Review for Intro to Nursing Exam PDF

Review for Intro to Nursing Exam Classes The Nurse-Client Relationship Pages: Potter and Perry, Canadian Fundamentals of Nursing, 2024 p. 273-279 Jarvis Physical Examination and Health Assessment 2024 p. 41-42 Learning Outcomes: 1. Define communication and describe the purpose within the nurse-client relationship. 2. Explain the different functions of interpersonal communication. 3. Describe the elements involved in the communication process. 4. Describe the various components of verbal and non-verbal communication. 5. Describe the factors that impact communication including a person’s physical, psychological and socio-cultural characteristics. The nurse-client relationship, the helping relationship, the therapeutic relationship Helping relationships are the foundation of clinical nursing practice. They are unique, intimate relationships with our clients that set us apart from other healthcare professionals, it makes the difference in the quality of care and the meaning of the illness experience for both. A therapeutic relationship between the nurse and the client does not just happen. The nurse uses her communication skills to demonstrate caring and to gain the client’s trust. Thus, communication is the means of establishing such a relationship. Communication is a critical/essential part of everyday nursing. Communication involves the exchange of information between individuals, groups, or organizations. Nurses' role in interpersonal communication: (from textbook) Communicate effectively with patients and families in stressful situations Function as patient advocates, ensuring patients’ needs are voiced and understood Collaborate with interprofessional teams, navigating different priorities for patient-centred care The intimate nurse-patient relationship enhances care quality and shapes the illness experience Enables nurses to form therapeutic relationships and uphold professional respect Some examples of how effective communication is used to perform our role. Teaching a client Completing a health assessment Handling a client’s irritation, frustration or anger Reporting to a colleague about a patient Making a referral Managing a life-threatening situation Effective communication promotes: (from textbook) interprofessional collaboration with others on the healthcare team helps ensure that ethical and legal responsibilities and professional practice standards are met earns the public’s respect and trust contributes to positive patient outcomes Ineffective communication may lead to: (from textbook) poor patient outcomes increases in adverse incidents decreases in professional credibility Therapeutic interpersonal relationships based on caring, mutual respect, and dignity are at the core of nursing care. Relational practice involves: (from textbook) Conscious participation with clients Skills: listening, questioning, empathy, mutuality, reciprocity, self-observation, reflection, and sensitivity to emotional contexts Nurse’s capacity in relational communication includes: (from textbook) Taking initiative in establishing/maintaining relationships Being authentic and responsive Initiative in relational communication: (from textbook) Actively reaching out and listening Meeting people where they are Authenticity in nurses: (from textbook) Spontaneous and genuine Aware of both patient’s and own in-the-moment experiences Builds public trust Mutuality in nurse-patient communication: (from textbook) Partnership where both are equal participants Respect for autonomy and value systems Commitment to patient’s well-being Nurses are further able to engage with complexity and uncertainty and expand their capacity to communicate by focusing on the following specific relational capacities: (from textbook) Collaboration Commitment Compassion Competence Leadership Orienting Scrutinizing Social VS Professional Communication Social: Not necessarily aware of all elements of the interaction – facial expressions, hand gestures, or tone of voice More spontaneous & relaxed Easy, superficial & not deeply personal Professional: Conscious of all elements of the communication process Remain aware of the effect the interaction is having on the other person Focused & deliberate More difficult, intense & uncomfortable Communication occurs on several levels 1. Intrapersonal: Self-talk (plan, organize, encourage, etc). Occurs within an individual and relates to personal qualities and values. 2. Interpersonal: One-to-one interaction, the nurse and the patient or doctor. Most frequently used in Nursing. It takes place within a social context and includes all the symbols and cues used to give and receive meaning. 3. Transpersonal: Interaction that occurs within a person’s spiritual domain. Examples: Prayer, meditation, religious rituals. Spiritual inquiry is an approach to communication whereby nurses can join with their patients to create a road map of what is meaningful, significant, and important for the patient in their unique context. 4. Small Group Communication: interaction that occurs when a small number of people meet together for a common purpose. Usually goal directed – requires an understanding of group dynamics 5. Public Communication: Interaction with a large group of people – audience, classroom or conference. The purpose of public communication by nurses is to increase audience knowledge about health-related topics, health care issues, and other issues important to the nursing profession. Communication involves the reciprocal process of sending and receiving messages between two or more people. Communication Process 1. Referent/Stimulus: what motivates a person to communicate with another. In a health care setting, sights, sounds, odours, time schedules, messages, objects, emotions, sensations, perceptions, ideas, and other cues trigger communication. 2. Sender: initiates the message (could be as small as a smile), the person who encodes and delivers the message, the sender puts ideas or feelings into a form that can be transmitted and is responsible for accuracy and emotional tone. The sender’s message acts as a referent for the receiver 3. Message: the content of the communication, info sent to the receiver – verbal, non-verbal, symbolic expressions of thoughts or feelings, personal perceptions sometimes distort the receiver’s interpretation of the message. 4. Receiver: the one who the message is directed towards, the person responsible for attending to, decoding, and responding to the sender’s message 5. Channel (from textbook): means of conveying and receiving messages through visual, auditory, and tactile senses. Facial expressions send visual messages, spoken words travel through auditory channels, and touch crosses tactile channels 6. Feedback: receiver responds to sender & sends a message back. This message reveals to the original sender whether it was clearly understood as intended. 7. Interpersonal variables (from textbook): characteristics within both the sender and the receiver that influence communication, interpersonal variables include educational and developmental levels, sociocultural backgrounds, values and beliefs, emotions, gender, physical health status, roles, relationships, pain, anxiety, and medication effects 8. Environment (from textbook): the setting for sender-receiver interaction, for effective communication, the environment should meet nurse and patient needs for physical and emotional comfort and safety Modes of Communication - Message Verbal includes: Vocabulary, the spoken word, pacing, intonation, denotative and connotative meaning, clarity and brevity, timing and relevance Non-Verbal includes: Eye movements or contact, facial expressions, body posturing, gestures, personal space, physical appearance, sounds (sighs, moans, groans, or sobs) Symbolic Communication (from textbook) includes: art, music, and dance Metacommunication (from textbook): it is communication about communication that reflects the relational aspects of messages ○ For example, a nurse observes a young patient holding his body rigidly, and his voice is sharp as he says, “Going to surgery is no big deal.” The nurse replies, “You say having surgery doesn’t bother you, but you look and sound tense. I’d like to help.” Factors that Influence Interactions The following can either facilitate or enhance communication or become a barrier to effective communication. Environmental factors: noise, comfort, safety, privacy Personal Characteristics: physical appearance – height, weight, attractiveness, dress habits, body odour, posture, age, etc. Physical and Mental Status: pain, hunger, weakness, etc. or anxious, angry, overwhelmed. Self-concept & self-esteem. Cultural Elements: Language, customs, religion, role expectations, sexual orientation, gender, etc. You must be able to recognize and address your implicit biases to counteract stigma and develop therapeutic relationships with patients. It is important to be aware of how your power and privilege in relation to patients, families, and colleagues are reflected in the way you communicate, both verbally and nonverbally, on an ongoing basis. Therapeutic Communication (typically employed in the implementation step of nursing process) Pages: Potter and Perry, Canadian Fundamentals of Nursing, 7th ed. (2024) p. 283-286 Jarvis Physical Examination and Health Assessment, 4th Ed 2024 p. 46-47 Learning Outcomes: 1. Describe the major techniques of an effective nurse-client relationship (attentive listening, open and closed-ended questions, perception checking, empathy, paraphrasing, clarifying, focusing, sharing observations, silence, touch). 