for a child. Cuffs that are too large give a false low reading and cuffs that are too small give a falsely high reading.
Procedures to assess the Blood Pressure using the Ausculatory Method. Client instructions
1. Not smoke or drink any caffeine for 30 minutes prior to measurement
2. Rest for 5 minutes before measurement
3. Sit in a chair, with the feet flat on the floor, the back and arm supported and the arm at heart level.
Procedures to assess the Blood Pressure using the Ausculatory Method. What the nurse should do?
1. Use properly calibrated and validated instruments
2. Use appropriate cuff size
3. Not measure BP in an arm with an IV infusion in progress or on the side where a mastectomy was performed or an arteriovenous shunt or fistula is present.
4. Average 2 or more readings, taken at least 2 minutes apart. If they differ more than 5 mmHg, obtain additional readings and average them.
5. After initial reading, measure BP with client standing
Procedures to assess the Blood Pressure using the Ausculatory Method. Step by Step
1. Apply cuff 2 cm above the antecubital space with the brachial artery in line with the marking on the cuff.
2. Use lower extremity if the brachial artery is not accessible
3. Estimate systolic pressure by palpating the radial pulse and inflating the cuff until the pulse disappears. Inflate the cuff another 30 mmHg and slowly release the pressure to note when the pulse is palpable again (estimated systolic pressure)
4. Deflate the cuff and wait 1 minute
5. Position stethoscope over the brachial artery
6. Close pressure bulb by turning bulb clockwise until tight.
7. Quickly inflate cuff to 30 mmHg above the palpated systolic pressure.
8. Release pressure no faster than 2 to 3 mmHg per second
9. The level at which the first clear sounds are hears is the SYSTOLIC PRESSURE
10. Continue to deflate the cuff until the sounds muffle and disappear and note the DIASTOLIC PRESSURE.
11. Record Systolic over Diastolic (110/70 mmHg)
Unexpected BP Readings
1. It is helpful to measure BP again toward the end of an interview with the client. Earlier pressures may be higher due to the stress of the clinical setting
2. The cuff must be completely deflated between attempts. Wait at least 1 full minute before reinflating the cuff. Air trapped in the bladder can cause a falsely high reading.
Complications of Blood Pressure and Nursing Interventions: Orthostatic (Postural) Hypotension
1. Assess for other related symptoms such as dizziness, weakness, and fainting.
2. Instruct client to activate call light and not get out of bed without assistance.
3. Have client sit at edge of bed for at least 1 minute before standing up. Assist with ambulation.

Home health considerations:
a) Warn of lightheadedness and dizziness
b) Advise client to sit or lie down when symptoms occur
c) Suggest client to get up slowly when lying or sitting and avoid sudden changes in position
Complications of Blood Pressure and Nursing Interventions: HYERTENSION
1. Assess for other symptoms (tachycardia, bradycardia, pain, anxiety). Primary hypertension is usually asymptomatic
2. Assess for identifiable causes of hypertension (renal disease, thyroid disease, medication)
3. Administer medication as prescribed
4. Assess for risk factors
5. Encourage lifestyle modification
HYPERTENSION: Lifestyle modification
1. Smoking cessation
2. Dietary modification: DASH (Dietary Approaches to Stop Hypertension) Diet - restrict sodium; consume adequate potassium, calcium, and magnesium. These minerals help lower BP; Restrict cholesterol and saturated fat intake
3. Weight control
4. Modification of alcohol intake
5. Stress reduction
6. Encourage follow up with physician.
Head and Neck Assessments
a) CN V (trigeminal) - Assess the face for strength and sensation
b) CN VII (facial) - Assess the face for symmetrical movement
c) CN XI (spinal accessory) - Assess the shoulders for strength
Abnormal findings for head and neck assessments
1. Decreased palpation of a mass
2. Range of motion of the neck
3. Enlarged lymph nodes
Assessing CN V (trigeminal) - face for strength and sensation
MOTOR : Test the strength of the muscle contraction by asking the client to clench her teeth while palpating the masseter and temporal muscles, and then the temporomandibular joint. TMJ movement should be smooth
SENSORY: Test light touch by having the client close her eyes while gently touching her face with a cotton swab and asking her to tell you when she feels the touch.
