Nursing Lecture Notes PDF

Lecture 1: STUDENT LEARNING OBJECTIVES: Health, Wellness, Health Assessment (Focused, Comprehensive, On -going/Partial), Chart Review, Interview, (Subjective, Objective), Health History, General Survey, V/S, Pain Assessment, Equipment, Techniques, Maslow’s Hierarchy, Vulnerable Population, S...

Lecture 1: STUDENT LEARNING OBJECTIVES: Health, Wellness, Health Assessment (Focused, Comprehensive, On -going/Partial), Chart Review, Interview, (Subjective, Objective), Health History, General Survey, V/S, Pain Assessment, Equipment, Techniques, Maslow’s Hierarchy, Vulnerable Population, Standard Precautions 1. Define the purpose of the Health Assessment in determining the patient’s current and ongoing health status, predicting risks of health, and identifying health promotion activities. So we can collect holistic info of a person's health status and how it is affecting a patient's ADLs. Explores how patients decide to cope with their health issues and any change or loss in their function. 2. Define Health and Wellness. Health integrates physical, intellectual, emotional, sociocultural, spiritual, and environmental aspects of the whole person. Wellness: An active state of being healthy; living a lifestyle that promotes good physical, mental, and emotional health. 3. Explain the different types of Health Assessments. Comprehensive: Broad, includes complete health 4. Explain the purpose of the chart review, health history, and patient interview. 5. Explain the purpose of assessing V/S. T P R O2 Sat B/P, and know the normal ranges. 6. Describe the method of assessing pain, using the acronym OLDCHART & ICE. 7. Explain and describe the technique in using medical equipment: stethescope, penlight, reflex hammer, and doppler. 8. Explain the application of the Maslow’s Hierarchy in prioritizing nursing care. 9. Define the groups of people who are considered the Vulnerable Population. 10. Explain Asepsis, Infection Control, Standard Precautions, and Types of Isolations. Lecture 2: STUDENT LEARNING OBJECTIVES: Eye, Ears, Nose, Mouth, Throat, Respiratory, Peripheral Vascular. 1. Describe the application and purpose of assessing the Integumentary System. 2. Describe the application and purpose of assessing the Neck and Lymphatic System. 3. Describe the application and purpose of assessing the Sensory System, Eyes, Ears, and Nose. 4. Describe the application and purpose of assessing the Mouth, and Throat. 5. Describe the application and purpose of assessing the the Respiratory System. 6. Describe the application and purpose of assessing the Peripheral Vascular System. Lecture 3: STUDENT LEARNING OBJECTIVES: Cardio-Vascular, Breast, Axillae, Abdomen 1. Describe the application and purpose of assessing the Cardio-Vascular, Breast, and Axillae. Cardiovascular and peripheral vascular assessment includes assessment of the heart and extremities. The physical examination is used to identify signs and symptoms of heart disease and peripheral vascular disease (most often found in the lower extremities). Techniques used for cardiovascular assessment are inspection, palpation, and auscultation. Equipment needed includes a stethoscope with a bell and diaphragm, sphygmomanometer (blood pressure cuff), and a watch. A quiet environment is necessary for accurate auscultation of heart sounds. Peripheral vascular assessment includes measuring BP and assessing the skin and perfusion of the extremities and the peripheral pulses (Temporal, carotid, apical, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial). Assessments are made by inspection and palpation, with patient sitting or supine. Physical assessment of the breasts and axillae is primarily conducted to identify any lumps in the breasts and/or enlargement or pain in axillary lymph nodes (if assessed patient should have further diagnostic tests). 2. Describe the application and purpose of assessing the Abdomen. When it comes to the abdomen we follow the following sequence: Inspection, Auscultation, percussion, and palpation. Percussion and Palpation is done last because it causes bowel sounds. ASK: If the patient has any painful areas of the abdomen. Ask to describe pain, palpate it last, and document. 2. Verbalize the Normal Pulse rate, rhythm, quality, audible sounds, (lub-dub) and skin color. Normal pulse: 60-100 beats/min Rhythm: regular Pulse quality: Strong, palpable +2 3. Describe the purpose of assessing the O2 Saturation and application areas. Determines the O2 level in the blood, assess respiration function Normal ranges: 95%-100% Application areas: fingers, toes, ears and nose 4. Perform and verbalize the area sounds of the heart while auscultating, ((anterior, posterior), with correct application of the stethoscope, and patient position. Patient may be in a sitting position or in a supine position with the head raised about 30 degrees. Use diaphragm to listen to high-pitched sounds. Use the bell to listen to low-pitched sounds. Areas sounds of the heart: - Aortic valve site, Listen over the RSB, second ICS ( in this location the S2 sound should be louder than the S1 sound) - Pulmonic Valve site, Listen over the LSB, second ICS (in this location the S2 sound should be louder than the S1 sound) - Erb’s point, Listen over the LSB, third ICS (You should hear both the S1 and S2 heart tones, relatively equal in intensity) - Tricuspid valve site, Listen at the LSB at the fourth ICS (In this location the S1 sound should be louder the the S2 sound) - Mitral valve site (Apical), Listen over the apex, fifth ICS, LMCL ( In this location the S1 sound should also be louder than the S2 sound) 5. Describe the application and purpose of the Incentive Spirometer. 