exam 1 notes.docx

**Joint Commission National Patient Safety Goals** 1. **Identify Patients Correctly**. 2. **Improve Staff Communication**. 3. **Use Medicines Safely**. 4. **Use Alarms Safely**. 5. **Prevent Infection**. 6. **Identify Patient Safety Risks**. 7. **Prevent Mistakes in Surgery**. **Facto...

**Joint Commission National Patient Safety Goals** 1. **Identify Patients Correctly**. 2. **Improve Staff Communication**. 3. **Use Medicines Safely**. 4. **Use Alarms Safely**. 5. **Prevent Infection**. 6. **Identify Patient Safety Risks**. 7. **Prevent Mistakes in Surgery**. **Factors Affecting Patient Safety** - **Age and Development**. - **Lifestyle**. - **Mobility and Health Status**. - **Sensory/Perceptual Alterations**. - **Cognitive Awareness**. - **Emotional State**. - **Ability to Communicate**. - **Safety Awareness**. - **Environmental Factors**. **Risk Factors for Errors in Healthcare** **Individual Risks for Errors** - Limited short-term memory. - Being late or rushed. - Limited ability to multitask. - Interruptions. - Stress and fatigue. - Environmental stimuli. **Work Environment Risks for Errors** - Inconsistent staffing levels. - Long work hours. - Ineffective nursing work processes. - Physical design of the workplace. **Fall Risks and Prevention** **Human Risks for Falls** - Low blood pressure. - Unsteady gait. - Poor vision. - Altered mental status. **Environmental Risks for Falls** - Poor lighting. - Objects on the floor. - Stairs. - Inappropriate bathroom equipment. **Fall Prevention Measures** - Use bathroom grab bars and assistive railings. - Provide nonskid footwear. - Keep environment tidy and clear of obstacles. - Perform fall risk assessments upon admission. - Use bed or chair alarms. **Fire Safety Protocol** **R.A.C.E. (Rescue, Alarm, Confine, Evacuate)** - Know the location of alarms, extinguishers, and evacuation routes. - Prioritize patient safety. **Fire Alarm Response** - Listen for \"Code Red\". - Close all doors. - Await further instructions; do not evacuate unless instructed. - Resume normal activities once the alarm and lights stop, and \"all clear\" is given. **Restraints and Alternatives** **Definition of Restraint** - A physical device used to limit a patient's movement. **Types of Restraints** - All four bed rails up. - Wrist/ankle cuffs. - Vest or jacket restraints. - Medications. **Hazards of Restraints** - Increased risk of serious injury, skin breakdown, contractures, incontinence, depression, delirium, anxiety, aspiration, respiratory difficulties, and death. **Restraint Orders** - Written orders required. - Licensed practitioner must evaluate the patient within one hour. - PRN orders are prohibited. - Regular removal of restraints for range of motion and skin checks. **Alternatives to Restraints** - 1-to-1 supervision. - Low bed position. - Bed/chair alarms. - Medication assessment. - Distractions. - Family assistance. **Sentinel Events** - **Definition**: Unexpected occurrences involving death or serious injury. **Examples of Sentinel Events** - Death in restraints. - Fall with injury. - Medication errors. - Unexplained death. **Infection Control** **Definition of Infection** - Invasion of the body by a pathogen. **Factors Increasing Infection Susceptibility** - Age (very young or old). - Nutritional status. - Stress. - Disease processes. - Medical therapy. **Measures to Reduce Nosocomial Infections** - Constant surveillance by infection-control committees. - Written infection-prevention practices. - Hand hygiene adherence. - Infection control precautions. - Keeping patients in optimal physical condition. **Chain of Infection** 1. **Infectious Agent** (pathogen). 2. **Reservoir** (where pathogens live and grow: people, animals, soil, water). 3. **Portal of Exit** (how pathogens leave the body: saliva, blood, mucous). 4. **Mode of Transmission** (how pathogens spread: direct contact, contaminated surfaces). 5. **Portal of Entry** (how pathogens enter the body: broken skin, respiratory tract). 6. **Susceptible Host** (individuals with weakened immune systems). **Aseptic Techniques** - Actions preventing the spread of pathogens and breaking the chain of infection. **Types of Asepsis** - **Medical Asepsis**: Areas are considered contaminated if they bear or are suspected to bear pathogens. - **Surgical Asepsis**: Areas are considered contaminated if touched by any non-sterile object. **Actions to Control the Spread of Infection** - Keep soiled items off clothing and floor. - Educate patients on infection prevention. - Avoid raising dust. - Proper disposal of contaminated items. - Clean from least dirty to most dirty. **Body\'s Defense Mechanisms Against Infection** - Skin. - Respiratory system. - Mouth. - GI/GU tracts. - White blood cells. - Inflammation and fever. - Immunizations. **Hand Hygiene** **Methods** - **Alcohol-Based Hand Rubs**. - **Soap and Water**: Use when hands are visibly soiled or dealing with C. Diff. **When to Perform Hand Hygiene** - Before and after direct patient contact. - Before and after donning gloves. - When moving from contaminated to clean areas during patient care. - Upon entering or exiting a patient area. - Before and after eating. **Universal Precautions** - Perform hand hygiene. - Wear non-sterile gloves. - Use PPE when in contact with body fluids. - Discard sharps in sealed containers. - Avoid cross-contamination. - Use private rooms to reduce environmental contamination. **Types of Precautions** - **Airborne**: Negative pressure room, PPE. - **Droplet**: PPE. - **Contact**: PPE. **Nursing Definitions** **International Council of Nurses (ICN) Definition** - Nursing involves autonomous and collaborative care of individuals, with a focus on health promotion, illness prevention, and care for the ill. **American Nurses Association (ANA) Definition** - Nursing involves the protection, promotion, and optimization of health, prevention of illness/injury, alleviation of suffering, and advocacy in care. **ANA Nursing Roles** - Caregiver. - Communicator. - Teacher/Educator. - Counselor. - Leader. - Advocate. - Researcher. - Collaborator. **Guides to Nursing Practice** - ANA scope and standards of practice. - Nurse Practice Act for NJ. - Licensure requirements. - The nursing process. **Nursing Theories Overview** - **Purpose of Nursing Theories**: Nursing theories describe the essence of nursing and the relationships among nurses, clients, the environment, and intended outcomes. They serve multiple functions: - Define nursing practice. - Form the basis for nursing education, practice, and research. - Explain and evaluate nursing care. - Predict outcomes, validate data, and contribute to the search for new knowledge. **Dorothy Orem\'s Self-Care Theory** - **Main Concepts**: - Guiding, teaching, and directing one another. - Providing psychological and physical support. - Creating a supportive environment to enhance the patient's ability to meet current and future demands. **Sister Callista Roy\'s Adaptation Theory** - **Focus**: Human adaptive system response to a constantly changing environment. - **Key Issues**: Problems arise when the system cannot cope with or adapt to internal or external stimuli. **Infection Control** **Infection Cycle** 1. Infectious agent (pathogen). 