Assessing CN VII (facial) - face for symmetrical movement
MOTOR: Test facial movement by having the client smile, frown, puff out cheeks, raise eyebrows, close eyes tightly, and show teeth
Assessing the NECK - muscles should be summetrical
- shoulders should be equal in height and with normal muscle mass
- ROM - the client should be able to move his head smoothly and without distress in the following directions:
a) Chin to chest (flexion)
b) Ear to shoulder bilaterally (lateral flexion)
c) Chin up (hyperextension)
Assessing CN XI (shoulder accessories)
Place hands on client's shoulders and ask client to shrug the shoulders against resistance.
Lymph Nodes - extend from lower half of the head down to the neck. Should be palpated for enlargement
1. Occipital lymph node - base of the skull
2. Preauricular lymph node - in front of the ear
3. Postauricular lymph node - over the mastoid
4. Submandibular lymph node - along the base of the mandible
5. Tonsillar (retropharyngeal) lymph node - angle of the mandible
6. Submental lymph node - midline under the chin
7. Anterior cervical lymph nodes - along the sternocleidomastoid muscle
8. Posterior cervical lymph node - posterior to the sternocleidomastoid
9. Supraclavicular nodes - above the clavicles
Examining the thyroid gland - bilobed
1. Inspect lower half of client's neck to see if an enlargement of the gland is visible. A normal thyroid gland is not visible
2. Having the client take a sip of water, watch the thyroid tissue move up
3. Approaching the client from behind and having the client tip her head forward and to the right. Use the left hand to displace the trachea slightly to the right while placing your fingers between the sternomastoid muscle and the trachea.
4. Instructing the client to take a sip of water, and feeling for the movement of the thyroid gland as it moves up with the trachea and larynx.
5. Palpage for size, masses and smoothness.
Auscultation of the thyroid
If thyroid is enlarged, auscultate gland using a stethoscope. The presence of a bruit indicates an abnormal increase in blood flow to the area.
Assessment of the eyes: Abnormal findings
1. Loss of visual fields
2. Asymmetric corneal light reflex
3. Periorbital edema
4. Conjunctivitis
5. Corneal abrasion
Assessment of the eyes: Tests and Equipment
1. Visual Acuity - distant vision - Snellen and Rosenbaum charts, eye cover, and Ishihara test; near vision - hand held card
2. Extraocular movements (EOMs) - Penlight or ophthalmoscope light, eye cover
3. Visual fields - eye cover
4. External structures - Penlight or ophthalmoscope light; gloves
5. Internal structures - ophthalmoscope
Assessment for visual acuity - CN II
1. Use Snellen chart with patient 20 feet from the chart. Snellen chart may be used for patients who cannot read.
2. Evaluate both eyes and then each eye separately with or without correction.
3. Ask client to read the smallest line of print visible
4. The line for which two or fewer letters are missed is recorded as the visual acuity (20/20 is normal)
5. The first number indicates the number of feet from the chart the client is standing. And the second number is the distance at which a normal sighted person can read the line.
Screen for MYOPIA
impaired FAR vision, using Snellen chart
Screen for PRESBYOPIA
impaired near vision or farsightedness, using the ROSENBAUM eye chart held 14 inches from client's face. Readings correlate with the Snellen Chart
Assess for COLOR VISION
using the ISHIHARA test. Client should identify various shaded shapes
Assess Extraocular movements (EOMs)
Determines coordination of the eye muscle using three different tests (CN III, CN IV, CN VI - 3, 4, 6)
Test CORNEAL LIGHT REFLEX
by directing a light into the client's eye and looking to see if the reflection is seen symmetrically on the corneas
Screen for STRABISMUS
with the COVER/UNCOVER test. While covering one eye, client looks in another direction. Cover is removed and both eyes should be gazing in the same direction
Six cardinal positions of gaze
require client to follow your finger with his eyes without moving his head. Move your finger in a wide "H" pattern about 20 to 25 cm from the client's eyes. Eye movements should be smooth and symmetrical with no jerky tremor like movements (NYSTAGMUS)
Evaluate Visual Field (CN II)
by facing client at distance of 60 cm.. Client covers one while you cover your direct opposite eye (client's right eye and your left eye) are covered. Ask client to look at you and report when she can see the fingers on your outstretched arm coming in from four directions (up, down, temporally, nasally). Expected finding is that the client should see your fingers in the same way that you do.
