NUR 235 Week 1.pdf

1 Week 1 Outline: Communication, Teamwork, Collaboration, and Vital Signs A. Communication a. A process by which information is exchanged between individuals through a com...

1 Week 1 Outline: Communication, Teamwork, Collaboration, and Vital Signs A. Communication a. A process by which information is exchanged between individuals through a common system of symbols, signs or behavior b. Desired outcomes: build rapport, transmit messages, patient safety, therapeutic communication c. The Interview i. Phases: Intro, discussion, summary ii. Most important factor to successful interviewing: establish rapport/trust! iii. Question strategies: 1. DO: ask clear questions, ask one question at a time, allow plenty of time for replies (especially for the very young, very old, or cognitively impaired), encourage patient to be specific, be attentive to patient feelings 2. DO NOT: use technical language/medical jargon, interrupt, judge the patient, be authoritarian, ask “why” iv. Open ended Q’s: free flow, longer responses 1. Ex: What is your favorite part about nursing school? v. Close ended Q’s: precise, focused responses 1. Ex: Have you taken NUR 235 Exam 1 yet? d. Health History i. A process of collecting and documenting subjective data about the client through an interview ii. Types: 1. Comprehensive: highest level assessment, most detailed history 2. Review of Systems (ROS): gather a patient's medical history by asking a series of questions about their body systems 3. Problem-based or focused: assessment limited to patient’s main problem/complaint 4. Episodic or follow-up: limited, short term, used to monitor progress of a certain complaint or condition iii. OLD CARTS 1. Onset: when did the complaint start? 2. Location: where is the complaint felt? 3. Duration: how long has the complaint been going on?  2 4. Characteristics: sharp, stabbing, dull, cramping, aching, or shooting? 5. Alleviating/aggravating factors: what makes the complaint better or worse 6. Related symptoms OR radiating: any other issues related to chief complaint? 7. Treatment: what treatment(s) have you tried to help? 8. Severity: rate pain on scale of 1-10 with 1 being no pain and 10 being worst pain ever? B. Teamwork a. Involves a defined group structure, with team members having specific roles and responsibilities, combining individual efforts to achieve a common goal C. Collaboration a. Involves a more inclusive approach, with people working together as equals to share ideas, expertise, and resources to complete a project or task collectively b. shared accountability, shared problem solving, shared decision making, knowledge-sharing c. Barriers to collaboration: i. Lack of education ii. Lack of experience iii. Poor engagement iv. Bad communication d. Lack of collaboration leads to worse patient outcomes, poor job satisfaction, poor clinical performance e. Types of collaboration: i. Nurse-patient: collaborate regarding healthcare decisions for the patient ii. Nurse-nurse: mentoring, shared governance iii. Interorganizational: networking, sharing resources, coalitions iv. Interprofessional: partnership between health providers to make decisions D. The Interprofessional Team a. Spiritual support staff: Provides spiritual care (pastors, rabbis, priests). i. Example of when to refer: A client requests communion, or the family asks for prayer prior to the client undergoing a procedure. b. Registered dietitian: Assesses, plans for, and educates regarding nutrition needs. Designs special diets, and supervises meal preparation. i. Example of when to refer: A client has a low albumin level and recently had an unexplained weight loss.  3 c. Laboratory technician: Obtains specimens of body fluids, and performs diagnostic tests. i. Example of when to refer: A provider needs to see a client’s complete blood count (CBC) results immediately. d. Occupational therapist: Assesses and plans for clients to regain activities of daily living (ADL) skills, especially motor skills of the upper extremities. i. Example of when to refer: A client has difficulties using an eating utensil with their dominant hand following a stroke. e. Pharmacist: Provides, monitors, and evaluates medication. Supervises pharmacy technicians in states that allow this practice. i. Example of when to refer: A client is concerned about a new medication’s interactions with any of their other medications. f. Physical therapist: Assesses and plans for clients to increase musculoskeletal function, especially of the