2. Reservoir. 3. Portal of exit. 4. Means of transmission. 5. Portal of entry. 6. Susceptible host. **Stages of Infection** 1. **Incubation Period**. 2. **Prodromal Stage** (most infectious). 3. **Full Stage of Illness**. 4. **Convalescent Period** (recovery). **Cardinal Signs of Infection** - Redness, heat, swelling, pain, loss of function. **Multi-Drug-Resistant Organisms (MDROs)** - **MRSA**: Found in nasal membranes, skin, respiratory tract. - **VRE**: Found in intestinal/genitourinary tracts. - **C. Diff**: Affects the GI tract, requires soap and water for hand hygiene. **Five Moments for Hand Hygiene** 1. Before touching a patient. 2. Before a clean/aseptic procedure. 3. After body fluid exposure risk. 4. After touching a patient. 5. After touching patient surroundings. **Standard Precautions** - Apply to all hospitalized patients, covering blood, body fluids, secretions, non-intact skin, and mucous membranes. **Types of Precautions** - **Airborne**: Measles, chickenpox, COVID-19. - **Droplet**: Rubella, mumps. - **Contact**: MRSA, VRE, C. Diff. **Personal Protective Equipment (PPE)** - **Order to Put On**: Gown, mask, goggles, gloves. - **Order to Remove**: Gloves, goggles, gown, mask. **Nursing Interventions** **Independent Nursing Interventions** - Actions initiated by a nurse without needing supervision or direction from others. **Collaborative Nursing Interventions** - Interdependent actions requiring the expertise of multiple healthcare professionals. **Additional Concepts** **Oxygenation** - **Ventilation**: Movement of air in/out of the lungs. - **Exhalation**: Breathing out. - **Diffusion**: Oxygen and carbon dioxide exchange between alveoli and blood. - **Perfusion**: Oxygen and carbon dioxide exchange between blood and tissues. **Labs** - **WBC Count**: Normal = 5,000-10,000. - **Potassium**: Normal = 3.5-5 mEq/L. - **Sodium**: Normal = 135-145 mEq/L. **Patient Identification** - Check identification bracelet. - Ask the patient to state their name and date of birth, and confirm with the bracelet. **Quality and Safety Education for Nurses (QSEN)** - **Goal:** - To prepare future nurses with the knowledge, skills, and attitudes (KSAs) necessary to improve the quality and safety of healthcare systems. - **Competencies:** - Patient-Centered Care - Teamwork and Collaboration - Evidence-Based Practice - Quality Improvement - Safety - Informatics **Patient Rights** - Right to see and copy their health record. - Right to update their health record. - Right to obtain a list of disclosures. - Right to request restrictions on certain uses or disclosures. - Right to choose how to receive health information. **Fall Prevention** **Factors Contributing to Falls** - **Personal**: - Lower body weakness - Poor vision - Gait/balance issues - Postural dizziness - Use of psychoactive medications - Problems with feet/shoes - **Environmental**: - Hazards in the home or community - Poor lighting - Objects on the floor - Stairs **Fall Risk Assessment Tools** 1. Morse Falls Scale 2. Hendrich II Risk Model 3. RWJB Health Falls Scale 4. Hourly patient rounding 5. Get Up and Go Test **Level of Awareness or Orientation (A/O x4)** - **Assessment Questions**: 1. What is your name? 2. Where are you? 3. What year is it? 4. Why are you here? **Nursing Interventions for Fever** - Encourage fluid intake (3,000 mL/day if kidneys/heart are healthy) - Rest - Apply cool packs - Ensure well-balanced diet - Light clothing/bedding - Keep linens dry - Administer antibiotics/antipyretics as ordered **Vital Signs & Pulse Characteristics** - **Pulse Characteristics**: - **Rate**: Beats per minute - **Rhythm**: Regular or irregular - **Strength**: Weak, normal, bounding - **Quality**: - 0 = Absent - +1 = Weaker than expected - +2 = Normal/brisk - +3 = Bounding **Do Not Take Blood Pressure On:** - Arm with IV infusion - Arm with a cast - Arm with dialysis access site - On the side of breast surgery - Injured arm or skin graft area **National Patient Safety Goals (The Joint Commission)** 1. Identify patients correctly. 2. Use medications safely. 3. Use alarms safely. 4. Prevent infection. 5. Identify patient safety risks. 6. Prevent mistakes in surgery. **Restraints** - **Definition**: Protective devices that limit or restrict movement. - Examples: Wrist/ankle restraints, vest/jacket, medications, all 4 bed rails up. - **Restraint Orders**: - Cannot be PRN (as needed). - Written orders required. - A licensed practitioner must evaluate the patient within one hour. - Document use and monitor the patient. **Safety Factors** 1. Age and development 2. Lifestyle 3. Mobility and health status 4. Sensory/perceptual alterations 5. Cognitive awareness 6. Emotional state 7. Ability to communicate 8. Safety awareness 9. Environmental factors **Conversions and Measurement Units** - **1 liter (L)** = 1,000 milliliters (mL) - **1 mL** = 0.001 L - **1 teaspoon (t or tsp)** = 5 mL - **1 tablespoon (T or tbsp)** = 3 tsp - **1 fluid ounce (fl oz)** = 2 tbsp - **1 cup** = 8 fl oz - **1 pint (Pt)** = 2 cups = 16 fl oz - **1 quart (qt)** = 2 Pt = 4 cups = 32 fl oz - **1 gallon** = 4 qt - **16 oz** = 1 pound **Common Medical Abbreviations** - **Ac** = Before meals - **Pc** = After meals - **ad lib** = As desired, freely - **prn** = As needed - **stat** = Immediately, at once - **bid** = Twice a day - **tid** = Three times a day - **qid** = Four times a day - **q2h** = Every 2 hours - **-a** = Before - **-p** = After - **-c** = With - **-s** = Without - **NPO** = Nothing by mouth - **Gtt** = Drop **Maslow\'s Hierarchy of Needs** 1. **Physiological Needs**: Breathing, food, water, sleep, homeostasis 2. **Safety and Security**: Security of body, employment, health 3. **Love and Belonging**: Friendship, family, sexual intimacy 4. **Self-Esteem**: Confidence, achievement, respect 5. **Self-Actualization**: Morality, creativity, problem-solving **Stress, Adaptation, and Developmental Theories** **1. Erikson's Developmental Stages** 1. Trust vs. Mistrust (Newborn-18 months). 2. Autonomy vs. Shame (18 months-3 years). 3. Initiative vs. Guilt (3-5 years). 