Final Exam Review Practicum Lab PDF

Module 2 Nurse’s Role in Health Assessment & Bedmaking ## Health Assessment Overview - Health assessment is a comprehensive process involving nursing history, behavioral and physical examination, and cultural assessment - Purposes include gathering baseline data, confirming nursing diagnoses, makin...

Module 2 Nurse’s Role in Health Assessment & Bedmaking ## Health Assessment Overview - Health assessment is a comprehensive process involving nursing history, behavioral and physical examination, and cultural assessment - Purposes include gathering baseline data, confirming nursing diagnoses, making clinical judgments, and evaluating care outcomes - Assessment involves critical thinking to identify, diagnose, and treat patient responses to health/ illness ## Types of Assessments - Initial Assessment - Focused Assessment - Emergent Assessment - Comprehensive Health History ## Assessment Techniques ### Inspection - First technique to be performed - Requires careful observation using sight and smell - Needs good lighting and proper patient exposure - Involves comparing right and left sides - Uses instruments like otoscope, ophthalmoscope, and penlight ### Palpation - Uses sense of touch to confirm inspection findings - Requires slow and systematic approach - Includes light versus deep palpation - Uses specific parts of hand for different assessments: - Fingertips for fine tactile discrimination - Finger/thumb grasp for organ assessment - Dorsa of hands for temperature - Base of fingers for vibration ### Percussion - Involves tapping skin to assess underlying structures - Produces characteristic sounds indicating location, size, and density - Types include direct and indirect percussion - Sounds include resonance, hyperresonance, tympany, dullness, and flat ### Auscultation - Uses stethoscope to detect sounds from heart, blood vessels, lungs, and abdomen - Requires proper stethoscope fit and quality - Diaphragm used for high-pitched sounds - Bell used for low-pitched sounds - Focuses on intensity, pitch, duration, quality, and location ## Bed Making Procedures ### General Principles - Maintain clean, comfortable, wrinkle-free beds - Follow medical asepsis principles - Avoid shaking linens or placing them on floor - Use proper body mechanics - Raise bed to appropriate height - Check frequently for soiled linens ### Occupied Bed Procedure 1. Gather equipment and perform hand hygiene 2. Adjust bed height and ensure patient comfort 3. Remove and dispose of soiled linens properly 4. Position patient appropriately 5. Make bed in sections using fan fold technique 6. Ensure patient comfort and safety ### Unoccupied Bed Types - Open bed: top covers folded back for easy access - Closed bed: covers drawn up to head for new admissions - Surgical/recovery bed: modified for easy patient transfer ## Cultural and Social Considerations - Assessment includes emotional, intellectual, physical, psychosocial, spiritual, and cultural dimensions - Requires patience and dedication to comprehensiveness - Focus on patient-oriented rather than disease-oriented approach ## Health Promotion - WHO defines as enabling people to improve their health - Five principles include: - Population-wide focus - Action on social determinants - Diverse methods - Public participation - Healthcare provider support ## Data Collection ### Types of Data - Primary Sources: Direct patient information - Secondary Sources: Medical records, diagnostic reports - Tertiary Sources: Literature and nursing experience ## Anatomical Terms and Planes - Standardized descriptions for assessment findings - Planes include sagittal, coronal, horizontal/transverse, and median - Used to describe body structures, surfaces, and movement This comprehensive framework ensures systematic and thorough patient assessment while maintaining professional standards and patient comfort. Module 3 Lifts, Transfers, Body Mechanics, & Mobility Aids ## Impaired Mobility and Safety - Impaired mobility due to muscle weakness, paralysis, or poor coordination increases fall risk - Immobilization can lead to additional physiological and emotional hazards - Healthcare organizations typically implement no-lift policies to prevent work-related injuries - Safe patient handling programs include: - Ergonomic assessments - Patient assessment criteria - Special transfer equipment - Safety protocols ## Body Mechanics and Safe Handling - Healthcare workers should: - Arrange adequate help before transfers - Use proper equipment (adjustable beds, ceiling lifts, slide sheets) - Encourage patient participation - Maintain proper body alignment - Use legs instead of back for lifting - Coordinate team efforts when moving patients - Back injuries often result from improper bending and lifting - Always assess patient weight and