lower extremities, to maintain mobility. i. Example of when to refer: Following hip arthroplasty, a client requires assistance learning to ambulate and regain strength. g. Provider: Assesses, diagnoses, and treats disease and injury. Providers include medical doctors (MDs), doctors of osteopathy (DOs), and physician assistants (PAs). State regulations vary in their requirements for supervision of PAs by a physician (MDs and DOs). i. Example of when to refer: A client has a temperature of 39º C (102.2º F), is achy and shaking, and reports feeling cold. h. Radiologic technologist: Positions clients and performs x-rays and other imaging procedures for providers to review for diagnosis of disorders of various body parts. i. Example of when to refer: A client reports severe pain in their hip after a fall, and the provider prescribes an x-ray of the client’s hip. i. Respiratory therapist: Evaluates respiratory status and provides respiratory treatments including oxygen therapy, chest physiotherapy, inhalation therapy, and mechanical ventilation. i. Example of when to refer: A client who has respiratory disease is short of breath and requests a nebulizer treatment. j. Social worker: Works with clients and families by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and discharge. i. Example of when to refer: A client who has terminal cancer wishes to go home but is no longer able to perform many ADLs. The client’s partner needs medical equipment in the home to care for the client.  4 k. Speech-language pathologist: Evaluates and makes recommendations regarding the impact of disorders or injuries on speech, language, and swallowing. Teaches techniques and exercises to improve function. i. Example of when to refer: A client is having difficulty swallowing a regular diet after trauma to the head and neck. E. Vital Signs a. Temperature: the balance between heat the body produces and heat lost from the body to the environment. i. Normal: 36-38 C 1. Rectal temps (these are the most accurate) are usually warmer than oral or tympanic 2. Axillary temps are usually colder than oral or tympanic ii. Hypothermia: Below 35 C 1. Nursing interventions: warm environment, heated humidified oxygen, blankets, keep the head covered, continuous cardiac monitoring, prepare to resuscitate iii. Fever: above 38 C, usually not harmful until above 39 C iv. Hyperthermia: Above 40 C (very bad!!!) 1. Nursing interventions: obtain specimens before antimicrobials, fluids, rest, prevent shivering, oral hygiene, dry clothing/linens v. Factors that can affect temperature: age (very young or very old), hormones, exercise, dehydration, illness, injury, recent food or fluid intake (wait 20-30 min before taking oral temp), smoking, stress, environmental conditions vi. Types of temp readings: 1. Oral temps: for clients 4 years and older a. Place probe under the tongue in the posterior sublingual pocket lateral to the center of the lower jaw. b. No oral temp if facial trauma, mouth breathers, vomiting 2. Rectal temps: Most accurate, usually warmer than oral or tympanic a. Lay patient in Sims’ position with the upper leg flexed and insert rectal probe 2.5 to 3.5 cm (1 to 1.5 in) for an adult. b. No rectal temps if diarrhea, bleeding precautions, low platelet count, rectal disorders, infants younger than 3 months 3. Axillary temps: usually colder than oral or tympanic  5 a. Place the oral probe of the thermometer (with cover) in the center of the client’s clean, dry axilla. Lower the arm over the probe. 4. Tympanic temps: ambient temperature and excess earwax can affect readings. a. Pull the pinna of the ear up and back (for an adult) or down and back (for a child who is younger than 3 years old). b. No tympanic temps for infants younger than 3 months 5. Temporal temps: dry skin with a towel if necessary a. Hold the probe flat against the forehead and press the scan button. Continue holding the button and keeping the probe flush with the skin over the temporal artery. Then lift the thermometer and touch the probe to the skin behind the earlobe. b. Pulse: measurement of heart rate and rhythm i. Normal rate: 60-100 BPM 1. Pulse rate starts out high in infancy and gradually decreases with age ii. Tachycardia: Above 100 BPM 1. Causes: exercise, fever, heat exposure, medications (epinephrine, levothyroxine, beta2-adrenergic agonists), acute pain, changing position from lying down to standing, stress, anxiety, hypoxemia, hypovolemia, shock, heart failure, hemorrhage 2. Nursing interventions: monitor for dizziness/fatigue, protect patient from injury (may be a fall risk!) iii. Bradycardia: Below 60 BPM 1. Causes: elite athletes, hypothermia, medications (digoxin, beta-blockers, calcium channel blockers), changing position from standing to lying down, relaxation 2. Nursing Interventions: monitor for dizziness/hypotension/ALOC, protect patient from injury (may be a fall risk!) iv. Rhythm: regularity of pulse beats (a regular pulse is expected finding) v. Strength (amplitude or pulse volume): volume of blood ejected against the arterial wall with each heart contraction on a scale of 0-4. The strength of the pulsation can weaken in older adult clients due to poor circulation or cardiac dysfunction. 1. 0= impalpable and/or absent  6 2. 1+ = weak 3. 2+ = expected 4. 3+= increased 5. 4+= full and bounding vi. Equality: Peripheral pulse impulses should be symmetrical in quality and quantity on both sides of the body vii. Dysrhythmia: An irregular heart rhythm viii. Measuring pulse: Locate the radial pulse on the radial- or thumb-side of the forearm at the wrist. Place the index and middle finger of one hand gently but firmly over the pulse. Assess for rate, rhythm, amplitude, and quality. 1. If the peripheral pulsation is regular, count the rate for 30 sec and multiply by 2. If the pulsation is irregular, count for a full minute and compare the result to the apical pulse rate. 2. Measure the temporal, carotid, brachial, femoral, popliteal, posterior tibial or dorsal pedal pulses using the same technique. 3. Locate the apical pulse at the fifth intercostal space at the left midclavicular line. Place the diaphragm of a stethoscope on the chest at the fifth intercostal space at the left midclavicular line. a. If the rhythm is regular, count for 30 sec and multiply by 2. If the rhythm is irregular or the client is receiving cardiovascular medications, count for 1 full min. b. Used to assess the heart rate of an infant, checking a heart rate prior to the administration of cardiac medications, or to validate a rapid or irregular pulse c. Respirations: breaths per minute i. Also observing depth and rhythm ii. Measuring respirations: Place the client in Semi-Fowler’s position, being sure the chest is visible. Have the client rest an arm across the abdomen, or place a hand directly on the client’s abdomen. Observe one full respiratory cycle before counting. 1. Count a regular rate for 30 seconds and multiply by 2. Count the rate for 1 min if irregular, faster than 20/min, or slower than 12/min. Note depth (shallow, normal, or deep) and rhythm (regular or irregular). 2. Do not tell patient you are counting their breaths so they don’t change their breathing pattern! iii. Normal (eupnea): 12-20 iv. Bradypnea: regular, below 12  7 v. Hypoventilation: shallow breathing pattern with rate below 12 vi. Tachypnea: regular, above 20 vii. Hyperventilation: deep breathing pattern with rate above 20 viii. Hyperpnea: Respiratory rate, depth, and work of breathing are increased; common during exercise ix. Apnea: no breathing (not good) x. Dyspnea: labored breathing xi. Cheyne-Stokes: shallow breaths that progress to a normal pattern, and increased rate, then the rate begins to slow again, ending with an apneic period (regular, cyclical pattern) xii. Kussmaul: Increased respiratory rate, regular pattern, but excessively deep (metabolic acidosis) xiii. Biots (ataxic): unpredictable breathing with periods of apnea (irregular pattern) d. Pulse oximetry: measurement of the oxygen saturation (SaO2) of the blood i. Normal: 95-100% for a healthy person 1. COPD acceptable range may be as low as 88%  8 ii. Measuring pulse ox: place probe on patient’s finger, ensuring no dark nail polish/cuts on skin/excessive edema. Record reading once stable 1. Use earlobe or bridge of nose for clients who have peripheral vascular disease. 2. A disposable sensor pad can be applied to the sole of an infant’s foot. e. Blood pressure: the force the blood exerts against the walls of the arteries during cardiac muscle contraction (systole - max amount of arterial pressure) and relaxation (diastole - least amount of arterial pressure) i. Determinants of blood pressure: cardiac output (CO - amount of blood pumped out of the heart's ventricles) and systemic (peripheral) vascular resistance (SVR - the resistance of blood vessels to have blood pumped through them) 1. BP = CO x SVR a. Any increase in CO or SVR will increase BP! 2. Cardiac output determined by heart rate, contractility, blood volume, and venous return 3. Systemic vascular resistance determined by arterial constriction, dilation, and vessel diameter ii. Normal: less than 120/80 Know these ranges!!! Base classification on HIGHEST reading iii. Hypertension: see reference ranges above 1. Factors that can contribute to hypertension: age, obesity, ethnicity, exercise, family history, stress, medications, alcohol, smoking, caffeine 2. Nursing interventions: Assess/monitor for tachycardia, bradycardia, pain, and anxiety, refer to provider for follow up, administer antihypertensives, encourage healthy lifestyle modifications (stop smoking, stop drinking, lose weight,  9 regular exercise, reduce stress, DASH diet, lower sodium intake, lower cholesterol and saturated fat intake, consume adequate potassium, calcium, and magnesium iv. Hypotension: SBP below 90 1. Nursing interventions: assess for dizziness/fainting/fall risk, assess fluid volume, Trendelenburg position v. Pulse pressure: systolic - diastolic reading vi. Orthostatic hypotension: blood pressure that decreases when a client changes position from lying to sitting or standing 1. Pulse pressure difference is 20 millimeters of mercury (mmHg) or more to diagnose orthostatic hypotension 2. Nursing interventions: assist with ambulation, assess for dizziness/fainting, have patient sit or lie down if they feel dizzy or faint, have the patient sit at the edge of the bed for at least 1 min before standing up and to move slowly when changing position, tell patient to activate the call light and not to get out of bed without assistance vii. Measuring blood pressure: Instruct patient to rest 5 min before measurement and to not use nicotine or drink any caffeine for 30 min prior to measurement. Have the patient sit in a chair with the feet flat on floor, the back and arm supported, and the arm at heart level. The level at which you hear the first clear sounds is the systolic pressure. Continue to deflate the cuff until the sounds muffle and disappear and note the diastolic pressure. Record the systolic over the diastolic pressure. 1. Average two or more readings, taken at least 2 min apart. 2. Do not measure BP in an arm with an IV infusion in progress or on the side where the client had a mastectomy or an arteriovenous shunt or fistula. 3. Width of the cuff should be 40% of the arm circumference 4. Bladder (inside the cuff) should surround 80% of the arm circumference of an adult and the whole arm for a child. 5. Cuffs that are too large give a falsely low reading, and cuffs that are too small give a falsely high reading. 6. Air trapped in the bladder can cause a falsely high reading (always deinflate cuff completely between attempts!)  10 Practice Questions A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietician D. Occupational therapist A nurse is caring for a group of clients in a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (select all that apply) A. A client with terminal cancer requests hospice care in the home B. A client asks about community resources available for older adults C. A client states, “I would like to have my child baptized before surgery” D. A client requests an electric wheelchair for use after discharge E. A client states, “I do not understand how to use a nebulizer” A nurse is teaching about barriers to interprofessional collaboration between health care professionals. Which of the following should the nurse include as a potential barrier? A. Unresolved conflicts between team members B. Cultural competency within team members C. Proper delegation of tasks D. Shared responsibility of duties A nurse and an assistive personnel (AP) disagree about how to move a client from the bed to a stretcher. Which of the following statements should the nurse make to promote conflict resolution? A. “I'm the nurse and you are the AP, so you need to do what I say” B. “You always need to get your own way” C. Let’s discuss how we can work together” D. “If you do not help me, I will report you to the charge nurse” A nurse is caring for a client who has diabetes mellitus and does not adhere to the prescribed diet. Which of the following interventions by the nurse demonstrates collaborative health care? A. Requesting a referral to a dietitian to work with the client B. Instructing the client's family not to bring in snacks for the client C. Asking the client why they are not adhering to the prescribed diet  11 D. Informing the client that they will get used to eating the prescribed diet A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication’s effects? (select all that apply) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? (select all that apply) A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist E. Physical therapist Which of the following terms is defined as an inclusive approach, involving shared accountability, shared problem solving, shared decision making, and knowledge-sharing to complete a problem or task? A. Delegation B. The interprofessional team C. Teamwork D. Collaboration A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs) can perform, which of the following client activities should the nurse include? (select all that apply) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs Which of the following types of collaboration involves mentoring and shared governance?  12 A. Nurse-patient B. Nurse-nurse C. Interorganizational D. Interprofessional Which of the following types of collaboration involves a partnership between health providers to make decisions? A. Nurse-patient B. Nurse-nurse C. Interorganizational D. Interprofessional A nurse is instructing a newly licensed nurse about choosing a site to measure a patient’s temperature. With each patient, determine if you would use an oral or rectal temperature. A. A patient who breaths through the mouth B. A patient who has low platelets C. A patient who has facial trauma D. A patient who has hemorrhoids A nurse is caring for a client who has an oral temperature of 38.6° C (101.5° F), heart rate 114/min, and respiratory rate 22/min. Which of the following interventions should the nurse take? (select all that apply) A. Obtain culture specimens before initiating antimicrobials B. Restrict oral fluid intake C. Encourage patient to rest and limit activity D. Allow the patient to shiver to dispel excess heat E. Assist patient with oral hygiene frequently You are working with an elderly patient who is hearing impaired. Which nursing intervention should you consider when performing a head-to-toe assessment of the patient? (select all that apply) A. Communicate only through verbal information. B. Check for needed adaptive equipment. C. Exaggerate lip movements to help the patient lip-read. D. Give the patient adequate time to respond to questions. E. Use technical language when explaining procedures. What is one desired outcome of motivational interviewing? A. Encourage ambivalence about harmful behaviors. B. Direct the patient to make poor health choices.  13 C. Increase the risk of relapse. D. Gain an understanding of the patient’s health goals. Which of the following is an example of closed ended questioning? A. “What concerns do you have about your treatment?" B. “Why did the doctor prescribe you to take metoprolol?” C. “Are you going to group therapy tomorrow?” D. “What problems brought you to the hospital today?” A nurse is caring for a client who has depression. The client states, "Things are always going to be bad for me. I wish I could just go to sleep and forget about all my problems." Which of the following is an appropriate therapeutic response by the nurse? A. “Don’t worry. This feeling will go away over time.” B. “Why do you want to forget about your problems?” C. “You need to stop being so sad. It’s not good for your health.” D. “It seems as though you're expressing feelings of hopelessness” A nurse is caring for an older adult client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life." Which of the following responses is appropriate? A. “This must be a difficult time for you.” B. “I understand how you feel. I have lost people very close to me too.” C. “Why do you think no one understands you?” D. “Your wife wouldn’t want you to be so upset over her death.” What is the first information you should provide when giving an SBAR report to the provider? A. Patient health history B. Request orders for medication C. Patient name D. Patient’s lab results E. Patient’s mental status What info do you provide during B of SBAR? (select all that apply) A. Allergies B. Name C. Health history D. Name E. Recommendations  14 A nurse is implementing therapeutic communication techniques with a client in an outpatient mental health facility. Which of the following actions allows the client an opportunity to organize thoughts, consider a topic, or think through a point? A. Active listening B. Focusing C. Summarizing D. Use of silence Which strategy should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a rehab facility? A. Avoiding collaboration between members of the healthcare team B. Using a standardized transfer policy and transfer tool C. Arranging all patient transfers for the same time each day D. Relying on family members to share information with the new facility A patient presents in the clinic with dizziness and fatigue and a radial pulse of 44. Which nursing intervention is of highest priority? A. Obtain oxygen saturation (SpO2). B. Assess the patient’s apical pulse for a full minute. C. Obtain blood pressure. D. Request the patient lie down in the stretcher. The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient does the nurse need to assess first? A. A 54-year-old woman admitted after surgery for repair of a fractured arm, BP 160/86 mm Hg, HR 72 B. A 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 C. A 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62 D. The 84-year-old man recently admitted with pneumonia, RR 28, SpO89% A nurse determines a patient’s radial pulse rate is 68 BPM and the simultaneous apical pulse rate is 84 BPM. What is the pulse deficit? A. 16 B. 152 C. -16 D. -152 Where is the apical pulse located? A. The fourth intercostal space (ICS) in the left midclavicular line (MCL)  15 B. The fifth intercostal space (ICS) in the right midclavicular line (MCL) C. The fourth intercostal space (ICS) in the right midclavicular line (MCL) D. The fifth intercostal space (ICS) in the left midclavicular line (MCL) The sphygmomanometer (blood pressure) cuff width should be _____ of the arm circumference of an adult and the cuff bladder should surround _____ of the arm circumference of an adult. A. 80%, 40% B. 40%, 80% C. 80%, 100% D. 100%, 80% Which of the following vital signs is abnormal and would indicate a referral to the provider is necessary? (Select all that apply) A. Blood pressure 102/72 B. Pulse 94 BPM C. SpO2 92% D. Respirations 8 breaths/min A nurse is instructing an assistive personnel (AP) how to measure a client’s respiratory rate. Which of the following statements should the nurse include? (select all that apply) A. Place the patient in Semi-fowler’s B. Have the patient rest an arm across their abdomen C. Observe one full respiratory cycle before counting the patient’s respiratory rate D. Count the respiratory rate for 30 sec if it is irregular E. Inform the patient you are counting their respirations What nursing intervention should be prioritized for the patient with orthostatic hypotension? A. Instruct the patient to rise quickly from a lying position to avoid a drop in blood pressure B. Instruct the patient to sit at the edge of the bed for several minutes before standing C. Request a prescription for a vasodilator medication D. Restrict the patient’s fluid intake Which of the following pulse measurements is within the normal reference range? A. 44 BPM B. 102 BPM C. 68 BPM D. 124 BPM  16 A nurse is caring for a client who has a fractured femur and a blood pressure of 140/94 mm Hg. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive B. Ask the patient if they are in pain C. Instruct patient about a low-sodium diet D. Return in 30 min to recheck blood pressure A nurse is teaching about lifestyle modifications to a group of clients with known hypertension. Which statement would the nurse include in the education session? A. Maintain a body mass index between 30 and 35. B. Limit alcohol consumption to no more than 3 drinks per day. C. Adhere to a ketogenic diet D. Engage in aerobic activity at least 30 minutes/day most days of the week. Officially, Stage II Hypertension is diagnosed when the client demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period. A. 140, 90 B. 130, 80 C. 110, 60 D. 120, 70 A 56-year-old male client at a screening event has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" What is the nurse's best response? A. "Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination." B. “We will need to reevaluate your blood pressure because your age places you at high risk for hypertension." C. “You have no need to worry. Your blood pressure is probably elevated because you are being tested.” D. "A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made." What is the medical abbreviation for “before meals?” A. HS B. AC C. PC  17 D. Q What is the medical abbreviation for “nothing by mouth?” A. QD B. NPO C. TID D. GTT What is the medical abbreviation for “both ears?” A. AU B. OS C. AD D. AS What is the medical suffix for “study of?” A. “-ology” B. “-emia” C. “-itis” D. “-osis” What is the medical abbreviation for “twice a day?” A. QID B. TID C. BID D. QD