4. Industry vs. Inferiority (5-13 years). 5. Identity vs. Role Confusion (13-21 years). 6. Intimacy vs. Isolation (21-39 years). 7. Generativity vs. Stagnation (40-65 years). 8. Ego Integrity vs. Despair (65+ years). **2. Maslow's Hierarchy of Needs** 1. **Physiological**: Basic needs (food, water, shelter). 2. **Safety**: Security of health, employment, etc. 3. **Love/Belonging**: Family, friendship. 4. **Esteem**: Confidence, respect. 5. **Self-Actualization**: Morality, creativity, acceptance. **3. Selye's Theory of Stress** - **Alarm Reaction**: Fight or flight response. - **Resistance**: Adaptation to stress. - **Exhaustion**: Inability to maintain stress adaptation. **Three Stages of General Adaptation Syndrome (GAS):** 1. **Alarm**: Immediate response to the stressor. 2. **Resistance**: Body adapts to the stressor. 3. **Exhaustion**: Adaptation to the stressor can no longer be maintained. **Nursing Theories & Nursing Process** - **Purpose**: Define nursing and its relationship among nurses, clients, the environment, and outcomes. - **Key Theorists**: Dorothea Orem, Sr. Calista Roy - **Nursing Process (ADPIE)**: - **Assessing**: Collect subjective and objective data. - **Diagnosing**: Analyze data to identify problems and strengths. - **Planning**: Develop individualized goals and interventions. - **Implementing**: Execute the care plan and reassess. - **Evaluating**: Measure the patient\'s progress toward outcomes. **Outcomes** 1. **Cognitive**: Knowledge-based (e.g., patient will state understanding). 2. **Psychomotor**: Skill-based (e.g., patient will demonstrate). 3. **Affective**: Emotion-based (e.g., patient will feel confident). 4. **Physiologic**: Measurable (e.g., vital signs, lung sounds). **Methods of Assessment** 1. **Inspection**: Observing general appearance, symmetry, gait, mood, behavior. 2. **Palpation**: Feeling for abnormalities (e.g., mass, tenderness). 3. **Auscultation**: Listening to body sounds (e.g., lungs, heart). **Types of Health Assessment** 1. **Comprehensive Assessment:** - Performed upon admission to establish a baseline. 2. **Ongoing Partial Assessment:** - Conducted at regular intervals (e.g., each hospital shift) to monitor changes. 3. **Focused Assessment:** - Specific to a particular problem (e.g., abdominal pain: assess bowel sounds, distension). 4. **Emergency Assessment:** - Performed in life-threatening situations to determine priorities (Airway, Breathing, Circulation - ABCs). **Health History Factors to Assess** - **Biographic Data** - **Reason for Seeking Health Care** - **History of Present Illness** - **Family History** - **Functional Health** - **Lifestyle Factors** - **Review of Systems** **Positions Used During Physical Assessment** - **Standing:** Assessment of posture, balance, and gait. - **Sitting:** Visualizes the upper body. - **Supine:** For relaxation of abdominal muscles; useful for vital signs, head, neck, lungs, and breasts. - **Prone:** Assessment of hip joint and posterior thorax. - **Lithotomy:** Assessment of female genitalia and rectum. - **Knee-Chest:** Assessment of the anus and rectum. **PERRLA** - **Pupils Equal, Round, Reactive to Light and Accommodation.** **Purpose of Documentation** - Documentation ensures: - What is not recorded did not happen. - Identifies actual and potential health problems. - Plans appropriate care. - Evaluates the patient's responses to treatments. - Must reflect the nursing process. **Guidelines for Documentation** - **Factual** - **Accurate** - **Complete** - **Current** - **Organized** - Avoid abbreviations. **Purpose of Documentation** - **Definition**: Written or electronic legal record of patient interactions. - **Importance**: Permanent legal document, critical for defending against allegations of nursing negligence. **ISBARQ (Extended SBAR)** - **I:** Introduction - **S:** Situation - **B:** Background - **A:** Assessment - **R:** Recommendation - **Q:** Question and Answer **SBAR Communication Framework** - **Situation:** What is going on with the patient? (Current vital signs, condition) - **Background:** Pertinent patient history. - **Assessment:** What is the patient\'s current concern? - **Recommendation:** What does the patient need? **Methods of Documentation** 1. **Electronic Health Record (EHR)** 2. **Problem-Oriented Medical Record (POMR):** - All health professionals record information on the same form. 3. **Charting by Exception (CBE):** - Highlights trends and variances. 4. **Personal Health Records (PHR)** 5. **Source-Oriented Records:** - Paper format where each healthcare group keeps data on separate forms. **SOAP Format (POMR)** - **Subjective:** Patient-reported information. - **Objective:** Observations and measurements. - **Assessment:** Diagnosis or interpretation. - **Plan:** Action or treatment plan. **PIE Charting** - **Problem:** Identified patient problem. - **Intervention:** Nursing intervention provided. - **Evaluation:** Evaluation of the effectiveness of the intervention. **Formats for Nursing Documentation** 1. **Initial Nursing Assessment:** Baseline data. 2. **Care Plan/Patient Care Summary** 3. **Critical Collaborative Pathways:** - Standardized care plans for patient populations with specific diagnoses or procedures. 4. **Progress Notes:** - Narrative nursing notes, SOAP notes, PIE notes, focus charting, charting by exception, or case management model. 5. **Flow Sheets and Graphic Records:** - Routine care documentation (e.g., pulse, respirations, BP, temperature, weight, fluid intake/output). 6. **Medication Record:** - Documents drug, dose, route, and time. 7. **Acuity Records** 8. **Discharge and Transfer Summary** 9. **Long-Term Care Documentation (RAI):** - Resident assessment instrument. 10. **Verbal Report/Handoff Report/Change of Shift Report:** - Alerts next caregivers of the patient\'s status, changes in condition, planned activities, tests, or procedures. **Nursing Process (ADPIE)** 1. **Assessment:** - Collect subjective and objective data (history, physical exam, consult team). 2. **Diagnosis:** - Clinical judgment about individual, family, or community responses. - Three types: problem-focused, risk, and health promotion. 3. **Planning:** - Developing a plan of care. 4. **Implementation:** - Carry out the plan; collect data and modify as needed. 