2. Explore language that demonstrates respect for the person’s values, needs, expectations and self-determination capacity. Therapeutic communication techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect. Therapeutic Techniques 1. Empathy a. The ability to emotionally and intellectually understand and accept another person’s reality, to accurately perceive unspoken feelings, and to communicate this understanding to the other person. b. Sensing meaning from the client without being judgmental. c. Requires the nurse to enter the private world of the client in a respectful manner and become thoroughly comfortable with this connection. d. What qualities must the nurse have to be empathetic? i. Caring, patient, curious, willing to understand a patient’s perception, self-aware, imaginative, non-judgmental, open-minded e. An empathetic response accurately reflects the factual and emotional content the client is communicating. f. This requires a relational approach that starts with the willingness to open the relational space and take action. Empathy can also be expressed in relational communication through clear intention, or a consciousness of the purpose and intention of one’s communication, and reflexivity, which involves paying attention to one’s responses and feelings as they influence communication and decision-making. g. Example - Client: “I hate not having my own room here. I feel like I’m on display. There’s no privacy and I can’t get any peace and quiet.” i. Nurse: “I can see that you’re really angry. Sharing a room has been a struggle for you. You really value your privacy.” h. Steps to an Empathetic Response i. What are the feelings (emotions) expressed in the statement? ii. Attend to both the verbal and nonverbal message. iii. What does the person want me to hear? iv. What are my feelings upon hearing these statements? v. Formulate an empathic response and communicate it. vi. Check to see if your empathic response was effective. 2. Paraphrasing a. Demonstrates understanding, reflects ideas/content back to the client for their consideration b. Validates the client that you are actively listening, and that the client is being heard. c. Example: “I take my medication everyday just as prescribed. I am doing the exercises that the physiotherapist suggested and I am following the diet plan from the dietician. I really want to get better.” i. Response: “In other words, you are doing everything you can to recover.” 1. What I am hearing you say is… 2. If I understand correctly, you are saying…. d. Make sure NOT to use the same words all the time. Don’t regurgitate or parrot them. Switch it up a little. 3. Perception Checking a. A way that we interpret sensory information (using our five senses – sight, touch, smell, taste, hearing) to give meaning to an encounter- the way we interpret the world b. Used to avoid misunderstandings/prejudging the client c. 3 Parts: i. A description of the behaviour you noticed. ii. At least two possible interpretations of that behaviour. iii. A request for clarification about how to interpret the behaviour. d. Example: “When you rushed out of the room and the door slammed” (behaviour), I wasn’t sure whether you were mad at me (first interpretation) or just in a hurry (second interpretation), “How did you feel?” (request for clarification) 4. Sharing Observations a. The nurse states an observation based on how the client looks, acts or sounds. b. Can work well with quiet and withdrawn clients. c. Encourages the client to verbalize without extensive questioning. d. Example: “You are very quiet today” or “You are sleeping a lot” or “You seem different today” or “I see you are wearing lipstick today” 5. Touch a. Sometimes words are not enough or there simply are no words to be said. b. In such a technical world, simple touch can have strong impact c. Touch can speak far more eloquently than words in times of deep emotion d. In response to the patient’s lead, holding a hand or offering a gentle touch on the shoulder may, be an expression of comfort, reassurance, and care for some, and may convey empathy in situations when words are insufficient e. Not for everybody. You have to be aware of what works for you and what doesn’t. Sometimes, asking for it can be a bit misplaced, use your judgment. Look for cues to see if touch is appropriate. f. People vary in their comfort with touch. g. Cultural competence requires an understanding of the meaning of touch to clients from different cultures. h. In certain situations, you will need to withhold touch, such as patients in psychosis may misinterpret touch as threatening; patients who have experienced abusive or violent contact from others may be fearful of even well-intentioned touch from a nurse 6. Silence a. In general, if the client initiates the silence, allow the client to break the silence. b. Don’t be afraid of silence. If you don’t have something smart to stay, just stay silent. c. Allows the client and nurse to observe one another and pay particular attention to nonverbal cues. d. Allows the client to sort out their feelings and time to think. e. Allows the client to consider (reflect) on what has been said. f. Prompts the client to verbalize. g. Demonstrates a nurse’s patience and willingness to wait for a client’s response so as not to rush the patient to reply quickly. h. Silence may be especially therapeutic during times of profound sadness or grief i. Example: “I don’t have any words to help, but I will stay with you for a while.” 7. Clarifying a. An attempt to understand the message from the sender through additional questions. b. To check whether an understanding is accurate the nurse can: i. Ask the client to restate an unclear message ii. Ask the client to explain further or give an example of the message iii. The nurse takes notice of a single idea or a single word c. Example - Client: I am tired of feeling like a wallflower. i. Nurse: Can you tell me what you mean by “wall flower”? 8. Focusing a. Rationale: i. Encourages the client to expand on an area of importance. ii. Guides the direction of the conversation. b. The nurse takes notice of a single idea or a single word c. Example - Client: When I go home, I am going to have so much to do. I have to pick up my medication, go to the CLSC to have my blood drawn, go to my doctor every couple of days. I have a grandson who has offered to help me out….Next week I have to have an X-ray and then an MRI. Oh my, I have a packed schedule for the next few weeks i. Response: You mentioned your grandson. What role will he play in your discharge? 9. Open and closed-ended questions a. Open-Ended Questions/Statements: i. Asks for narrative information ii. Encourages patients to respond in paragraphs and to give a spontaneous account in any order chosen iii. Let patients express themselves fully 1. Ex. What brought you to the hospital? 2. Statements often start with: What, How, Tell me, Describe, etc. b. Closed-Ended Questions/statements: i. Ask for specific information ii. Elicit a short one- or two-word answer iii. Use direct questions after the patient’s opening narrative to fill in any details that the patient left out or when you need many specific facts, such as when asking about past health problems or when you must complete the interview in a brief time 1. Ex: “Are you having trouble breathing?” 2. Questions often begin with: Can you, do you, will you/would you/should you, Are you, Is…Does… 10.Active Listening a. Listening attentively with one’s whole being – mind, body, spirit. b. Enhances trust and facilitates client communication because the client feels accepted and respected. c. Active Listening Includes: i. Full concentration of both verbal and nonverbal behaviour ii. Listening to conversational themes iii. Acknowledging and responding iv. Giving appropriate feedback v. Being attentive to the content, the intent, the values, attitudes & the feelings vi. Gives acceptance and respect for the client d. Sit, Open Posture, Lean Forward, Eye Contact, Relax e. Face the client at a distance of 3 feet, Remove physical barriers, Maintain intermittent eye contact, Assume an open & relaxed posture, Sit down, Lean forward slightly, Nod in acknowledgment Health Promotion Pages: Potter and Perry Canadian Fundamentals of Nursing 7th ed. 2024 Chapter 1 p. 1-18 Jarvis Physical Examination and Health Assessment 4th ed. p. 5 Expanding the concept of health, p.8 Social determinants of health, Ch. 2 p. 11-17 Learning Outcomes: At the end of this class the student will: 1. Describe the most current definitions of health (Roy, Pender, World Health Organization, OIIQ). 2. Distinguish between health and illness. 3. Describe the dimensions of health and well-being (physical, mental, social) 4. Describe the major determinants of health affecting the Canadian population. 5. Describe strategies for health promotion and disease prevention (primary, secondary, tertiary). 6. Describe the factors that influence individual health promotion activities using the Pender Model. Why do you need to know this? Knowledge of health and health determinants is seen as an essential component of nursing education in Canada. Better equips you to assist your patient in making or maintaining healthy behaviours. Roy Model: “Health is the process of being and becoming an integrated and whole person.” Pender: “Health is a positive dynamic state not merely the absence of disease.” WHO: 1947: “Health is a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity.” 1984: “Health is the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living; it is a positive concept emphasizing social and personal resources, as well as physical capacities.” Ordre des infirmiers et infirmieres du Quebec 2010 Outlook on the Nursing Practice: “Health is a dynamic and continuous process in which a person, family, group or community aspires to a state of equilibrium that fosters well-being and quality of life. This process involves adaptation to environmental factors, learning and commitment on the part of the part of the person and society.” Can health and illness co-exist? Labonte (1993) says YES! Where disease is seen as an objective state of ill health, the pathological process of which can be detected by medical science, whereas illness is a subjective experience of loss of health. Illustrates key concept of holism, whereby health is more than the sum of the component parts in that the interrelationships between and among different components result in different aspects of health 1. Physical health: focuses on the body and different body systems (ex: cardiovascular, strength, flexibility) 2. Mental health: looks at how we take in, process, and communicate information 3. Social health: who we choose to spend our time with, identify patients who lack social support a. Need to look at all 3 aspects to be holistic. Good health and poor health do not exist as a dichotomy, but as a continuum. The absence of disease or disability is neither sufficient nor necessary to produce a state of good health. This definition of health denotes that health is not a dichotomous variable, that health status is experiential, and that while it is shaped by social influences, an individual’s experience of health itself is psychological and physical in nature. Social determinants of health = non-medical factors that influence health outcomes. Socioeconomic environment ○ Income, Income distribution and Social Status: seen as the greatest determinant of health as it influences most other determinants Poverty exerts its effects on health through lack of material resources that support health, through higher levels of psychosocial stress, and through the adoption of health-threatening behaviours to cope with limited resources and stress People living in countries with greater economic inequality have lower overall health and life expectancies ○ Social support networks: affects health through practical, emotional and affirmational support For instance, experiences of social isolation during the COVID-19 pandemic, which resulted from the implementation of necessary physical distancing measures, highlighted that those relationships are essential for good mental health and are as important to overall health as established risk factors such as obesity, smoking, and high blood pressure ○ Education and literacy affect: Directly: Access to health services and health information, reading medication prescriptions, or knowing where to go when they have questions about their health Indirectly: Use of services, personal health practices, income, work environments, and stress levels Individuals with low literacy skills are more likely to be unemployed, earn minimum wages, and have less access to preventative health services Health literacy “describes the skills that enable individuals to obtain, understand, and use information to make decisions, and take actions that will have an impact on health status” ○ Unemployment and Job Security Unemployment is linked to material and social deprivation, adoption of health-threatening coping behaviours, psychological stress, and physical and mental health challenges ○ Employment and Working Conditions Risk factors for poor workplace psychological health may include, but are not limited to, high demand and low control, high effort and low reward, unfair treatment, excessive workload, unfulfilling work, low employee engagement, poor physical work environment, limited professional development opportunities, physical violence at work, abuse of authority, discrimination, harassment, and lack of work flexibility ○ Physical environments: includes factors such as housing, food security, environmental quality, indoor air quality, urban development, lighting, and transportation systems and community planning ○ Healthy childhood development: maternal and/or childhood exposure to poverty, violence, neglect, and food insecurity have been associated with many lifelong health concerns ○ Personal health practices and coping skills research focuses on 3 main things: physical inactivity, poor nutrition and tobacco use I Should Educate Unemployed Employers on Professional Hiring Practices Biology and genetic endowment: there are certain diseases where we have a higher likelihood of getting it due to genes that are passed down Health services: quality and accessible healthcare are seen as essential to maintaining health ○ Prenatal care, well-child and immunization clinics, education services about health practices, and services that maintain older persons’ health and independence, as well as the COVID-19 vaccine initiative across Canada, are good examples of preventive and primary health care services Gender ○ Also intersects with and influences all other health determinants, such as income, culture, education, employment, and access to health services ○ Women disadvantaged by lower wages, fewer social protections, and less individual agency have fewer household resources and poorer health ○ Men are more likely than women to experience extreme forms of social exclusion and to die prematurely, largely as a result of heart disease, unintentional fatal injuries, cancer, and suicide Culture, Race, and Racism: health inequities in our Indigenous populations, limited access to healthcare among immigrants and refugees, racialized individuals in Canada (i.e., visible minorities) are more likely to be unemployed, employed in hazardous work environments, have limited social benefits, and experience job insecurity than are non-racialized Canadians, experiencing racism can cause significant distress, triggering negative psychological states such as anxiety and depression Strategies for health promotion and disease prevention: Primary prevention: Protect against a disease before signs and symptoms occur Includes activities that prevent known health problems, protect existing states of health and promote psychosocial wellness. ○ Ex. Immunizations, teaching a group of Grade 3 students about the harmful effects of tobacco use. Secondary prevention: Include activities that promote early detection of disease, before symptoms emerge. ○ Ex. BP screening, routine mammograms, preventive screening for cancer (e.g., Pap test, testicular self-examination), blood pressure screening to detect hypertension, and blood glucose screening to detect diabetes. Tertiary prevention: Include activities that prevent complications when a condition or disease is present or has progressed. ○ Ex. teaching foot care to a newly diagnosed diabetes patient, cardiac rehab after the patient had an MI (myocardial infarction). Examples to study: Routine colonoscopy for colorectal cancer screening at age 45 = secondary Having to wear seatbelts = primary Well-child check-ups by CLSC nurses in the community = primary/secondary Oxygen therapy at home for a patient with lung disease = tertiary Health Promotion Strategies should: 1. Build healthy public policy. a. Healthy public policy necessarily extends beyond traditional health agencies and government health departments to other sectors such as agriculture, education, transportation, labour, social services, energy, and housing. b. Therefore, policymakers in all government sectors and organizations should ensure that their policies have positive health consequences. c. Ex: Cathy Crowe, a Toronto “street nurse,” is an excellent example of a nurse who advocates for healthy public policy to reduce homelessness 2. Create supportive environments. a. Encourage reciprocal maintenance, to take care of each other, our communities and our natural environment b. Ex: improving school environments by providing health instruction, social support, support services, and positive physical environments c. Ex: flexible workplace policies, quality child care programs that support early child development 3. Strengthen community action. a. Health promotion works through concrete and effective community action in setting priorities, making decisions, and planning and implementing strategies b. Partnering with other community organizations to achieve better health, empowerment of communities, and community ownership and control of development and change c. Public participation in all phases of community programming is key to community development d. Ex: community gardens and collective kitchens targeted at enhancing food security 4. Develop personal skills. a. Helps clients develop personal skills, enhance coping strategies, and gain control over their health and environments so that they can make healthy lifestyle choices b. Health education, but it also emphasizes adequate support and resources c. Ex: Early intervention programs for children, home visiting by public health nurses, parenting classes, and fall prevention programs for older persons 5. Reorient health services. a. Shift the emphasis from treating disease to improving health, and to make the health care system more efficient and effective b. Ex: COVID-19 vaccine delivery within various communities to ensure access for all Canadians Balloons Can Sour Down Rivers Pender’s Health Promotion Model The purpose is to “assist nurses in understanding the major determinants of health behaviours as a basis for behavioural counselling to promote healthy lifestyles” Factors that influence individual health promotion strategies using the Pender model Individual Characteristics and Experiences = UNCHANGEABLE ○ Prior related behaviour ○ Previous experience with behaviour change. Ex. What happened the last time the patient tried to quit smoking? ○ Personal Factors Biological: age, illness, family hx Psychological: self-esteem, perceived health, self-motivation Sociocultural: race, ethnicity, culture, education, SES Behaviour specific cognitions and affect = CHANGEABLE ○ Perceived benefit of action Ex. “What will I get out of making this change?” ○ Perceived barriers to action Ex. “What is stopping me from making this change?” ○ Perceived self-efficacy “Am I capable of doing the healthy activity?” ○ Activity-related affect “How will doing the healthy activity make me feel?” ○ Interpersonal influences “How do the people around me influence my ability to perform the healthy behaviour?” ○ Situational influences “How does my environment influence my ability to perform healthy behaviours?” ○ Immediate competing demands & preferences Behavioural outcome = CHANGEABLE ○ What is the level of commitment to a plan of action for behaviour change? → Do they know strategies needed to carry out this behaviour change? → Health promoting behaviour Health promotion vs disease prevention: Health promotion is “directed toward increasing the level of well-being and self-actualization” while disease prevention (specifically primary prevention) is “action to avoid or forestall illness/disease” Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. Participation is essential to sustain health promotion action Activity & Exercise Pages: Potter and Perry, Canadian Fundamentals of Nursing, 2024 p. 221, 833-870 Optional: The Roy Adaptation Model, Chapter 8 (on reserve in the library) Learning Outcomes: 1. Describe the benefits of activity and exercise to maintain wellness. 2. Describe subjective and objective assessment parameters for activity. 3. Identify causes that affect activity. 4. Describe age-related changes in the older adult that affect activity. 5. Describe physical and psychosocial factors that affect activity and exercise. 6. Describe health promotion activities to increase exercise. 7. Describe nursing interventions to promote activity in the hospitalized client. Benefits of Activity (FEELS GOOD) F – Flexibility, increased strength E – Energy boost E – Endurance, enhanced body system function (cardiopulmonary, musculoskeletal) L – Lowers risk of heart disease, high blood pressure, controls blood sugar S – Sleep and concentration improvement G – Good moods (optimism, confidence) O – Optimizes immune function, fights disease O – Overall well-being (weight control, body image, psychological) D – Disease prevention (heart disease, improved overall health) Health Promotion Increase awareness of the importance of activity/exercise and provide information as needed Have client consider the pros and cons of being active vs sedentary Encourage client to select activities they feel competent and safe in performing…and ENJOY! Be supportive, encouraging and nonjudgmental Assist client to set small, obtainable goals and encourage client to reward themselves when goals are met Encourage client to anticipate barriers to performing exercise and to problem-solve solutions. Patients should be taught to monitor their pulse during exercise so that the heart rate is maintained within the target range. Regardless of the exercise prescription implemented by the patient, warm-up and cool-down periods must be included in the program Nursing Assessment: Signs & Symptoms The following must be assessed in your clients: ○ Physical activity ○ Mobility ○ Activities of Daily Living (ADLs) ○ Muscle mass, tone and strength ○ Range of motion/joint mobility ○ Posture/body alignment ○ Gait ○ Motor Coordination ○ Acronym: Planning More Adventures Means Real Progress Gets Made (S&S) Signs & Symptoms: Physical Activity Physical Activity – describe the amount and type of activity performed by the client. Signs & Symptoms: Mobility Mobility: The ability to move easily and independently Ambulation: To walk or move freely Assess the need for walking aids (Cane/walker/crutches) Assess the ability to transfer independently Assess the client’s bed mobility Signs & Symptoms: Functional Assessment - Activities of Daily Living (ADLs) What self care activities required on a daily basis can the client perform independently? If not independent what level of assistance is required. Examples: ○ ADLs = Eating, grooming, dressing, bathing/hygiene care, toileting, (ambulation) ○ Instrumental ADLs (IADLs) = Shopping, cooking, housekeeping, managing finances, using phone/computer, laundry, managing medications Signs & Symptoms: Muscle Mass, Tone & Strength Compare one side to the other whenever possible! Any swelling, masses, deformities? Inspect muscles for size Palpate muscles for firmness Test muscle strength (pt flexes muscle as you apply opposing force) Signs & Symptoms: Body Alignment/Posture Head, shoulders and pelvis should be aligned Signs & Symptoms: Range of Motion (ROM)/Joint mobility/the range of normal movement for a joint Can the patient (pt) move the joint? To what degree? Does pt perform Active/passive ROM? Of which joints Assess if joints move freely and without pain Observe for contractures Assess for any swelling, masses or deformity Signs & Symptoms: Gait Assess rhythm, speed, presence of limp, symmetry of movement, distance between steps, ability to walk with or without assistance Shuffling, waddling gait, scissor gait Signs & Symptoms: Muscle Coordination Requires muscles and joints to engage with the brain/environment/sight, hearing and touch Assess ct’s ability to perform simple movements in rapid succession Assess if movements are balanced, smooth and purposeful Nursing Assessment: Causes Causes provoke a response Can be: primary, secondary or possible Verify if the following causes are affecting your client Nursing Assessment: Causes (Advanced Age: After 30) M – Muscle tone decreases U – Unsteady coordination (↓ coordination) S – Shrinking muscle fibers (↓ strength, stamina, endurance) C – Contractility & flexibility decrease L – Leaning posture (forward-leaning, stooped) E – Energy levels decrease G – Gait becomes slower, short-stepped, shuffling A – Arms out for balance P – Posture and ROM decrease Causes: Physical Condition Trauma/Effects of surgery Musculoskeletal structure and function Chronic illnesses (Cardiac, Respiratory) Pain Fatigue/Weakness Tired Muscles Can’t Perform Fully Causes: Psychological Condition D – Depression A – Anxiety/Stress F – Fear (of falling) L – Level of motivation Y – You (Personal values, attributes, lifestyle) DA FLY Causes: Prescribed Therapy Doctor’s orders : Ex: ○ Complete bed rest* ○ No weight bearing (NWB) ○ No adduction ○ Activity as tolerated (AAT) Casts/Splints/Traction Presence of other medical devices (Ex. IVs) Causes: External Factors Extreme Heat/Cold Unsafe environment (wet floor/insufficient space) Lack of facilities/equipment Causes: Culture Cultural/social norms involve establishing social values and beliefs about physical activity Ex: walking rather than driving short distances to run errands, or taking the stairs rather than the elevator, religious fasting periods Causes: Medications May alter muscle tone/spasm and motor coordination Pain medications Side effects of medications: drowsiness, dizziness, orthostatic hypotension, weakness Causes: Nutrition Low caloric intake will not produce sufficient energy to move Poor nutrition can result in muscle weakness and decrease activity Obesity can cause stress to joints/adversely affect balance and posture and make moving more difficult Interventions Things to consider before intervening M – Medications (check for side effects, administer pain meds) O – Observe activity tolerance (sweating, rapid breathing, chest pain) B – Baseline (assess client's prior mobility, routine, use of aids) I – Interventions (create ambulation schedule, turn/position in bed) L – Look for safety (proper shoes, obstacle-free path) I – Include physiotherapy (consult, ensure attendance) T – Tolerate activity (walk with client, balance with rest) Y – Your culture (consider client's cultural factors) P – Physiotherapy sessions, encourage participation in institutional activities L – Level of motivation (ask client about feelings, fears) A – Assess ROM, joint movement, client’s understanding of exercise N – Nutrition (ensure adequate intake) Non-Therapeutic Communication Pages: Potter and Perry, Canadian Fundamentals of Nursing, 7th Ed. 2024 p. 286-287 Read: Jarvis Physical Examination and Health Assessment 4th Canadian Ed, p. 48-50 Learning Outcomes: At the end of this class the student will: 1. Describe communication techniques that are non-therapeutic to the nurse-client relationship. 2. Analyze and explain the barriers or blocks to effective communication. 3. Explore the impact of cultural healthcare beliefs in the communication process. There are many non-therapeutic ways of communicating. As nurses, we must be aware of these so that we can avoid using this format of communication and build our relationships with our patients. 1. Sympathy a. Ex. “Oh, that’s too bad…. Poor you” b. Ex: “I’m so sorry about your mastectomy; it must be terrible to lose a breast” i. Alternative: “The loss of a breast is a major change. How do you think it will affect your life?” c. Concern, sorrow, sadness, or pity – feelings felt by the patient because the nurse is feeling this way. The nurse is over-identifying in the situation and there is no effort to see the problem from the client’s perspective (as in empathy). You end up projecting your feelings onto the patient instead of acknowledging how they feel. It’s a subjective vision of the client’s situation that prevents a clear perspective of the client’s problem, If a nurse over-identifies with the problem, they will lose objectivity. d. Ask yourself: Why is sympathy non-therapeutic? e. Possible question: What is the difference between sympathy and empathy? f. Video on non-therapeutic interaction with the nurse: http://www.youtube.com/watch?v=jR5kq5Qc9ws 2. False Reassurance a. Example - Client: “I am really frightened about giving birth.” Nurse: “Don’t worry about it, everything is going to be fine.” b. Instead, the nurse should work through the patient’s feelings to better understand her specific concerns. Offering reassurance that is not based on reality or fact does more harm than good. The nurse may promise something that will not occur or is unrealistic. c. Discourages trust, open, honest communication, and negates the concerns of the client. d. Trivializes their anxiety and effectively denies any further talk of it e. Alternative to false reassurance: Tell me a bit about what’s scaring you. What are you concerned about? f. Reassure the client that you are listening to them and address their concerns. Work through it. 3. Automatic Response/Reassuring Clichés a. Examples: “Well you can’t win them all!” “Better late than never!” “What doesn’t kill you makes you stronger!” b. Can refer to certain stereotypes (e.g., “Older persons are always confused” or “Administration doesn’t care about the staff”) c. What is the problem with this technique? i. Negates the patient’s feelings, and almost makes the orthopedic surgeons’ behaviours acceptable. ii. Dismisses the other person’s feelings and minimizes the importance of their message 4. Giving Unwanted Advice or Personal Opinions a. Examples: “If I were you…” “I think you should try….” b. Note: This is not the same as giving professional advice. i. Inhibits independent decision-making and problem-solving abilities of the client ii. Actually shifts the accountability for decision-making to the nurse iii. Inhibits personal growth because the client does not learn anything about themselves, but rather learns about the nurse iv. Can create doubt for the client v. You should give the facts and research, and they can make their own informed decision. You can ask them about how what they’re doing presently helps them, if they want to get better, etc. vi. Suggestions should be presented to patients as options because the final decision rests with the patient c. What is an alternative to giving unwanted advice or a personal opinion? i. Maybe make them explain to you how smoking is bad for their lungs or second-hand smoking, etc. Ask them if they know about the consequences. Lead them to it rather than judging them immediately or just outright saying it without considering them. 5. Giving Approval or Disapproval a. Judgemental responses often contain terms such as should, ought, good, bad, right, and wrong b. Example: “I think you are making a good choice” or, “I think the surgery will be of great benefit to you” or “I disagree with your decision to seek a second opinion” or “You shouldn’t even think about assisted suicide; it’s not right” i. Limits the client’s freedom to think, act, speak in a certain way ii. Disapproval implies that the nurse has the right to pass judgment on client’s thoughts/actions or the patient needs to meet your expectations or standards iii. Approving implies that the behaviour being praised is the only acceptable one c. Alternative: help patients explore their own beliefs and decisions 6. Using Authority a. Example: Your nurse knows best” “ I am the expert here” b. Why is using authority a problem? i. Does not promote mutual respect or collaboration ii. Promotes dependency and inferiority c. Alternative: avoid using authority completely d. You want to be on equal footing. You’re in a helping relationship. Also, could bleed into how you treat other coworkers. 7. Distancing a. Use of impersonal speech to put space between a threat and the self. “The appendectomy in room 210, the gastro in room 215 or “When they amputate the limb” The use of the instead of your!! i. This can be an attempt to soften the reality but instead comes across as impersonal, uncaring or uncomfortable ii. The use of seemingly blunt-sounding specific terms actually is preferable for defusing anxiety 8. Use of Professional Jargon a. Can cause anxiety and misunderstandings for the patient. b. Can exclude the patient from the conversation because they don’t understand what is being said. c. We are obligated to use language that our patients can understand about the information that we are giving them. If it is necessary to use medical terminology then it is important to teach patients the meaning of the terms. d. Can sound exclusionary, controlling & paternalistic. e. Need to adjust your vocabulary without sounding condescending or too medicalized. f. Can require us to use common terms or teach our clients the meaning of medical terms. 9. Use of Leading or Biased Questions: a. Examples: “You are not following your diet, are you?” or “Don’t tell me you are still smoking?” b. Implies that one answer is better than the other c. Puts client in the position of being forced to answer in a way corresponding to your values or they feel guilty when they must admit the other answer d. It is imperative to convey unconditional positive regard 10.Talking Too Much a. We may think that we are being effective but usually the KISS (KEEP IT SHORT and SIMPLE) technique is better received by patients who often have short attention spans i. Gives us a false impression that we are being effective when the opposite occurs ii. The attention spans of clients vary iii. Some patients let examiners talk at the expense of the need to express themselves iv. Rule: Listen more than you talk! 11.Interrupting a. Demonstrates boredom, lack of respect and impatience b. Communication is a two-way process! c. If you are thinking about what you want to say, you are not listening! d. Aim for a pause between the patient’s statement and your reply 12.Asking for Explanations/Using WHY Questions a. What is the problem with asking too many “why” questions? i. Too frequent use can be intimidating ii. Can imply blame and condemnation iii. Can put the client in defensive mode iv. Can cause resentment, insecurity, and mistrust v. Sounds accusatory and judgemental vi. May feel like an interrogation b. Avoid having the patient feel like they are being interrogated!! c. Instead, ask client to describe feelings or try to rephrase: “I see that your anger began early this morning. Would you like to tell me about what has happened to anger you?” or “Tell me about how you are feeling today compared with yesterday” 13.Asking Personal Questions a. “Why are you and your partner living together instead of being married?” b. Rule: Do not ask irrelevant questions just to satisfy your curiosity. Ask yourself, “What is the purpose of my question?” c. Not appropriate professional communication d. Invasive and unnecessary 14.Changing the Subject a. Example: “My husband won’t even look at me since my surgery.” Response: “You should be able to go home in a few days if all goes well.” = Blocks communication. i. Spontaneity is lost and interrupts thoughts ii. Can result when the nurse is uncomfortable with a subject. Implies only what the nurse considers important will be discussed. Certain topics are “off limits.” iii. Rude and shows a lack of empathy and mutuality iv. ***If you have to change subjects (i.e. client must go to physio…set up a time to discuss the concern later) v. There is nothing wrong with being honest. Tell them that maybe you were caught off guard. You don’t have to have the perfect answer every single time. vi. In some instances, changing the subject serves as a face-saving manoeuvre. If this happens, reassure the patient that you will return to their concerns: “After your walk, let’s talk some more about what’s going on with your job.” 15.Passive Response a. Example: “That’s just the way it has always been done on this unit” or “Things are bad, and I can’t do anything about it” b. Passive responses demonstrate powerlessness, lack of caring and unwillingness to engage, avoidance of conflict. They serve to avoid conflict or sidestep issues. c. Follow up on their concern instead. Engage. 16.Aggressive Responsive – Provoke confrontation a. “You are always ringing the call bell!” or “Things are bad, and it’s all your fault” b. Aggressive responses provoke confrontation at the other person’s expense and reflect feelings of anger, frustration, resentment, and stress. c. Can imply blame 17.Triangulation a. Ex: “That nurse always forgets to do the pharmacy order.” b. You blame someone else for something you did. c. Using a third party rather than expressing concerns directly to the source. (i.e. rather than speaking directly to the nurse, speak about her to others) i. Lowers team morale and draws other people into the conflict situation d. Used when nurses lack assertiveness skills to confront the issue directly Concepts of Caring Resources: Read Handout: Caring in the Nursing Practice (see appendices for classes) Case Study given in class Learning Outcomes: At the end of this class the student will: 1. Explain the concept of caring and its relevance to nursing practice. 2. Explain the importance of treating individuals as unique persons. 