6. Define the term Tachycardia and Bradycardia, verbalize the terms definitions. Tachychardia: pulse rate greater than 100 beats/min Bradycardia: pulse rate below 60 beats/min 7. What are the medical terms for slow breathing and fast breathing? Bradypnea: slow breathing Tachypnea: fast breathing 8. Describe the purpose and application of assessing the Cardio-Vascular System. The purpose of assessing the cardiovascular system is to identify signs and symptoms of heart disease and peripheral vascular disease. To ensure proper function. 9. Verbalize the all Pulses and their locations. Temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis. 10. Describe what is a Pulse Deficit, and how it is assessed. A pulse deficit is the difference between the apical and radial pulse rates indicating that not all heartbeats are reaching peripheral arteries or too weak to be felt. You assess a pulse deficit with a second nurse by palpating the radial pulse rate while another nurse auscultates the apical pulse for one whole minute. 11. Name, locate, and verbalize the areas of the heart sounds: Aortic, Pulmonic, Erb's Point, Tricuspid, and Mitral. - Aortic valve site, Listen over the RSB, second ICS ( in this location the S2 sound should be louder than the S1 sound) - Pulmonic Valve site, Listen over the LSB, second ICS (in this location the S2 sound should be louder than the S1 sound) - Erb’s point, Listen over the LSB, third ICS (You should hear both the S1 and S2 heart tones, relatively equal in intensity) - Tricuspid valve site, Listen at the LSB at the fourth ICS (In this location the S1 sound should be louder the the S2 sound) - Mitral valve site (Apical), Listen over the apex, fifth ICS, LMCL ( In this location the S1 sound should also be louder than the S2 sound) 12. Verbalize the location of the Apical pulse or PMI, (point of maximum impulse). Left, midclavicular line in the 5th intercostal space. 13. Verbalize the normal range of Blood pressure. Normal: 120/80 14. Define Systolic and Diastolic. What is occurring in the heart? Systolic: highest pressure created during ventricular contraction Diastolic: lowest pressure present on arterial walls during the rest between beats Maximum blood pressure is exerted on the walls of arteries when the left ventricle of the heart contracts and pushes blood through the aortic valve into the aorta at the beginning of systole. The pressure rises as the ventricle contracts (systole) and falls as the heart relaxes (diastole). The continuous contraction and relaxation of the left ventricle creates a pressure wave that is transmitted through the arterial system. 15. Verbalize the stages of hypertension. What range of B/P would be considered Hypotension? Prehypertension: 120-129 systolic or = 140 systolic or >= diastolic Hypertensive crisis: > 180 systolic and/or >120 diastolic 16. Verbalize the method of assessing the abdomen. Inspecting- look at the skin color, the umbilicus(should be centered), contour, symmetry, peristalsis, pulsations, and any visible masses. In thin people an upper midline pulsation may normally be visible. ABNORMAL FINDINGS: asymmetry(Enlarged organs or mass), Distention(possibly indicating retained gas or air; obesity), swelling of the abdomen(possibly indicating fluid retention called ascites), and abdominal masses or unusual pulsations, scars, rashes. Auscultating: Hear bowel sounds, listen to all 4 quadrants for at least 3-5 sounds in 1 minute minimum before documenting. Listen for gurgles and clicks and note their frequency. ABNORMAL FINDINGS: increased bowel sounds (often heard with diarrhea or in early bowel obstruction), or decreased bowel sounds (heard after surgery), or absent bowel sounds bowl(indicating peritonitis or paralytic ileus). Bowl sounds of high pitched tinkling or rushes can indicate partial bowel obstruction. Palpating: Use light palpation to assess, apply pressure with the fingers about 1 to 2 cm. Watch patients' faces for pain during palpation. Abdomen should be soft, relaxed, and free of tenderness. Palpate pain area last. ABNORMAL FINDINGS: spasm, masses, and pain(which may indicate trauma, Peritonitis, infection, tumors, or enlarged or diseased abdominal organs) 17. Demonstrate the pattern to auscultate the abdomen. Start at RLQ- RUQ-LUQ-LLQ -Hypoactive: >3-5 sounds/min -Hyperactive: