Nursing Fundamentals Quiz

• 1180: Holistic Health Assessment focuses on health assessment skills

Health Assessment

• Involves collecting history and physical assessments to determine the purpose and type of assessment

Health History Types

• Focused health history is common and collects data on something specific like a body part, injury, or problem
• Emergent health history is abbreviated, urgent, and restricted to what needs to be known immediately
• Comprehensive health history focuses on gathering information on everything, such as all body systems, and provides a broad assessment of the client's health through annual medical exams or when joining a new primary health team

Why Perform Physical Assessments

• To obtain baseline data to supplement, confirm, or refute nursing history data
• To establish nursing diagnoses and plans of care
• To evaluate the physiological outcomes of healthcare via client health and make clinical judgements
• Advanced assessments helps distinguish between differential diagnoses
• Consists of inspection, palpation, percussion (advanced, determines density), and auscultation (w/ stethoscope)

Clinical Judgement

• Clinical Judgement requires Interpreting, Responding, Reflecting, Noticing new information

• Requires understanding the clinical situation and nurse's contribution using a holistic view

Data Types

• Subjective includes information reported by the client influenced by experience, opinions, or preferences
• Provides clues to physiologic, psychological, and sociologic problems like sensations, feelings and personal information
• Objective includes information measured or observed through senses such as physical assessment, observation and diagnostic testing
• A general survey that takes into account clients mental state and behavior
• Takes place during initial encounter and provides a snapshot in time, which can be used to determine any changes

The ASEPTIC acronym

Vital Signs

• Includes Temperature which can be measured
• Afebrile means no fever is present
• Pyrogen, a substance such as bacteria that produces fever when introduced to/present in the bloodstream
• Diaphoresis indicates sweating
• Antipyretic is a substance such as acetaminophen or ibuprofen that combats fever, which indicates sweating

Pulse/Respiration

• Bradycardia occurs when heart rate is below 60 bpm
• Tachycardia occurs when heart rate is above 100 bpm
• Arrhythmia is an abnormal/irregular heartbeat
• Pulse deficit represents an abnormal difference in rate between radial/apical sites
• Asystole indicates an absent pulse
• Apnea represents periods of no breathing/respiration
• Excursion is assessed by placing hands on client's back to look for symmetrical chest expansion with breathing
• Temperature ranges include 36.5-37.5°C under the tongue, 35.9-37.2°C under the arm, 36.5-37.5°C in the ear, 36.5-37.5°C on the forehead, and 37.0-37.5°C in the rectum

Oxygen Saturation

• Measures the percentage of hemoglobin molecules on red blood cells that are oxygen-bound, where each hemoglobin can carry 4 oxygen molecules
• Normal range is between 92-100%, with a preference over 95%
• Ranges over 95% are less preferred w/ as with clients with certain lung conditions like emphysema
• Normal pulse pressure is typically ~ 40-60 mmHg

Respiratory

• Normal rate for adults is 12 to 20 breaths per minute, varying by age for children
• Assessed before/after a treatment or procedure, when the patient's condition changes, or when physician orders dictate

Pulse Measurement

• Pulse wave originates from ventricular contraction (~60 mL stroke volume) and travels through the aorta to distal arteries
• Radial pulse is the most common measurement site, though hard to find in children age 3 and below
• Apical pulse is used to check pulse rate in children under 2 years of age or when an abnormal/irregular rate is found via palpation of peripheral pulses
• Blood pressure represents the force exerted on artery walls from the heart, with Systolic (top) and Diastolic (bottom) numbers

Blood Pressure

• Influenced by cardiac output, peripheral vascular resistance, circulating blood volume, viscosity, and vessel wall elasticity

Hypertension Factors

• Low Risk: Systolic ≤ 120 and Diastolic ≤ 80

• Medium Risk: Systolic 121-139 or Diastolic 81-89

• High Risk: Systolic 140+ or Diastolic 90+ Hypotension: Systolic <90 or Diastolic <60

• Concerning blood pressure when

  • Systolic is lower than 100 or higher than 139
  • Diastolic is lower than 60 or higher than 89