5. **Evaluation:** - Monitor progress and determine if the patient has improved. **Breath Sounds** - **Adventitious Breath Sounds:** - Abnormal sounds (wheezing, stridor, rhonchi, crackles). - **Bronchovesicular Breath Sounds:** - Combination of vesicular and bronchial sounds (muffled/blowing), heard continuously throughout inspiration and expiration. **Common Skin and Physical Findings** - **Cyanosis:** Bluish skin discoloration. - **Diaphoresis:** Profuse sweating. - **Ecchymosis:** Bruising. - **Edema:** Fluid accumulation in tissues. - **Erythema:** Skin redness. - **Inspection:** Systematic observation of the body. - **Jaundice:** Yellowing of the skin. - **Pallor:** Paleness of the skin. - **Petechiae:** Pinpoint purple or red spots from minute hemorrhages under the skin. - **Turgor:** Elasticity of the skin. - **Precordium:** The chest area overlying the heart and related structures. **Percussion** - **Definition:** - Act of striking one object against another to produce a sound; used to assess the location, shape, size, and density of tissues. **Clinical and Functional Outcomes** - **Clinical Outcomes:** - Describe the expected status of health issues after treatment. - **Functional Outcomes:** - Describe the patient\'s ability to function in usual activities. - **Quality of Life Outcomes:** - Focus on factors affecting the ability to enjoy life and achieve personal goals. **Maslow's Hierarchy of Human Needs** - **Priority of Needs:** - Basic physiological needs must be met before focusing on higher-level needs. - Includes: 1. Physiologic needs 2. Safety needs 3. Love and belonging needs 4. Self-esteem needs 5. Self-actualization needs **Vital Signs Overview** **Sequence of Vital Signs:** 1. **Temperature (T)** 2. **Pulse (P)** 3. **Respirations (R)** 4. **Blood Pressure (BP)** 5. **Pain (P)** 6. **Oxygen Saturation (O₂)** **Normal Ranges:** - **Temperature:** 98.6°F (37°C) - **Pulse:** 60-100 beats per minute (bpm) - **Respirations:** 12-20 breaths per minute - **Blood Pressure:** 120/80 mm Hg - **Pain:** Assessed on a scale (numeric or descriptive) - **Oxygen Saturation:** 95% or higher **Temperature** **Normal Temperature Range:** - **General Range:** 96.7°F - 100.5°F **Temperature Measurement Sites and Ranges:** - **Axillary (Underarm):** 95.6°F - 98.5°F - Typically reads lower than core temperature; least accurate. - **Rectal:** 97.4°F - 100.5°F - Most accurate; avoid in patients with cardiac problems due to vagal stimulation. - **Temporal (Forehead):** 98.7°F - 100.5°F - Highly accurate and non-invasive. **Types of Fever Patterns:** - **Intermittent Fever:** - Body temperature returns to normal at least once every 24 hours. - **Remittent Fever:** - Body temperature does not return to normal and fluctuates up or down. - **Sustained/Continuous Fever:** - Body temperature remains above normal with minimal variations. - **Relapsing/Recurrent Fever:** - Body temperature returns to normal for one or more days with episodes of fever lasting several days. **Hypothermia:** - **Symptoms:** - Poor coordination - Slurred speech - Amnesia - Hallucinations - Decreased respirations - Weak pulse - Lowered blood pressure - **Hypothermia Blanket Precautions:** - Turn patient every 30 minutes to 1 hour. - Check vital signs and neurological status every 15 minutes. **Important Notes:** - **Primary Source of Body Heat:** Metabolism. - **Primary Site of Heat Loss:** Skin. - **Aspirin Precaution:** Should not be given to anyone under 16 years old due to the risk of Reye\'s syndrome. **Pulse** **Pulse Characteristics:** - **Normal Rate:** 60-100 bpm - **Pulse Sites:** - **Temporal** - **Carotid** - **Brachial** - **Radial** (most common site) - **Femoral** - **Popliteal** - **Posterior Tibial** - **Dorsalis Pedis** **Factors Affecting Pulse Rate:** - **Tachycardia (Fast Heart Rate):** - Causes: Hyperthyroidism, decreased blood pressure, exercise, anxiety, pain, certain medications. - **Bradycardia (Slow Heart Rate):** - Causes: Coronary artery disease, myocardial infarction (heart attack), decreased body temperature, sleep apnea, hypothyroidism, stroke (CVA). **Gender Differences:** - Women tend to have a stronger pulse rate compared to men. **Respirations** **Definitions:** - **Respiration:** Gas exchange between atmospheric air in the alveoli and blood in the capillaries. - **Eupnea:** Normal respirations. - **Apnea:** Absence of breathing. - **Dyspnea:** Difficult or labored breathing. - **Orthopnea:** Easier breathing when sitting or standing; difficulty breathing when lying down. **Respiratory Rates:** - **Bradypnea:** Slow breathing rate (\20 breaths per minute). **Ventilation Components:** - **Ventilation:** Inhalation and exhalation. - **Diffusion:** Exchange of O₂ and CO₂ between alveoli and blood. - **Perfusion:** Exchange of O₂ and CO₂ between blood and tissues. **Abnormal Breathing Patterns:** - **Cheyne-Stokes Respirations:** - Pattern of deep, rapid breathing followed by periods of apnea. **Blood Pressure (BP)** **Definitions:** - **Blood Pressure:** The force of blood against arterial walls. - **Hypertension:** High blood pressure. - **Hypotension:** Low blood pressure. - **Orthostatic Hypotension:** - Temporary fall in BP when moving from lying down to an upright position. **Normal and Abnormal Values:** - **Normal BP:** 120/80 mm Hg - **Hypertension Stages:** - **Stage 1:** Systolic 130-139 mm Hg or diastolic 80-89 mm Hg - **Stage 2:** Systolic ≥140 mm Hg or diastolic ≥90 mm Hg - **Hypertensive Crisis:** Systolic \>180 mm Hg or diastolic \>120 mm Hg **Orthostatic Hypotension Guidelines:** - A decrease in systolic BP of ≥20 mm Hg or a decrease in diastolic BP of ≥10 mm Hg within 3 minutes of standing compared to sitting or supine positions. **BP Measurement Methods:** - **Oscillometric:** Automatic devices. - **Auscultatory:** Manual measurement using a stethoscope and sphygmomanometer. - **Ambulatory BP Monitoring:** - Cuff remains on the patient; measures BP at regular intervals (every 20-30 minutes). - **Direct Electronic Measurement:** - Invasive method using a catheter inserted into the femoral or radial artery. **Special Considerations:** - **Popliteal BP Measurement:** - BP readings at the popliteal artery (behind the knee) are usually 10-40 mm Hg higher than those taken at the brachial artery. - **Biological Sex Differences:** - Women generally have lower BP than men of the same age until menopause. **Additional Vital Signs Terms** - **Auscultatory Gap:** - A period of diminished or absent Korotkoff sounds during manual BP measurement. - **Dysrhythmia:** - Abnormal cardiac rhythm. - **Comorbidity:** - Presence of two or more diseases or medical conditions in a patient. **Physical Assessment** **Techniques Used:** 1. **Inspection:** Visual examination of the body. 2. **Palpation:** Using hands to feel body parts. 