3. Describe nursing behaviours that demonstrate caring 4. Compare theoretical views on caring 5. Define and describe culturally competent care. Caring Definition: Having a sense of dedication to another person; Feeling and exhibiting concern and empathy for others Client-centred approach vs task-oriented Increasing technological advances do not diminish the need for caring Nursing Interventions for Caring: Providing Presence Touch Listening Knowing the client Providing Spiritual Care Providing Family Care Providing Presence: Person-to-person encounter Conveys the message, “You are important to me”. “Being there, Being with” Achieved with eye contact, body language, voice tone, positive and encouraging attitude and communication Providing Touch: Conveys comfort, concern and support, acceptance Establishes a connection between nurse and person Task-oriented touch Caring touch Must be culturally sensitive Listening: Conveys full attention and interest “Taking in”, interpreting and understanding the meaning of what the person is saying Pay attention to words, tone of voice and perspective This leads to knowing your client KNOWING the client = the core of the nursing caring process: Much more than simply gathering data on the person Recognizing the person is unique and understanding what matters most to them. Allows you to choose the most appropriate therapies/interventions for your client Providing Spiritual Care: Spiritual health is a dimension of health just as physical, psychosocial Beliefs and expectations can impact physical health Spirituality offers a sense of connection with oneself, others, the environment, and a higher power Providing Family care: Caring for an individual does not occur in isolation from his family Family is a valuable resource Critical element: Encourage family to be active participants in the person’s care (if they wish) Family Perceptions of Caring: Be honest, open and willing to communicate Give clear explanations Keep family members informed Try to make the person comfortable Provide necessary emergency care Assure the person that nursing services will be available Allow patients to do as much for themselves as possible Teach the family how to keep their loved one physically comfortable Nurses Role in health care delivery: Incorporate caring into the philosophy of the workplace environment Include care concepts into nursing practice guidelines Demonstrate a commitment to caring by establishing personal, competent, compassionate, and meaningful nursing care Benner: Caring is primary Caring practices and expert knowledge are the heart of nursing practice and must be valued and embraced Caring facilitates a nurse’s ability to understand a client’s uniqueness, his/her problems and how they view their illness/health. Caring = being connected Leininger: transcultural perspective Caring distinguishes nursing from other health disciplines Stresses the importance of understanding cultural caring behaviours and other cultural aspects of care. The need for caring is universal, but the process of caring is unique to a specific culture Nurses must learn culture-specific words and behaviours Transcultural Nursing: IMPLICATIONS for Nursing Practice 1. Know about cultural norms 2. Become informed about end-of-life practices specific to a person's culture 3. Discover who is the most appropriate person(s) to provide presence or touch 4. Determine the need for gender-congruent caregivers 5. Avoid idioms Swanson: 5 Caring Processes 1. Knowing: Assisting the person to find meaning when they’re experiencing a challenging health situation 2. Being with- Being emotionally present for the person 3. Doing for -Tending to the person: comforting, doing what the patient could do for themselves if they were able 4. Enabling - Facilitating through life transitions: birth, death, divorce, etc. and or unfamiliar events 5. Maintaining belief-Sustaining faith: assists a person to get through an event, transition, and face a future with meaning. Instilling hope. Watson-Transpersonal Caring: Caring is almost spiritual Rather than focus on disease, focus on inner sources of healing to protect, enhance and preserve human dignity, humanity, wholeness and inner harmony Care is more important than cure Caring preserves human dignity in the technological, cure-dominated healthcare system Transforms client and nurse (a connection is formed) ROACH- the human act of caring: 1. Compassion 2. Competence 3. Confidence 4. Conscience 5. Commitment PULSARI (1998) added to the above: 6. Courage 7. Culture 8. Communication Barriers to being Caring include: The student nurse's values, prejudices Fears Lack of knowledge Lack of communication skills Personal characteristics (shyness) Hygiene and Skin Assessment Pages: Potter and Perry, Canadian Fundamentals of Nursing, 2024 p. 901-951 Jarvis, Physical Examination & Health Assessment, 2024 Ch. 13 p. 225-228 and table on p. 241 Learning Outcomes: 1. Describe the structure and function of the skin and mucous membranes. 2. Describe the parameters for subjective and objective assessment of the skin, hair, nails, and mucous membranes. 3. Describe the characteristics of adaptive skin, hair, nails and mucous membranes. a. Skin: Protects the body from sunlight and pollution. It can tan, thicken with exposure, and repair itself by growing new cells after cuts or injuries. b. Hair: helps keep the body warm by trapping heat & protects sensitive areas like the scalp from sunlight and dirt. c. Nails: protect the tips of fingers and toes from injury, help with gripping and picking up small objects. d. Mucous Membranes: membranes line areas like the mouth and nose, keeping them moist and trapping harmful particles like dust or bacteria to protect the body. 4. Describe changes to the skin, nails and mucus membranes related to the aging process. 5. Describe factors that influence hygiene practices in the adult and elderly (vision and sensation, self-care ability, cultural factors, hospitalization). 6. Identify clients at risk of alteration to the integrity of the skin, nails and mucus membranes. Hygiene care protects the body and reveals key info about a patient's health. It’s an intimate and vulnerable activity – maintaining privacy and warmth. Nurses need strong observation and communication skills to make patients comfortable and assess their skin. It strengthens the nurse-client relationship by allowing interaction and focusing on the patient’s needs. Goals of bathing and hygiene care (Reduce, Remove, Promote, Improve, Circulation): Reduce the number of microorganisms = reduced risk for infection Remove irritating substances ex. Urine Promote comfort Improve self-image and feelings of well-being Increase circulation Excellent opportunity to assess; Range of Motion (ROM). Dependency level for Activities of Daily Living (ADLs). Skin condition (overall). Hygiene care is never routine – a patient’s personal preferences for hygiene needs to be taken into consideration. Influenced by: Social practices – learned from parents, peers, work. Personal preferences – products, bath/shower, grooming. Body image – how appearance reflects self-view. Socioeconomic status – lack of resources. Health beliefs and motivation – understanding hygiene's link to health. Cultural variables – frequency, use of deodorant. Physical condition – limitations, pain, disabilities. Bathing rituals and use of water Guidelines for bathing a pt (WIPSO): ○ Warmth ○ Independence ○ Privacy ○ Safety ○ Organized Human body is like a fortress under attack. Defense system: ○ Physical barrier ○ Inflammatory response ○ Immune system Structure of skin: has three primary layers - epidermis, dermis, and subcutaneous (hypodermis) Function of the Skin The skin is a waterproof, almost indestructible covering that has protective and adaptive properties: 1. Protection – Minimizes injury from physical, chemical, thermal, and light sources. Anatomic barrier – Keratinized outer layer; sebum lowers pH (3-5), making it acidic and resistant to microorganisms. Shedding – Skin sheds daily, helping remove harmful bacteria (1 lb/year). 2. Temperature regulation – Heat dissipation via sweat, heat storage via subcutaneous insulation. 3. Water and electrolyte retention – Prevents loss of water and electrolytes. 4. Wound repair – Skin repairs itself by replacing cells at wound sites. 5. Vitamin D production – Converts cholesterol to vitamin D for absorption of calcium, iron, magnesium, phosphate, and zinc. 6. Mucous Membranes – Protective, excretory, sensory a. Respiratory Tract i. Mucous traps microorganisms ii. Cilia in nose and lungs, traps and propels b. Mouth i. Saliva – washes away ii. Contains lysozyme = inhibits growth c. Urinary Tract i. Urine acidic ii. Flow of urine cleanses the urethra d. Gastrointestinal Tract i. Very acidic e. Vagina i. Low pH (acidic) inhibits bacterial growth Assessment for changes in skin and mucous membranes Cultural Considerations: Be aware of normal biocultural differences Have the ability to recognise the unique clinical signs and symptoms of diseases that are especially important for people with dark pigmented skin. Melanin = various colours and tones of skin observed Melanin protects the skin against harmful ultraviolet rays, a genetic advantage accounting for the lower incidence of skin cancer in people with dark pigmented skin = Melanoma Tips for assessing Dark Pigmented Skin Light – Use natural light for accurate observation; fluorescent lights can alter perception. Areas to assess – Focus on lighter areas, like palms, nail beds, lips, or mucosa. Conjunctiva – Check the conjunctiva for pallor; it’s a reliable indicator. Erythema – Palpate surfaces to feel for redness (erythema). Pigment variations – Be aware of normal variations and hyperpigmented skin, including pigment on the tongue and nails. History – Listen to family comments about color changes and note any Mongolian spots (bruiselike marks in babies). Pigmentation Disorders/Disfiguring skin disorders Vitiligo: a long-term condition where pale white patches develop on the skin Albinism: the body makes little or no melanin KELOID Scarring: an area of irregular fibrous tissue formed at the site of a scar or injury. Hypertrophic scar. Keloid Skin Assessment 1. Skin - Inspect and Palpate for color, texture, thickness, turgor, temperature and hydration. a. Pallor= WHITE – no pink undertone – dark skin may look grey b. Erythema= RED – sunburn or inflammation – very difficult to observe in darker pigmented skin. Due to excess blood in dilated superficial capillaries, as in fever, local inflam-mation, or emotional reaction c. Cyanosis= BLUE – Reduced hemoglobin in the blood – oxygen deficient – nail beds, lips or mucous membranes d. Jaundice= YELLOW – yellowish staining of the skin, sclera. Increased bile Pigment (bilirubin) - juncture between hard and soft palate 2. Temperature - Normal skin feels warm to touch a. Hyperthermia = skin is hot to touch. A body temperature greater than 40°C b. Hypothermia = skin is cool/cold to touch. A drop in body temperature below 35°C 3. Moisture – Normal skin is dry to touch a. Perspiration is a normal response to activity, increased temp. or anxiety b. Diaphoresis – heavy perspiring c. Dehydration – skin dry, flaky & cracked. A condition that occurs when the body loses too much water and other fluids that it needs to work normally 4. Texture – Normal skin is smooth, soft, firm, even surface. 