Exophthalmos
Bulging eyes
Strabismus
Crossing eyes
Expected External Structures of the eye
1. Parallel without bulging
2 Eyebrows should be symmetrical and evenly distributed from inner canthus
3. No edema or redness on the lacrimal gland
4. Conjunctiva: palpebral is pink, bulbar is transparent
5. Sclera should be white, light yellow in dark-skinned clients
6. Corneas are clear
7. Lenses are clear (cloudiness indicates cataracts)
PTOSIS
Covering of the pupil by the upper eyelid
PERRLA (CN II, CN III)
P - Pupils should be clear
E - Equal in size and between 3 to 5 cm
R - Round in shape
R - Reactive to light both directly and consensually when a light is directed into one pupil and then the other
L - Light
A - Accommodation of the pupils when they dilate to look at an object far away and then CONVERGE and CONSTRICT to FOCUS on a near object.
Expected condition of IRIS
Should be round and illuminate fully when a light is shined across from the side. A partially illuminated iris indicates glaucoma.
Expected internal eye structures
1. Optic disk is light pink or more yellow than the surrounding retina.
2. Retina should be without lesions, and color will be dark pink in those with a dark complexion and light pink in fair-skinned clients.
3. Arteries and veins are found in a 2-to-3 ratio and without nicking
4. Macula may not be readily visible without pupil dilation but may be briefly glimpsed when the client looks directly at the light.
5. Clear fluid tears without discharge.
Assessment of ears, nose, mouth and throat
a) Incudes external, middle and inner ear. Evaluates hearing, nose and sinuses, mouth and throat
b) Abnormal findings include: Otitis externa, osteoma, polyp , retracted drum, decreased hearing acuity, and lateralization
Assess ears for hearing
CN VIII - acoustic
Assess nose for smell
CN I - olfactory
Assess mouth for taste
CN VII - facial
CN IX - glossopharyngeal
Assess tongue for movement and strength
CN XII - hypoglossal
Assess mouth for movement of soft palate and gag reflex
CN IX - glossopharyngeal
Assess swallowing and speech
CN X - vagus
Expected findings for external ear
1. Alignment - top of auricles should meet an imaginary horizontal line that extends from the outer canthus of the eye.
2. Ear color should be the same as face color
3. Lesions and tenderness in ears are unexpected
4. Ear canal should be free of foreign bodies or discharge
5. Cerumen is expected finding
Assessment of the INTERNAL EAR
Straighten the ear canal by pulling the auricle up and back for adults and older children, and down and back for younger children. Using otoscope, insert speculum 1 to 1.5 cm following but not touching the ear canal to visualize
a) tympanic membrane that are pearly gray and intact, free from tears.
b) a light reflex that is visible and in a well defined cone shape
c) umbo and manubrium land marks that are readily visible
d) ear canals that are pink with fine hairs
Auditory Screening Test: WHISPER TEST CNV III
TECHNIQUE: One ear is occluded and the other tested to see if the client can hear whispered sounds without seeing mouth move
EXPECTED FINDINGS: Client can hear you softly whisper 30 to 60 cm away
Auditory Screening Test: RINNE TEST
TECHNIQUE: (1) Place a vibrating tuning fork firmly against the mastoid bone and not the time; (2) Have client state when he can no longer hear the sound, note the time, and then move the tuning fork in front of the ear canal. When client can no longer hear the tuning fork, not the time.
EXPECTED FINDINGS: Air conduction (AC) greater than bone conduction (BC) 2 to 1 ratio.