• Term Definitions -Hypertension: A blood pressure above the expected range -Hypotension: A blood pressure below the expected range -Orthostatic/Postural Hypotension: A sudden blood pressure drop when standing from a seated or prone position -Pulse Pressure: The difference between systolic and diastolic BP

Pain

• Pain is a primary reason clients access healthcare in Canada
• Pain's Physiology
• Gate control theory
  • Transduction: A noxious stimulus causes "gate" opening on a nociceptor through nerve depolarization -Transmission: Noxious stimuli passes through the peripheral to central nervous system up the afferent (nerves to the brain) nerve pathways -Perception: The pain stimulus passes through the dorsal horn of the spine and cerebral cortex -Modulation: Stimulus is identified as pain in cerebral cortex and a pass down the efferent pathways, resulting in a response
• Duration: Is either Acute or Chronic -Acute means from actual/potential tissue damage, has a purpose to further alert and protect, lasts less than 6 months and can have physiologic changes -Chronic means lacks acute warning, doesn't have a purpose, has more emotional effects, and lasts longer than 6 months
• Other Pain Types -Frequency: Continuous (constant), Intermittent (comes and goes) and Episodic (particular event/cycles) -Form types include Nociceptive, Neuropathic and Associated with Cancer
• Subjective - Nociceptive is tissue/can be thermal - Visceral is heart and kidney/can be crampy or numb - Somatic is muscles, bones joint/can be sharp pain
• Also types include Cutaneous, Rreferred parietal and Neuropathic

ASEPTIC mnemonic is used to

Infection Controls/Self Study

• NOSOCOMIAL indicates infections acquired in the hospital
• Aseptic represents "Clean" technique, where microorganisms are reduced, not completely eliminated
• Chain of infection: This is the circuit that, without interruption, produces an infection, meaning breaking 1 part interrupts this infection
• Microorganisms represented by bacteria, viruses, fungi, or parasites
• Types
  • Pathogen: A microorganism that causes disease
  • Sterile: Complete eradication of microorganisms, unlike clean technique
  • HAI: Infection the client acquired while in the hospital, also known as nosocomial infections
  • Contact: Includes humans, and indirect contact which involves transmission
• Four moment of hand hygiene -Before entering the room for washing -Before aseptic procedures Before/after glove exposure, after exiting the room

Precautions Types

 - Contact: Includes humans, and indirect contact which involves transmission
    - Wear a gown and gloves to protect hands and uniforms against contact with pathogens.
- Droplet: Large released particles during sneezing which requires eyewear to filter out large partiles

-Airborne: For situations involving very small particles suspended in the air

• Requires N95-type respirator to prevent infection vs Aseptic

Transmission Chain Info

1. Infectious organism: Microogranisms used to cause illness (viruses, bacteria/fungi)
2. "Reservoir": The place for infectous organism needs room to live.
3. Portal of Exit: The method used by organism in order to leave reservior.
4. Transmission: Pathgen goes from one host to another.

Spinal Nerve Details

• Dermatone: Area of skin, supplied by nerve fibres
• Paraesthesia:"Pins & Needles" to related injury.
• Persyncope: The sensation of fainting
• Syncope - Fainting
• Diplopia: Double vision
• Tinnitus: Ringing

Cranial info with functions/names

| Number | Location | Function/Mnemonic | | | ----------- | ----------- | ----------- | |I | Olfactoy | Some | | II| Optic | Old | Say | |III| Oculomotor | Olympus' | Marry | |IV| Trochlear | Towing | Money | |V| Trigeminal | Top | But | |VI | Abducens | A| MY | |VII |Facial | Fin |Brother | |VIII |Auditory or Vestibulochochlear| And |Says |IX |Glossopharyngeal | German |BIG | |X| Vagus | Viewed |Brains | |XI| Spinal Accessory | Some | |XII

Test your knowledge of key concepts in nursing fundamentals, including oxygen saturation targets for lung conditions like emphysema, blood pressure determinants, pulse measurement sites, stroke volume, and pain management.