determine needed assistance before repositioning ## Fall Prevention - Implementation strategies include: - Clear communication - Proper use of sensory aids - Regular comfort rounds - Accessible call bells and walking aids - Non-slip footwear - Clear pathways - Patient and family education ## Mobility Aids ### Walkers - Provides maximum stability - Should align with patient's waist crease when standing - Elbows should flex 15-30 degrees when holding handgrips - Available with wheels for easier advancement ### Canes - Provides less support than walkers - Should be kept on stronger side of body - Length measured from greater trochanter to floor - Three-step walking process: 1. Place cane forward 2. Move weaker leg to cane 3. Advance stronger leg past cane ### Crutches - Types: double adjustable or forearm crutch - Proper fitting includes: - 2-3 finger widths from axilla - Correct handgrip placement - Tips positioned 5cm lateral and 10-15cm anterior to shoes - Special techniques for: - Sitting and standing - Ascending stairs (unaffected leg leads) - Descending stairs (affected leg leads) ## Transfer Techniques ### Patient Assessment Before Transfer - Evaluate: - Joint mobility and range of motion - Strength and coordination - Balance and proprioception - Activity tolerance - Vital signs - Fall risk ### Transfer Methods - Bed Positioning: - Use drawsheet for moving up in bed - Proper body mechanics with weight shifting - Coordinate movements with patient - Bed to Chair Transfer: - Position chair on patient's strong side - Use transfer belt - Ensure non-slip footwear - Support patient's weaker leg - Guide patient to pivot and sit ### Mechanical Aids - Always require two people - One person operates while second spots - Requires organization-specific training - Include sit-to-stand devices and Hoyer lifts ## Special Considerations for Older Adults - Progressive bone mass loss - Reduced muscle tone and contractility - Decreased strength and endurance - Slower walking pace - Reduced overall energy Module 4 ## Health Assessment Overview - Assessment is a holistic process including emotional, intellectual, physical, psychosocial, spiritual, and cultural dimensions - Comprises nursing history, behavioral/physical examination, and cultural assessment - Serves to gather baseline data, confirm nursing diagnoses, make clinical judgments, and evaluate care outcomes ### Types of Assessments - Initial Assessment - Focused Assessment - Emergent Assessment - Comprehensive Health History ### Assessment Techniques 1. Inspection - First technique to be used - Requires good lighting and careful observation - Involves comparing right and left sides - Uses tools like otoscope, ophthalmoscope, penlight 2. Palpation - Uses sense of touch - Requires slow and systematic approach - Includes light versus deep palpation - Uses specific parts of hand for different assessments 3. Percussion - Involves tapping skin to assess underlying structures - Produces characteristic sounds - Types: Direct and indirect percussion - Sounds include resonance, hyperresonance, tympany, dullness, flat 4. Auscultation - Uses stethoscope to detect body sounds - Diaphragm for high-pitched sounds - Bell for low-pitched sounds - Requires perfect seal and elimination of artifacts ## Bed Making Procedures ### General Principles - Maintain clean, comfortable, wrinkle-free beds - Follow medical asepsis principles - Avoid shaking linens or placing them on floor - Check frequently for soiling, especially with diaphoretic or incontinent patients ### Occupied Bed Procedure 1. Preparation - Gather equipment - Practice hand hygiene - Adjust bed height to waist level - Ensure patient comfort 2. Execution - Remove soiled linens carefully - Cover patient appropriately - Make bed in sections - Use fan fold technique - Ensure proper positioning of patient ### Unoccupied Bed Types - Open bed: top covers folded back for easy access - Closed bed: covers drawn up to head, used for new admissions - Surgical/recovery bed: modified for easy patient transfer ## Health Promotion - WHO definition: Process of enabling people to increase control over and improve their health - Five principles including population involvement and social determinants focus - Emphasizes social and environmental interventions ## Anatomical Terms and Planes - Standardized descriptions for assessment findings - Planes: Sagittal, Coronal, Horizontal/Transverse, Median - Used to describe body structures and movement ## Data Collection ### Sources - Primary: Direct patient information - Secondary: Client charts, diagnostic reports - Tertiary: Literature and nursing experience ## Safety Considerations - Proper body mechanics during bed making - Clean equipment and environment - Standard precautions - Transmission-based precautions - Regular hand hygiene ## Professional