Auditory Screening Test: WEBER TEST
TECHNIQUE: Place a vibrating tuning fork on top of the client's head. Ask client if sound is heard best in the right, left or both ears equally
EXPECTED FINDINGS: Sound is heard equally in both ears (negative Weber test)
PRESBYOPIA
Diminishing ability to see close objects or read small print
PRESBYCUSIS
Hearing loss, loss of acuity for high frequency tones
Breast Self Examination (BSE)
a) Inspection can be done in front of a mirror. Palpation can be done in a shower.
b) BSE should always be performed following a menstrual cycle.
e) If client is menopausal, BSE should be performed on the same day of each month.
Breast Examination: Expected findings
FEMALE: Breast should be firm, elastic, and without lesions or nodules. Breast tissue may feel granular or lumpy bilaterally in some women
MALE: No edema, masses or tenderness should be present. Areolas are round and darker pigmented.
Breast Examination: Unexpected findings
FEMALE: Fibrocystic breast disease is characterized by tender cysts that are often more prominent during menstruation
MALE: Unilateral or bilateral (but asymmetrical) gynecomastia in adolescent boys or bilateral gynecomastia in older adult males may be present.
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : Positioning
The posterior Thorax is best assessed with the client sitting or standing. The anterior Thorax can be assessed with the client sitting, lying or standing.
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : Anatomical Reminder
The right lung has three lobes, while the left lung has two lobes. Auscultating the right middle lobe is done using the axillary sites.
CHEST LANDMARKS (used to perform assessments correctly and describe the findings)
1. midsternal line is through the center of the sternum
2. midclavicular line is through the midpoint of the clavicle
3. anterior axillary line is through the anterior axillary folds
4. midaxillary line is through the apex of the axillae
5. posterior axillary line is through the posterior axillary fold
6. right and left scapular lines are through the inferior angle of the scapula
7. vertebral line is along the center of the spine.
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : Percussion and auscultatory sites
POSTERIOR THORAX: Sites are between the scapula and the vertebrae on the upper portion of the back. Below scapula, sites are along the right and left scapular lines
ANTERIOR THORAX: Site are along the midclavicular lines bilaterally with several sites at the anterior/midaxillary lines bilaterally in the lower portions of the chest wall and on either side of the sternum following along the rib cage.
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : Inspection
1. Shape - anteroposterior diameter should be half of the transverse diameter.
2. Symmetry - chest should be symmetric with no deformation of the ribs, sternum, scapula, or vertebrae with equal movements of respiration.
3. ICS - you should not see excessive retractions
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : Respiratory Effort
a) Rate and pattern - regular with 16 to 20 / minute
b) Character of breathing (diaphragmatic, abdominal, thoracic)
c) Use of accessory muscles
d) Chest wall expansion
e) Depth of respiration (unlabored, quiet breathing is the expected finding).
f) If cough is productive, note color and consistency of sputum
g) trachea should be midline
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : Palpation
1. Surface characteristics include tenderness, lesions, lumps, and deformities. Tenderness is an unexpected finding.
2. Chief excursion or expansion of the posterior thorax
3. Vocal (tactile) fremitus: expected findings - vibration is symmetric and more pronounced at the top.
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : Percussion
a) Normal percussion of the thorax should result in resonance.
b) Abnormal findings and significance : (1) Dullness - caused by fluid or solid tissue, this can indicate a pneumonia or tumor;
(2) Hyperresonance - caused by the presence of air, this can indicate pneumothorax or emphysema.
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : Auscultation
EXPECTED SOUNDS:
a. Bronchial - loud, high pitched, expiration heard longer than inspiration over the trachea.
b. Bronchovesicular - medium pitch and intensity, equal inspiration and expiration, and heard over the larger airways
c. Vesicular - use of accessory muscles
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : Abnormal or Adventitious Sounds
1) Crackles or rales - fine to coares popping heard as air passess through the fluid or re-expands small airways
2) Wheezes - high-pitched whistling, musical sounds as air passes through narrowed or obstructed airways, usually louder in expiration
3) Rhonchi - Coarse sound heard during either inspiration or expiration resulting from fluid or mucous. MAY CLEAR WITH COUGHING.