3. **Auscultation:** Listening to sounds produced by the body. 4. **Percussion:** Tapping on body parts to assess underlying structures. **Equipment Needed:** - Thermometer - Blood pressure cuff (sphygmomanometer) - Scale - Penlight - Stethoscope - Metric ruler - Eye chart (Snellen chart) - Gloves **Patient Positions for Assessment:** - **Standing:** Assess posture, balance, and gait. - **Sitting:** Examine the upper body. - **Supine:** Patient lies flat on back; relaxes abdominal muscles. - **Prone:** Patient lies flat on stomach; assesses hip joint and posterior thorax. - **Fowler\'s Position:** Sitting up at 45-60 degrees; used for cardiac and respiratory assessments. - **Lithotomy:** Supine position with legs separated, used for examining the pelvic area (e.g., childbirth). **Additional Terms and Definitions** **Skin and Appearance:** - **Diaphoresis:** Excessive sweating. - **Erythema:** Redness of the skin. - **Pallor:** Paleness of the skin. **Heart and Breath Sounds:** - **Heart Sounds:** - Produced by blood flowing through the heart chambers and valves. - **Bronchial Breath Sounds:** - Heard over the larynx and trachea. - High-pitched, harsh \"blowing\" sounds. - Expiration sound longer than inspiration. - **Adventitious Breath Sounds:** - Abnormal sounds heard over the lungs (e.g., wheezes, crackles). **Infection Control & Prevention** **First Line of Defense:** - **Skin: Acts as the primary barrier against infections.** **N95 Respirators:** - **Do not protect against:** - **Oxygen-deficient atmospheres** - **Chemical vapors and gases** **1. Stages of Infection** - **Incubation Period**: Time between pathogen invasion and appearance of symptoms. - **Prodromal Stage**: Most infectious stage. - **Full Stage**: Symptoms are evident (localized or systemic). - **Convalescent Stage**: Recovery phase. **2. Types of Infections** - **Endogenous**: Infection from microbial life within the person. - **Exogenous**: Infection acquired from outside the host. - **Iatrogenic**: Infection due to a treatment or diagnostic procedure. - **Healthcare-Associated Infections (HAIs)**: Acquired in a hospital, possibly from surgical sites, medical devices, bloodstream infections, or bacteria like *C. diff*. **3. Chain of Infection** - **Infectious Agent** - **Reservoir**: Where the virus lives. - **Portal of Exit**: How it leaves (e.g., GI tract). - **Transmission Means**: Direct, indirect, airborne, etc. - **Portal of Entry**: Same as the exit. - **Susceptible Host**: Where it resides (humans, objects, etc.). **4. Infection Response** - **Inflammation**: Redness, swelling, heat. - **Vascular Phase**: Vessels constrict, then dilate with increased blood flow. - **Cellular Phase**: WBCs (especially neutrophils) engulf the pathogen. **5. Laboratory Indicators of Infection** - Elevated **WBC count** (normal: 5,000-10,000). - **Increased ESR** (erythrocyte sedimentation rate). - Pathogens detected in sputum, urine, or blood. **6. Personal Protective Equipment (PPE) Guidelines** - **Donning Order**: Wash hands, gown, mask, goggles, gloves. - **Doffing Order**: Gloves, gown, goggles, mask, wash hands. **7. Precaution Categories** - **Airborne**: TB, chickenpox, measles, shingles. - **Droplet**: Influenza, pneumonia, pertussis. - **Contact**: MRSA, VRE, MDRO, ESBL. **8. Hand Hygiene (WHO 5 Moments)** - Before patient contact. - Before aseptic procedures. - After body fluid exposure. - After patient contact. - After touching patient surroundings. **Nursing Practice and Education** **1. Historical Nursing Figures** - **Florence Nightingale**: Founder of modern nursing, established the first training school for nurses. - **Clara Barton**: Founder of the American Red Cross. - **Lillian Wald**: Founder of public health nursing. - **Mary Elizabeth Mahoney**: First African American nurse. **2. Nursing Theories** - **Dorothea Orem**: Self-Care Theory. - **Sister Callista Roy**: Adaptation Theory. **3. Nursing Competencies** - **Cognitive**: Critical thinking and decision-making. - **Technical**: Proficiency in clinical skills. - **Interpersonal**: Effective communication with patients. - **Ethical/Legal**: Understanding nursing ethics and legalities. **4. Nursing Education** - **Diploma**: 3-year hospital-based program. - **Associate degree (ADN)**: 2 years in community college. - **Bachelor\'s (BSN)**: 4 years. - **Master\'s (MSN)**: Advanced practice roles. - **Doctor of Nursing Practice (DNP)**: Focus on clinical practice. **5. Professional Organizations** - **American Nurses Association (ANA)**: Focuses on ethics and public policy. - **National League for Nurses (NLN)**: Open to all in nursing. - **American Association of Colleges of Nursing (AACN)**: Represents BSN and higher degree programs. **Communication and Safety in Nursing** **1. Therapeutic Communication** - **Phases**: - **Orientation**: Establish goals with patient. - **Working**: Patient actively participates. - **Termination**: Concludes at discharge or end of shift. - **SBAR** (Situation, Background, Assessment, Recommendation): Used for information handoffs between nurses. **2. Safety Protocols** - **Near Misses**: Incidents where harm could have occurred but didn't. - **Sentinel Events**: Incidents resulting in death or serious injury. - **Fire Safety** (Code Red): Rescue, Alarm, Contain, Evacuate (RACE). - **Restraints**: Must be ordered; include physical (e.g., wrist restraints, side rails) and chemical restraints. **3. Fall Prevention** - **Orthostatic Hypotension**: A drop in BP when standing, particularly in the elderly. - **Best Safety Practice**: Keep the bed in the lowest position. **Patient Hygiene and Care** **1. Oral Health** - **Caries**: Cavities. - **Gingivitis**: Inflammation of the gums. - **Halitosis**: Bad breath. - **Glossitis**: Inflamed tongue due to vitamin B deficiency. **2. Common Skin and Hair Conditions** - **Alopecia**: Hair loss. - **Pediculosis**: Lice infestation. **3. Incontinence and Infection** - **Bacterial Vaginosis**: Abnormal vaginal discharge due to infection. - **Pelvic Inflammatory Disease**: Infection of reproductive organs. **Mobility and Activity** **1. Body Systems and Movement** - **Muscular System**: - **Skeletal**: Facilitates body movement. - **Cardiac**: Controls the heartbeat. - **Smooth**: Involuntary organ and blood vessel movements. **2. Effects of Immobility** - **Cardiovascular**: Risk of orthostatic hypotension and venous stasis. - **Respiratory**: Increased risk of atelectasis and pneumonia. - **Musculoskeletal**: Atrophy, contractures, and osteoporosis. - **Skin**: Increased risk of pressure ulcers. - **Psychosocial**: Depression, apathy, and sensory deprivation. **3. Exercise Types** - **Isotonic**: Muscle shortening with movement (e.g., walking). - **Isometric**: Muscle contraction without movement (e.g., holding a position). - **Isokinetic**: Muscle contraction with resistance (e.g., weight