Practice Requirements - Full uniform required - Regular attendance - Pre-reading of weekly content - Communication regarding absences - Proper documentation of findings This comprehensive framework ensures systematic patient care delivery while maintaining professional standards and patient safety. Vital signs and assessment ## Overview of Vital Signs Vital signs are essential bodily functions that maintain life, including: - Body temperature - Pulse - Blood pressure - Respiratory rate - Oxygen saturation - Pain (considered the fifth vital sign) These measurements provide crucial baseline health data and are often interconnected. Nurses can take vital signs independently without a doctor's order. ## When to Take Vital Signs - On admission - According to doctor's orders or institutional practices - Before and after surgery/tests - Before, during, and after certain medications - When condition changes - When patient reports non-specific symptoms ## Body Temperature ### Normal Temperature Ranges - Average oral/tympanic: 37°C - Average rectal: 37.5°C - Average axillary: 36.5°C - Normal range: 36°C to 38°C ### Measurement Methods - Oral - Rectal - Axillary - Tympanic - Temporal artery ### Factors Affecting Temperature - Age - Exercise - Environment - Menstrual cycle - Hormonal levels - Circadian rhythm - Stress (physical/emotional) ## Pulse ### Normal Pulse Rates - Varies by age group - Adults: 50-104 beats per minute - Infants (0-28 days): 104-162 beats per minute ### Assessment Components - Rate - Rhythm - Strength - Equality ### Pulse Sites - Temporal - Carotid - Apical - Brachial - Radial - Ulnar - Femoral - Popliteal - Posterior tibial - Dorsalis pedis ## Respiratory Rate ### Normal Ranges - Adults: 12-20 breaths per minute - Varies by age group ### Assessment Components - Rate - Rhythm - Depth - Oxygen saturation - Type of breathing (abdominal, diaphragmatic, intercostal) ## Blood Pressure ### Normal Ranges - Adults: Less than 140/90 mmHg - Average: 120/80 mmHg ### Factors Affecting Blood Pressure - Age - Ethnicity - Gender - Stress - Position - Site - Pain - Medical conditions - Medications - Smoking - Weight ## Pain Assessment ### OPQRSTUV Assessment Method - O: Onset/Origin - P: Provocation/Palliation - Q: Quality - R: Region/Radiation - S: Severity - T: Timing - U: Understanding - V: Value ### Pain Management #### Non-pharmacological Interventions - Relaxation - Distraction - Music - Acupuncture - Therapeutic touch - TENS #### Pharmacological Interventions - Analgesics - Patient-controlled analgesics - Topical/local analgesics - Epidural - Sucrose (for infants) ### WHO Pain Management Ladder 1. Mild pain (1-3/10): Non-opioid analgesics 2. Moderate pain (4-6/10): Weak opioids 3. Severe pain (7-10/10): Strong opioids ## Documentation - Record in graphic flow sheets and/or progress notes - Use electronic medical records (EMR) - Document accompanying symptoms - Record interventions - Track vital signs as outcomes Module 5 Integumentary Assessment Skin, Hair and Nails ## Overview The integumentary system consists of skin, hair, and nails, with skin serving as the body's first line of defense. The skin has three layers: - Epidermis: shields underlying tissue - Dermis: contains collagen, nerves, blood vessels, sweat glands, sebaceous glands, and hair follicles - Subcutaneous: contains blood vessels, nerves, lymph, and fat cells ## Functions of Skin - Protection - Secretion - Excretion - Temperature regulation - Sensation ## Assessment Components ### Subjective Assessment Key areas to assess include: - Previous skin disease history - Changes in pigmentation - Mole changes - Skin condition - Pruitus - Bruising - Medications - Hair loss - Nail condition changes - Environmental exposures - Self-care behaviors ### Age-Specific Considerations #### Infants & Children - Birthmarks - Jaundice - Allergic rashes - Diaper rash - Viral rash - Mongolian spots - Stork bites - Millia #### Adolescents - Acne #### Older Adults - Dry skin - Skin thinning - Senile lentigines - Skin tags - Delayed wound healing - Mobility issues #### Pregnant Women - Striae - Linea nigra - Chloasma ### Objective Assessment #### Equipment Needed - Strong direct lighting - Small centimeter ruler - Penlight - Gloves #### Assessment Parameters 1. Color - General pigmentation - Freckles - Moles - Birthmarks 2. Temperature - Bilateral assessment - Check for hypothermia/hyperthermia 3. Moisture - Perspiration - Diaphoresis - Dehydration 4. Texture and Thickness - Smooth and firm texture - Location-dependent thickness 5. Edema - Pitting vs. Non-pitting - Four-point scale 6. Mobility and Turgor 7. Vascularity and Bruising ## Skin Lesions ### ABCDE Assessment for Pigmented Lesions - Asymmetry - Border - Color - Diameter - Elevation and Evolution ### Types of Lesions - Macule: Flat color change (