4) Pleural friction rub - Grating sound produced as the inflamed visceral and parietal pleura rub against each other during inspiration or expiration.
5) Absence of breath sounds should be noted.
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : HEART - Cardiac Cycle - SYSTOLE - Lub - Apex
Closure of the MITRAL and TRICUSPID valves signals the beginning of VENTRICULAR SYSTOLE (contraction) and produces the S1 SOUND (Lub). This is heard best with the DIAPHRAGM of the stethoscope at the APEX.
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : HEART - Cardiac Cycle - DIASTOLE - Dub - Aortic Area
Closure of the AORTIC and PULMONIC valves signals the beginning of VENTRICUAR DIASTOLE (relaxation) and produces the S2 SOUND (Dub). This is heard best with the diaphragm of the stethoscope as the AORTIC AREA
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : HEART - Ventricular Gallop - S3 - BELL
An S3 sound (VENTRICULAR GALLOP) is produced by RAPID VENTRICULAR FILLING and can be a normal finding in children and young adults. This is heard best with the BELL of the stethoscope
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : HEART - S4 - Strong Atrial Contractions - Bell
An S4 sound is produced by a strong atrial contraction and can be a normal finding in older and athletic adults and children. This is heard best with the bell of the stethoscope.
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : HEART - Murmurs - Swishing - Bell
Murmurs are heard best when blood volume is increased in the heart, or the flow of blood is impeded or altered. A murmur is heard in the heart as a blowing or swishing sound. This is heard best with the bell of the stethoscope.
a) Systolic murmurs are heard just after S1
b) Diastolic murmurs are heard just after S2
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : HEART - Thrills
THRILLS are palpable vibration that may be present with murmurs or cardiac malformations
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : HEART - Bruit
BRUITS are produced by obstructed peripheral blood flow and are heard as a blowing or swishing sound with the Bell of the stethoscope.
CARDIAC LANDMARKS
1. AORTIC - just right of the sternum at the second ICS
2. PULMONIC - just left of the sternum at the second ICS
3. ERB'S POINT - just left of the sternum at the third ICS
4. TRICUSPID - just left of the sternum at the fourth ICS
5. APICAL / MITRAL - left midclavicular line at the fifth ICS
ASSESSMENT FOR RIGHT-SIDED HEART FAILURE
Inspect JUGULAR VEINS with client in bed with the head of the bed at 30 to 45 degrees angle to assess for RIGHT SIDED HEART FAILURE
1) No neck vein distention should be noted
2) Jugular venous pressure (JVP) - should be measured at less than 2.5 cm. above the sternal angle.
Assessment of ANTERIOR AND POSTERIOR THORAX AND LUNGS : HEART - PMI
APICAL PULSE or point of maximal return (PMI)
a) May be visible just lateral to the left midclavicular line at the fifth ICS. With female clients, displace the breast tissue.
b) Palpate where it was visualized, try to palpate the location and the size.
c) Expected finding - The apical pulse should be just lateral to the left midclavicular line at the fifth ICS and no longer than 2.5 cm in diameter.

Heaves or lifts are abnormal, visible elevations of the chest wall that are seen with heart failure, and are often located along the left sternal border or at the PMI
What is a THRILL
Use the ULNAR surface of the hand to feel for vibrations similar to that of a purring kitten. This is NOT AN EXPECTED FINDING.
AUSCULTATION OF THE HEART
Positioning the client in three different ways allows for optimal assessment of heart sounds, as some extra or abnormal sounds are accentuated by the various positions.
1. Sitting, leaning forward
2. Lying supine
3. Turned toward the left side (best position for picking up extra heart sounds, as some extra heart sounds or murmurs.
Determining the HEART RATE
Listen and count for 1 minute. Determine if rhythm is regular. If a dysrhythmia exists, check for a pulse deficit in which the radial pulse will be slower than the apical pulse.