training). **Chapter 24 Vital Signs Overview:** **Vital Signs Terminology and Procedures** **Key Terms** - **Afebrile**: Without fever. - **Febrile**: Fever present. - **Apnea**: Absence of breathing. - **Bradypnea**: Decreased respiratory rate. - **Tachypnea**: Rapid breathing. - **Orthopnea**: Difficulty breathing when lying down. - **Eupnea**: Normal breathing. - **Pulse Deficit**: Difference between apical and radial pulse rates. - **Hypertension**: Blood pressure above 130/80 mmHg. - **Hypotension**: Low blood pressure. - **Orthostatic Hypotension**: Blood pressure drop with position changes (lying to standing). - **Bradycardia**: Heart rate below 60 bpm. - **Tachycardia**: Heart rate over 100 bpm. - **Pyrexia**: Fever. - **Pulse Amplitude**: Force or quality of the pulse. - **Key Vital Signs:** - Temperature - Pulse - Respiration Rate (RR) - Blood Pressure (BP) - **5th Sign: Pain** - **Frequency of Assessment:** - **q4h:** For patients with changes in temperature, BP, pulse, or RR (especially in critical care) - **Monthly:** For patients in long-term care (LTC) - **Daily:** For LTC patients covered under Medicare A (discharged from hospital, Medicare pays) **Temperature:** - **Normal Range (Surface Body):** 96.7°F - 100.5°F - **Control Mechanism:** - Hypothalamus regulates core body temperature via the thermoregulatory set point. - **Heat Production:** - Metabolism is the primary source of heat. - Hypothalamus triggers shivering and piloerection ("goose bumps") to generate heat. - **Heat Loss:** - The skin is the main source of heat loss. - Arteriovenous shunts open to release heat and close to retain heat. - **Circadian Rhythm:** - Temperature is lower in the morning, cools down between 4-8 PM. - **Temperature Terms:** - **Afebrile:** Without fever. - **Febrile:** With fever; recommend 3,000 mL/day of fluid intake. - **Hyperpyrexia:** Fever ≥ 106°F (medical emergency). - **FUO:** Fever of unknown origin. - **Neurogenic Fever:** Caused by hypothalamus damage (trauma, bleeding, pressure). - **Normal Temperature by Location:** - **Oral:** 98.6°F - **Rectal:** 99.5°F (most accurate) - **Axillary:** 97.7°F - **Tympanic (Ear):** 99.5°F - **Temporal Artery:** 98.6°F - **Effects of Fever:** - Loss of appetite, headache, hot/dry skin, flushed face, thirst, fatigue. - **Treatment:** Antipyretic drugs (aspirin, ibuprofen, acetaminophen). - **Hypothermia:** - Body temperature \< 95°F. - At-risk groups: alcoholics, malnourished individuals, newborns. **Vital Sign Ranges** - **Normal BP**: 120/80 mmHg. - **Normal Pulse Rate**: 60-100 bpm. - **Normal Respiratory Rate**: 12-20 breaths per minute. - **Normal Oxygen Saturation**: 95-100%. - **Normal Temperature**: - Oral: 97.7-99.5°F. - Tympanic: 98.2-100°F. - Axillary: 96.7-98.5°F. - Rectal: 98.7-100.5°F. **Sites for Detecting Pulse** - **Common Sites**: Carotid (1 at a time), brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis. **Factors Affecting Vital Signs** - **Body Temperature**: Influenced by circadian rhythms, age, gender, activity, health status, environment, and metabolism. - **Respiratory Rate**: Affected by tissue demands (e.g., exercise) and the respiratory centers in the medulla and pons. **Pulse Pressure** - The difference between systolic and diastolic blood pressure. **Steps for Measuring Vital Signs** 1. **Vital Sign Order**: Temperature (T), Pulse (P), Respirations (R), Blood Pressure (BP), Pain Level, Oxygen Saturation (O2SAT). 2. **Measuring Apical Pulse**: Locate the left midclavicular line, 5th intercostal space. **Pulse:** - **Normal Pulse Rate:** 60-100 bpm. - **Tachycardia:** 100-180 bpm. - **Bradycardia:** \ - **Pulse Rate:** Number of pulsations per minute at a peripheral artery or apex of the heart. - **Doppler Ultrasound:** Used for difficult-to-palpate/auscultate pulses. - **Pulse Amplitude:** - **0:** Absent, unable to palpate. - **+1:** Diminished, weaker than expected. - **+2:** Normal, expected. - **+3:** Bounding. - **Pulse Sites:** - **Temporal:** Side of the head. - **Carotid:** Neck (emergency assessment). - **Brachial:** Inner elbow (for infants). - **Radial:** Wrist. - **Femoral:** Groin. - **Popliteal:** Behind the knee (usually 10-40 mmHg higher). - **Dorsalis Pedis:** Top of foot. - **Posterior Tibial:** Inner ankle. - **Pulse Deficit:** - Difference between apical and radial pulse rates. Should be equal; if unequal, apical \ radial. **Respirations:** - **Normal Respiratory Rate:** 12-20 breaths/min. - **Eupnea:** Normal, unlabored breathing. - **Dyspnea:** Difficulty breathing. - **Orthopnea:** Difficulty breathing while lying down. - **Abnormal Respiratory Patterns:** - **Tachypnea:** \> 25 breaths/min (fever, anxiety, exercise, respiratory disorders). - **Bradypnea:** \< 10 breaths/min (medication depression, brain damage). - **Hyperventilation:** Increased rate and depth (fear, exercise, diabetic ketoacidosis). - **Hypoventilation:** Decreased rate and depth (drug overdose). - **Cheyne-Stokes:** Periods of deep, rapid breathing followed by apnea (drug overdose, heart or renal failure). - **Biot's Respirations:** Irregular, shallow breaths alternating with apnea (brain damage). **Blood Pressure (BP):** - **Normal BP:** 120/80 mmHg. - **Pre-hypertension:** 120-139/80-89 mmHg. - **Hypertension (HTN):** ≥140/90 mmHg. - **Primary HTN:** No known cause (elevated systolic and diastolic). - **Secondary HTN:** Caused by another condition. - **Medications:** - **Diuretics:** Decrease fluid. - **Beta-blockers:** Decrease cardiac output. - **Vasodilators & Calcium Channel Blockers:** Decrease peripheral vascular resistance. - **ACE Inhibitors:** Prevent vasoconstriction and reduce circulating fluid volume. - **BP Terms:** - **Systolic Pressure:** Top number; ventricles contract. - **Diastolic Pressure:** Bottom number; ventricles relax. - **Pulse Pressure:** Difference between systolic and diastolic pressures. - **Orthostatic Hypotension:** Systolic BP decreases by 20 mmHg and diastolic by 10 mmHg. - **Korotkoff Sounds:** Sounds heard during BP measurement due to changes in blood flow, audible with a stethoscope. **Pain Assessment:** - **Numeric Pain Scale:** 1-10 scale. - **WONG/BAKER Faces Scale:** Used for toddlers, visual scale from happy to sad faces. - **FLACC Scale:** Nonverbal pain cues from newborns/infants (Face, Legs, Activity, Cry, ability to consol). **CHAPTER 25: PHYSICAL ASSESSMENT** **Health History (Health HX)** - **Includes**: Name, address, date of birth (DOB), marital status, occupation, allergies. **Types of Assessments** 1. **Comprehensive Assessment** - When: At patient's first hospital entry. - Purpose: Establish baseline for comparison. 2. **Ongoing Assessment** - When: Follow-up to monitor changes (positive or negative). 3. **Focused Assessment** - When: Specific body parts/problems. 4. **Emergency Assessment** - When: To determine potentially fatal situations. **Physical Examination Order** 1. **Inspect**: Visual examination. 2. **Auscultate**: Listening to body sounds with a stethoscope. 3. **Percuss**: Tapping body areas to assess underlying structures. 4. **Palpate**: Feeling body parts with hands to assess tenderness, texture, etc. **Skin Assessment** - **Erythema**: Redness; causes include sunburn, inflammation, fever, allergic reactions. - **Cyanosis**: Blue discoloration; indicates difficulty in breathing. - **Jaundice**: Yellowing; due to bilirubin buildup. - **Pallor**: Paleness; indicates decreased circulation. - **Vitiligo**: Patchy depigmentation. - **Tan/Brown**: Overexposure to the sun. - **Ecchymosis**: Purple discoloration; blood in subcutaneous tissue. - **Petechiae**: Small red hemorrhagic dots from capillary bleeding. **Types of Lesions** 1. **Primary Lesions**: Arise from normal skin. - **Macule/Patch**: Flat, non-palpable (e.g., freckle). - **Papule/Plaque**: Elevated, with borders (e.g., wart, psoriasis). - **Vesicle/Bulla**: Fluid-filled (e.g., herpes zoster, blister). - **Wheal**: Elevated, no fluid (e.g., insect bite, hive). 2. **Secondary Lesions**: Result from changes to primary lesions. - **Nodule/Tumor**: Elevated mass, deeper into dermis (e.g., carcinoma). - **Pustule**: Pus-filled (e.g., acne, blackheads). - **Cyst**: Encapsulated and fluid-filled. **Other Skin Considerations** - **Diaphoresis**: Excessive sweating. - **Turgor**: Skin elasticity. - **Edema**: Excessive fluid in tissues; can be pitting (indentation that takes time to return) or non-pitting. **Nails** - **Onycholysis**: Painless separation of nail plate from bed. - **Clubbing**: Sign of lack of oxygen. **Hair/Scalp** - **Alopecia**: Balding. - **Hirsutism**: Excessive hair on face or body. - **Lanugo**: Fine hair on infants. **Head and Face** - **Periorbital Edema**: Swelling around the eyes. - **Ptosis**: Drooping of upper eyelids. - **Entropion**: Inward turning of lower lids and lashes. - **Mydriasis**: Dilation of pupils. - **Miosis**: Constriction of pupils. - **PERRLA**: Pupils Equal, Round, Reactive to Light and Accommodation. **Lungs/Breath Sounds** - **Bronchial**: Normal; over trachea; high-pitched. - **Bronchovesicular**: Normal; over anterior chest and intercostal areas. - **Vesicular**: Normal; over peripheral lungs. - **Adventitious Sounds**: Abnormal. - **Wheeze**: High-pitched; air through narrow airways. - **Rhonchi**: Low-pitched, snoring or coarse; air through/around secretions. - **Crackles**: Popping, bubbling; air through fluid/secretions. - **Stridor**: High-pitched, hard; narrowing of larynx/trachea. - **Friction Rub**: Rubbing, grating; inflamed pleura rubbing against chest wall. **Cardiovascular and Peripheral Vascular Systems** - **S3**: \"Third sound\"; follows S2 (\"lub-dub-dee\"); normal in children and young adults; abnormal in middle-aged and older adults. - **S4**: Normal in older adults; abnormal in younger adults. **Assessing the Abdomen** - **Quadrants**: Right Lower Quadrant (RLQ), Right Upper Quadrant (RUQ), Left Upper Quadrant (LUQ), Left Lower Quadrant (LLQ). **Mental Status** - **Assessment**: Ask about time, place, person, situation. - **Glasgow Coma Scale**: Assess Level of Consciousness (LOC). - **Awake and Alert** - **Lethargic**: Drowsy but responsive. - **Stuporous**: Unconscious, responds to stimuli. - **Comatose**: No response. **Speech** - **Aphasia**: Inability to comprehend or express speech. - **Expressive Aphasia**: Difficulty getting words out (e.g., stroke). - **Receptive Aphasia**: Difficulty understanding spoken words. **Infectious Agents** - **Bacteria**: - **Gram-positive**: Thick cell wall, stains violet, responsive to antibiotics. - **Gram-negative**: Complex cell wall, does not stain. - **Aerobic**: Requires oxygen. - **Anaerobic**: Can live without oxygen. - **Viruses**: Smallest microorganisms, visible only with an electron microscope. - **E. coli**: Normally harmless in the intestinal tract, can cause UTIs if migrated. **Transmission of Infections** - **Carriers**: Individuals who harbor pathogens without showing symptoms. - **Nosocomial**: Infections acquired in hospital settings. - **Transmission-based Precautions**: - **Vehicle Transmission**: Microorganisms transferred via contaminated items. - **Direct Contact Transmission**: Body surface-to-surface contact. - **Droplet Transmission**: Exposure to secretions from coughing, sneezing, etc. - **Airborne Transmission**: Pathogens suspended in the air. **Assessing Risk for Falling (DAME)** - **D**: Drug and alcohol use. - **A**: Age-related physiological status. - **M**: Medical problems. - **E**: Environment. **Sensory Systems** - **Labyrinthine Sense**: Provides sense of position, orientation, and movement. - **Proprioceptor**: Informs the brain of limb or body part location due to joint movements. **Application of Body Mechanics** - **Lifting**: - Flex knees, keep close to the object, use internal girdle. - Break heavy loads into smaller portions; lift limits of 35 lbs. - Push rather than pull when possible. **Positions** - **Fowler's Position**: Semi-sitting, bed elevated 45 to 60 degrees; aids cardiac and respiratory function. - **Supine or Dorsal Recumbent Position**: Flat on back with head and shoulders slightly elevated. - **Prone Position**: Lying on the abdomen with head turned to the side. **Postural Reflexes** - **Definition**: Automatic movements that maintain body position and equilibrium, whether at rest or moving. **CHAPTER 10: NURSING PROCESS** **Critical Thinking** - **Definition**: Reasoning both inside and outside of the clinical setting. - **Components**: - **Clinical Reasoning**: Thinking about patient care issues, recognizing problems, and solving them using cognitive skills. - **Clinical Judgment**: The outcome of critical thinking or clinical reasoning. **Five Rights of Clinical Reasoning** 1. Right Cues 2. Right Action 3. Right Patient 4. Right Time 5. Right Reason **Problem Solving** 1. **Trial and Error Problem Solving** - Testing multiple solutions until finding one that works. 2. **Scientific Problem Solving** - A systematic, seven-step process: - Identify the problem - Collect data - Formulate a hypothesis - Plan action - Test the hypothesis - Interpret results - Evaluate 3. **Creative Thinking** - Involves imagination, intuition, and spontaneity to understand the art of nursing. **Nursing Process Overview** - **Published By**: Walsh (first comprehensive book) - **Five Steps**: 1. **Assessment**: Determine patient needs. 2. **Diagnosis**: Identify health problems (actual and potential). 3. **Planning/Outcome Identification**: Set expected outcomes and plan patient care. 4. **Implementation**: Execute the care plan. 5. **Evaluation**: Assess the results of nursing care. **Framework of the Nursing Process** 1. **Assessing**: Systematically collect patient data. 2. **Diagnosing**: Identify patient strengths and problems. 3. **Planning**: Develop an individualized care plan with goals and interventions. 4. **Implementing**: Execute the care plan. 5. **Evaluating**: Evaluate the effectiveness of the care plan in achieving patient goals. **Characteristics of the Nursing Process** - **Systematic**: Each step relies on the accuracy of the previous one. - **Encourages Collaboration**: Helps patients use their strengths to meet their needs. **Documenting the Nursing Process** - **Requirements**: Accurate, concise, timely, and relevant documentation. - **Legal Aspect**: If nursing action was not documented, it was considered not performed. **CHAPTER 11: NURSING PROCESS (ASSESSING)** **Assessment Overview** - **Purpose**: Establish the database by interviewing the patient to obtain a nursing history. - **Medical Assessment**: Targets data pointing to pathologic conditions. - **Nursing Assessment**: Focuses on patient responses to health problems. **Characteristics of Nursing Assessment** 1. **Purposeful**: Identify the type (comprehensive, focused, emergency, time-lapsed). 2. **Prioritized**: Obtain important information first. 3. **Complete**: Gather all data needed to understand and plan care. 4. **Systematic**: Use a methodical approach to avoid missing information. 5. **Factual and Accurate**: Ensure information is precise; consult others if biased. 6. **Relevant**: Record pertinent data concisely. **Types of Nursing Assessments** 1. **Initial Assessment**: Establishes a complete database for problem identification and care planning. 2. **Focused Assessment**: Gathers data about a specific problem; part of ongoing data collection. 3. **Emergency Assessment**: Identifies life-threatening problems. 4. **Time-Lapsed Assessment**: Compares current status to baseline data; reassesses and revises care. 5. **Quick Priority Assessment**: Short, prioritized assessments to gather crucial information quickly. **Collecting Data** - **Subjective Data**: Information perceived only by the affected person. - **Objective Data**: Observable and measurable data seen, heard, felt, or measured by someone other than the person. **Methods of Data Collection** 1. **Nursing History**: Captures and records patient uniqueness for tailored care. 2. **Physical Assessment**: Examines body systems using a head-to-toe format. - **Methods**: - Inspection - Palpation - Percussion - Auscultation **Patient Interview** - **Phases**: - Preparatory Phase - Introduction - Working Phase - Termination **CHAPTER 12: NURSING PROCESS: DIAGNOSIS** **Purpose of Diagnosis** - **Identify Responses**: How individuals, groups, or communities respond to actual or potential health and life processes. - **Etiologies**: Factors contributing to or causing health problems. - **Resources/Strengths**: Identifying what can be utilized to prevent or resolve problems. **Types of Diagnoses** 1. **Nursing Diagnosis** - **Definition**: Clinical judgment about individual, family, or community responses to actual or potential health problems. - **Components**: - **Problem**: Describes the health state or problem. - **Etiology**: Factors related to the problem (cause or contributing). - **Defining Characteristics**: Subjective and objective data indicating the problem. - **Scope**: Problems nurses can treat independently (e.g., activity, pain, comfort, tissue integrity, perfusion). - **Dynamic**: Changes as the patient's response changes. 2. **Medical Diagnosis** - **Definition**: Identifies the disease and is managed by the physician. - **Characteristics**: Remains the same as long as the disease is present. 3. **Collaborative Problems** - **Primary Responsibility**: Nurses. - **Characteristics**: Involves potential complications and requires delegated medical orders. 4. **Types of Nursing Diagnoses** - **Actual Nursing Diagnoses**: Four components---Label (NANDA), Definition, Defining Characteristics, Related Factors. - **Risk Nursing Diagnoses**: Clinical judgment about vulnerability to a problem. - **Possible Nursing Diagnoses**: Suspected problems needing further data. - **Wellness Diagnoses**: Desire for a higher level of wellness. - **Syndrome Nursing Diagnosis**: Cluster of diagnoses predicted due to certain events or situations (e.g., post-trauma). **CHAPTER 13: PLANNING** **Purpose of Planning** - **Partnership**: Work with the patient and family. - **Activities**: - Establish priorities. - Write expected outcomes. - Plan interventions. - Communicate the plan of care. **Expected Outcomes** - **Definition**: Specific, measurable criteria to evaluate goal achievement. - **Purpose**: Design a plan of care to achieve prevention, wellness, recovery, and coping. **Types of Outcomes** - **Long Term**: Achieved over more than a week. - **Short Term**: Achieved within a short period. - **Psychomotor**: Achievement of new skills. - **Clinical**: Expected health status at certain points. - **Quality of Life**: Factors affecting enjoyment of life and personal goals. **Measurable Patient Outcomes** - **Subject**: The patient or a part of the patient. - **Verb**: Action the patient will perform (e.g., Define, Prepare, Describe). - **Conditions**: Specific circumstances for achieving the outcome. - **Performance Criteria**: Observable, measurable terms describing expected behavior. - **Target Time**: Specific date and time for achieving the outcome. **Writing Goals and Outcomes** - **S**: Specific - **M**: Measurable - **A**: Attainable - **R**: Realistic - **T**: Time-bound **CHAPTER 14: IMPLEMENTING** **Purpose of Implementation** - **Action**: Carry out planned actions to help the patient achieve health outcomes. - **Tasks**: - Determine new or continuing needs. - Promote self-care. - Assist in achieving outcomes. **Delegation** - **Definition**: Transfer of responsibilities while retaining accountability. - **Considerations**: Supervision and communication with Unlicensed Assistive Personnel (UAP). Ensure clarity and adherence to state policies to prevent patient risk. **CHAPTER 15: EVALUATION** **Purpose of Evaluation** - **Definition**: Assess the patient's achievement of outcomes and modify care as needed. - **Relation to Other Steps**: Starts in the planning step; core to reassessing and planning according to patient progress.