Sites to assess for BRUITS ( produced by obstructed peripheral blood flow and are heard as a blowing or swishing sound with the Bell of the stethoscope).
1. Carotid arteries - over the carotid pulses
2. Abdominal aorta - just below the xiphoid process
3. Renal arteries - midclavicular lines above the umbilicus on the abdomen
4. Iliac arteries - midclavicular lines below the umbilicus on the abdomen
5. Femoral arteries - over the femoral pulses.
Assessment of the ABDOMEN
a) Includes observing the shape of the abdomen, palpating for masses, and auscultating for vascular sounds
b) Use INSPECTION, AUSCULTATION, PERCUSSION and PALPATION. This is done to allow the bowel sounds to be heard without being disturbed or distorted by percussion or palpation assessments.
Preparing and positioning a client for an abdominal assessment
Have the client VOID prior to an abdominal examination. Position the client lying SUPNE with arms at his sides with his knees slightly bent.
ABDOMINAL LANDMARKS
Designated using the UMBILICUS. Imaginary vertical and horizontal lines pass through the umbilicus that divide the abdomen into 4 quadrants:
XIPHOID PROCESS - upper boundary
SYMPHYSIS PUBIS - lower boundary
1. Right Upper Quadrant - RUQ
2. Left Upper Quadrant - LUQ
3. Right Lower Quadrant - RLQ
4. Left Lower Quadrant - LLQ
ASSESSMENT FOR THE ABDOMINAL SKIN
1. Lesions - bruises, rashes or other lesions
2. Scars - location and length
3. Striae or stretch marks that are silver in color (expected findings)
4. Dilated veins - unexpected related to cirrhosis or inferior vena cava obstruction
5. Jaundice, cyanosis, or ascites - may be associated with cirrhosis
ABDOMINAL AUSCULTATION
Bowel sounds are produced by the movement of air and fluid in the intestines. The most appropriate time to auscultate bowel sounds is in between meals
a) Listen with the diaphragm of the stethoscope in all four quadrants
b) Expected sounds are high pitched clicks and gurgles which are heard 5 to 30 times per minute. To determine for absent bowel sounds, you must listen for full 5 minutes without hearing anything.
Abdominal Friction Rubs
Caused by the rubbing together of the inflamed layers of the peritoneum.
1. Listen with diaphragm over the liver and the spleen
2. Ask client to take a deep breath while you listen for grating sounds like sandpaper rubbing together
TYMPANY
a) Expected percussion sound heard over most of the abdomen. A lower pitch tympany over the gastric bubble in the left upper quadrant may be heard.
b) Dullness over the liver or a distended bladder may be heard.
ASSESSMENT OF KIDNEY TENDERNESS
Assessed by FIST percussion over the costovertebral angles at the scapular lines on the back, The expected finding is no tenderness.
EXPECTED CHANGES WITH AGING: Breasts
With menopause, breast tissues atrophies and is replaced with adipose tissue, making it feel softer and more pendulous. The atrophied ducts may feel like thin strands. Nipples no longer have erectile ability and may invert.
EXPECTED CHANGES WITH AGING: Lungs
Chest shape changes. Chest expansion diminishes. Cough reflex diminishes. Cilia becomes ineffective. Alveoli dwindle and there is greater resistance and higher risk of infection. Kyphosis takes place due to osteoporosis and weakened cartilage.
EXPECTED CHANGES WITH AGING: Cardiovascular system
Systolic hypertension is common with atherosclerosis. PMI becomes more difficult to palpate. Coronary blood vessel walls thicken and become more rigid with a narrowed lumen. Cardiac output decreases, weak contraction leads to poor activity tolerance. Heart valves stiffen due to calcification. Left ventricle thickens. Pulmonary vascular tension increases. Systolic blood pressure rises. Peripheral circulation lessens.
EXPECTED CHANGES WITH AGING: Abdomen
Abdominal muscles decline in tone and more adipose tissues create a rounder gird. Diminished signs and symptoms of peritoneal inflammation, such as less pain, guarding, fever. Saliva, gastric secretions and pancreatic enzymes decrease. Smooth muscle changes.