5. Thickness – Normal skin is uniform, thin with thickened areas on palms and soles of feet. 6. Turgor/Mobility – Ability of skin to return to normal shape. Normal skin moves easily when pinched & returns immediately < 3 secs = elasticity 7. Mucous Membranes - inspect membranes for any lesions, pain/discomfort, color, increase or decreased secretions, edema. ○ Nose ○ Eyes ○ Vagina ○ Mouth 8. Sensory – ability to respond to – touch, heat, cold, pain? 9. Hair a. Growth, distribution, pattern = General health status b. Assess the hair and scalp c. Healthy hair is clean, shiny and untangled, scalp free of lesions. d. Darker skin usually = darker, coarser and curlier hair e. Hair loss = alopecia = malnutrition, chemotherapy, hormonal changes, or improper hair care practices 10.Nails a. Inspect the condition of the fingernails and toenails b. The skin around the nails should be smooth without inflammation. c. Note the color, shape, thickness, adherence to nail bed, cleanliness Also assess for other abnormalities: L.I.C.C.F. (pronounced "lick if") 1. Lesions 2. Inflammation 3. Cracking 4. Curvature 5. Fungus 11.Hygiene - cleanliness or odor? Self-care ability? Overview of Skin Assessment 4 major causes for skin changes: Environmental Factors Internal: Increased body temperature (fever, exercise, anxiety, inflammation). External: Temperature extremes, irritants (clothing, soaps, urine, feces), sun exposure, injuries, piercings. Integrity of Body Systems Body systems interact; issues in one can affect others (e.g., lung disease causing cyanosis and clubbing; malnutrition causing skin and hair issues). Learned Behaviors Educated on healthy practices from family: ○ Proper hygiene ○ Effective oral care ○ Balanced diet ○ Sun protection Age-Related Issues Babies: prone to dehydration and rashes. Adolescents: acne. Elderly: skin issues. Changes in aging skin place patients more at risk for skin breakdown and injury Hair color – Looks grey or white, feels thin and fine. Axillary and pubic hair – Decreases in distribution. Nail changes – Nails grow slowly and become thicker and more brittle. Distribution changes – Males may have a symmetrical W-shaped balding; females may develop bristly facial hair. Psychological Impact: Changes in the skin and hair with ageing are very visible, normal processes of ageing. - Sagging and wrinkling skin - greying and thinning hair - For many self-esteem can be linked to a youthful appearance as portrayed in the media. The Elderly are at higher risk for skin disease and breakdown: Thinning of the skin – Skin becomes thinner over time. Vascularity – Decrease in vascularity and nutrients to the skin. Wound healing – Slower cell replacement and delayed healing when breakdown occurs. Cushioning loss – Loss of protective cushioning from the subcutaneous fatty layer. Social changes – Aging leads to less nutrition, limited financial resources, and sedentary lifestyles, increasing the chance of immobility. Identify five reasons why elderly people are more at risk for alterations in skin integrity? 1. Thinner skin – Skin gets thinner and is easier to tear. 2. Immobility – More sedentary lifestyle leads to a greater chance of immobility. 3. Nutrition – Decreased resources and nutrition, along with reduced blood flow and nutrients to tissues. 4. Damage from exposure – Lifetime exposure to harmful influences like sun and chemicals. 5. Skin dryness – Skin becomes drier, allowing lesions that let microorganisms penetrate Identify factors that influence hygiene practices in the older adult? 1. Mobility – Decreased mobility makes it difficult to get in and out of the shower or tub unassisted. 2. Energy – Decreased energy and stamina to wash thoroughly (due to aging or diseases like COPD). 3. Lack of resources – Lower income can limit access to hygiene products and services. 4. Vision – Decreased vision can hinder personal hygiene tasks. 5. Institutionalization – Hospitalization or institutionalization can lead to lack of privacy and unfamiliar surroundings. 6. Numbness – Decreased sensation can affect the ability to perform self-care tasks. Some additional skin conditions we may need to know LESION: An area of abnormal or damaged tissue caused by injury, infection, or disease ECCHYMOSIS: A small bruise caused by blood leaking from broken blood vessels into the tissues of the skin or mucous membranes EDEMA: swelling caused by too much fluid trapped in the body's tissues SCLERA: The white layer of the eye that covers most of the outside of the eyeball CONJUNCTIVA: a thin, clear membrane that covers the inner surface of the eyelid and is continued over the forepart of the eyeball PRURITIC: itching or a sensation on your skin that you want to scratch PERSPIRATION: the release of liquid from the body's sweat glands Other Lesions to include: MACULE: a flat, distinct, discolored area of skin PAPULE: a solid or cystic raised spot on the skin that is less than 1 cm wide NODULE: a growth of abnormal tissue TUMOUR: An abnormal mass of tissue that forms when cells grow and divide more than they should or do not die when they should. VESSICLE: A small blister-like elevation on the skin containing serous fluid PUSTULE: small, inflamed, pus-filled, blister-like sores (lesions) on the skin surface CYST: A closed sac or pouch with a definite wall, containing fluid, semifluid, or solid material ULCER: areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body Oxygenation: Cardiac Pages: Potter and Perry, Canadian Fundamentals of Nursing, 2024 pg. 538-545 & 549-563 Learning Outcomes: 1. Describe the objective and subjective assessment of oxygenation (cardiac). 2. State the parameters of normal pulse and blood pressure. 3. Identify and compare anatomical sites for determination of pulse and blood pressure. 4. Describe the factors that influence pulse and blood pressure. 5. Describe causes of changes in pulse and blood pressure in the hospitalized client. Vital Signs T = temperature P = pulse R = respiratory rate BP = blood pressure O₂ = oxygen saturation What is a Pulse? A heartbeat has two parts. Lubb and Dubb. Lubb happens when the upper chambers (atriums) of the heart contract to squeeze the blood downward into the ventricles. Dubb happens when the lower chambers (ventricles) contract. Every time the lower chambers of the heart contracts, the blood in the left ventricle rushes towards the aorta Measuring Pulse Rate Wash hands Choose appropriate site Locate pulse Note: ○ Rate the patient’s baseline rate should be reviewed for comparison Changes in posture cause changes in heart rate because of alterations in blood volume and sympathetic nervous system activity. The heart rate temporarily increases when a person changes from a lying to a sitting or standing position. Factors of heart rate: Exercise, Temperature, Emotions, Pain, Medications, Hemorrhage, Postural changes, Pulmonary conditions ○ Rhythm Normally, a regular interval occurs between each pulse or heartbeat. An interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm, or dysrhythmia. Dysrhythmia threatens the heart’s ability to provide adequate cardiac output, particularly if it occurs repetitively. ○ Quality/ Strength Reflects both the volume of blood ejected against the arterial wall with each heart contraction and the condition of the arterial vascular system leading to the pulse site. Is the pulse absent, present, bounding? grading scale of 0 to 4: absent (0, arterial clot), diminished (1+, blood loss, shock), normal (2+), full pulse increased (3+) or bounding (4+, fever) ○ Equality A pulse in one extremity may be unequal to the pulse in the other extremity in strength, or it may be absent in many disease states Ex: blood clot, stroke Pulse Deficit If pulse is regular, then count for 30 seconds and multiply by 2 if irregular then take for a full minute. Normal adult = 60-100 bpm (beats per minute) Peripheral Pulse Sites (most important: brachial, radial, carotid, dorsalis pedis) When cardiac output declines significantly, peripheral pulses weaken and are difficult to palpate. Nurses most commonly assess the radial and apical pulses in adult patients, but people who are learning to monitor their own heart rates use the radial or carotid pulse. If the radial pulse at the wrist is abnormal or intermittent, or if it is inaccessible because of a dressing or cast, the apical pulse should be assessed. In infants or young children, it is best to assess the brachial or apical pulse because other peripheral pulses are deep and difficult to palpate accurately. Most used location = Radial Artery Get your thumb OUT OF THE WAY Apical Pulse PMI (Point of Maximal impulse) or the true pulse How to locate: Auscultated with stethoscope over apex of heart Apex located on the left side of the chest between the fifth and sixth ribs, midclavicular line (MCL) Just below left nipple in men, under left breast in women Listen for two sounds – LUB/DUB The louder sound LUB is counted Count for a full minute Define the following terms: Pulse Deficit: When the heart is too weak to send blood to peripheral arteries: dysrhythmias (abnormal speed or rhythm) or circulatory problems. The difference between the apical pulse and the radial pulse. One person counts apical. One person counts the radial pulse. ○ Apical pulse = 110 ○ Radial pulse = 80 ○ Pulse deficit = 30 Arrhythmia/Dysrhythmia (one of the defining characteristics of many nursing diagnoses): abnormal heart rhythm AT REST (ex: fibrillation) Bradycardia (one of the defining characteristics of many nursing diagnoses): Pulse rate AT REST less than 60 bpm Tachycardia (one of the defining characteristics of many nursing diagnoses): Pulse rate AT REST more than 100 bpm Factors which can affect pulse rate: 1. Bradycardia: Adult < 60bpm a. Athlete, emotions, extreme cold, medications, horizontal position (sleeping) 2. Tachycardia: Adult > 100bpm a. Exercise, fever, hot environment, emotions, pain, medications, hemorrhage, lack of oxygen Blood Pressure To assess BP – you will need: Blood Pressure Cuff / Sphygmomanometer Important - Choose the correct cuff size Stethoscope What is Blood Pressure? Force created by the blood pushing against the artery walls/force exerted on the walls of an artery by the pulsing blood under pressure from the heart Left (Lt.) ventricle contracts – blood is forced out into the aorta to the large arteries, smaller arteries & capillaries. Systolic: force exerted against the arterial wall as lt. ventricle contracts & pumps blood into the aorta = max. pressure exerted on vessel wall. Diastolic: arterial pressure during ventricular relaxation, when the heart is filling, minimum pressure in arteries. What is a Baseline Blood Pressure? Normal blood pressure Why is this important to know? Provides a comparison How do we determine what this is? 1. Look at the previous readings on the graphic sheet OR 2. Determine the systolic BP by palpating it Why is it important to know what the client's baseline blood pressure is? Assists the nurse to know how high to inflate the cuff Avoids false readings due to the “Auscultatory Gap” (extremely important for hypertension patients, you could miss the fact that they’re about to have a stroke) How do I determine this if there is no previous reading recorded? 1. Inflate the cuff while palpating radial/brachial artery 2. Note reading it at which pulse disappears 3. Continue to inflate 30 mmHg 4. Deflate the cuff slowly and note reading when pulse is felt/reappears 5. Deflate cuff completely and wait 30 sec a. = Palpated Systolic Value 6. 3 tries to get BP right or get the teacher to get someone else to do it Next: With stethoscope in ears locate the brachial artery – place diaphragm over site Close valve on bulb. Inflate cuff 30 mm Hg above palpated systolic pressure. Slowly release valve. Note point on manometer when first clear sound is heard = systolic pressure Continue to deflate noting point @ which sound disappears = diastolic pressure Deflate and remove cuff Auscultatory/Korotkoff Sounds Phase 1: The first appearance of faint, repetitive, clear tapping sounds that gradually increase in intensity for at least 2 consecutive beats is the systolic blood pressure. Phase 5: The point at which all sounds disappear completely is the diastolic pressure The 1st and 5th sounds are most important to identify. What is the auscultatory gap and why does this matter? The auscultatory gap is a brief period when blood flow sounds disappear during blood pressure measurement, which can lead to inaccurate readings, especially underestimating systolic pressure. It often occurs in people with cardiovascular issues like hypertension or arterial stiffness. Blood Pressure: Normal adult average: 120/80 Normal range for adult BP: 90-139/60-89 Hypertension = more than 140-159/more than 90-99, often asymptomatic, is associated with thickening and loss of elasticity in the arterial walls Hypotension = less than 90 (might have symptoms like feeling dizzy when getting up), for the majority of people, low blood pressure is an abnormal finding associated with illness. Orthostatic Hypotension/Postural Hypotension Position changes B/P = lying to sitting to standing Blood pressure drops within 3 min of standing 20 mmHg systolic/10mmHg diastolic Symptoms for Orthostatic Hypotension: Dizziness, lightheadedness, blurred vision, fainting Major Causes/Factors for Changes in Blood Pressure Measurements Age: increases with age from child to elderly due to stiffening of arteries and reduced elasticity of blood vessels. Emotions/Stress: pain, fear, anxiety (white coat syndrome) result in stimulation of the sympathetic nervous system, which increases heart rate, cardiac output, and peripheral vascular resistance. These alterations, in turn, increase blood pressure. Ethnicity: South Asian, Indigenous, and people of African descent Gender: minor variances. After puberty, children with male genitalia tend to have higher blood pressure readings. Factors such as pregnancy, birth control, and menopause can increase the risk of hypertension in persons with female genitalia throughout the lifespan. Daily variations: lower during sleep, higher throughout the day Medications: cardiac meds, analgesics, IV fluids Others: smoking, obesity, exercise, hemorrhage, dehydration Comparison of anatomical sites for determination of blood pressure Oxygenation: Respiratory Pages: Potter and Perry, Canadian Fundamentals of Nursing, 2024 pg. 545-549 & 957-961 Learning Outcomes: 1. Describe the objective and subjective assessment of oxygenation: respiratory. 2. State parameters of normal respiration. 3. Describe physiological changes in oxygenation in the adult and elderly. 4. Describe factors that can affect oxygenation in the hospitalized adult and elderly. 5. Identify diagnostic tests used to assess oxygenation: respiratory. 6. Describe nursing interventions to promote healthy oxygenation in the hospitalized client. What is oxygen? Oxygen and nitrogen are the two main gases in the air we breathe. Oxygen accounts for about 21% of gas in air. The abbreviation for oxygen is O2. Every cell in our body needs oxygen to live. 3 processes of Oxygenation 1. VENTILATION: Breathing or respiration ○ The process of moving gases into and out of the lungs = breathing/respiration (inspiration/expiration = 1 respiration) ○ Breathing : Expansion of the lungs or inspiration = active process Contraction of the lungs or expiration = passive process 2.GAS EXCHANGE - Oxygen & Carbon Dioxide Oxygen is transferred from the lungs to the blood for transport to tissues Carbon dioxide is transferred from the blood to the alveoli to be exhaled Gas Exchange occurs on the Alveolocapillary membrane by diffusion. ○ Diffusion: Movement of molecules from an area of higher concentration to an area of lower concentration. Hemoglobin: a protein composed of iron in RBCs (red blood cells) binds with oxygen and releases it in the tissues Normal Gas Exchange depends on the following factors: i. The concentration gradient of the gases (% Oxygen & Carbon dioxide) ii. Intact Alveolar membranes (No disease, edema, or surgical procedures) iii. Adequate blood supply to the alveoli Gas exchange cannot be observed since it is occurring in the lungs at a cellular level. Lab tests can help provide data – Arterial Blood Gases (ABG’s) measure the concentration of oxygen and CO2 in the blood. 3. TRANSPORT OF GASES ○ For oxygen to be delivered to body tissues it is dependent on an intact and functioning cardiovascular system ○ Heart and Vessels (veins and arteries) and sufficient blood flow. The accurate assessment of respiration depends on the recognition of normal thoracic and abdominal movements. During quiet breathing, the chest wall gently rises and falls. Contraction of the accessory muscles of breathing is not visible. Assessment of Ventilation 1. Respiratory Rate: Normal 10-20 bpm ○ The following are terms used to describe changes in respiratory rate. Bradypnea: Respirations less than 10 bpm Tachypnea: Respirations more than 24 bpm Hyperpnea: Respirations are laboured, increased in depth, and increased in rate (>20 breaths per minute). This occurs normally during exercise. Apnea: Short periods with NO breathing then resume Respiratory Arrest: Prolonged period with NO breathing ○ When Taking a Respiratory Rate You need to be aware of the following: ○ Important to be discreet when taking RR ○ Not a conscious process ○ Average adult respiratory rate = 12-20 pm (P&P) & 10-20 bpm (Jarvis) 2. Respiratory Rhythm (Ventilatory Rhythm): ○ normal rhythm can be described as: Rhythmic, even chest wall movements Effortless Equal intervals between cycles (regularity) ○ breathing pattern can be determined by observing the chest or the abdomen. ○ diaphragmatic breathing results from the contraction and relaxation of the diaphragm and is best observed by watching abdominal movements 3. Depth of Respirations ○ Described as either Shallow, Normal or Deep A deep respiration involves full expansion of the lungs with full exhalation. Respirations are shallow when only a small quantity of air passes through the lungs and ventilatory movement is difficult to see. ○ Any Use of Accessory muscles? ○ Assess with the inspirometer or with pulmonary function tests 4. BREATH SOUNDS Normal breath sounds will be described as: ○ Clear ○ “Swishy or breezy” ○ Can also be described by the absence of any Abnormal or Adventitious sounds (Abnormal sounds like wheezing or crackling) 5. SUBJECTIVE FEELINGS Examiner would ask the following questions: ○ Shortness of breath (SOB) ○ Difficulty breathing? What is DYSPNEA? Subjective feeling of having difficulty breathing. Ex: SOB, chest pain, “can’t” catch my breath 6. Assess Blood pressure and Pulse: See cardiac oxygenation class (transport of oxygen and adequate blood supply to the lungs) 7. SKIN COLOR, WARMTH & MOISTURE: Warm and dry to touch Pink undertone No sign of pallor or cyanosis 8. CAPILLARY REFILL Normal = push on nail bed to make it blanch, colour should return to the nail in less than 3 seconds ○ This tells you how well the tissues are being perfused with blood Then Transport of Gases 9. ACTIVITY TOLERANCE Usual ADLs should not cause SOB or fatigue 10. LOC = level of consciousness/ responsiveness Fainting = decreased oxygen to the brain 11. BEHAVIOUR Orientation x3 = Person, Place & Time No signs of confusion or agitation 12. PRESENCE OF A COUGH Productive cough (When they cough, do they produce anything? Can they spit up mucous? wet-sounding cough) Non-productive cough Sputum – It is important to take notice of any mucus that the client might expectorate (spit) ○ Look at amount, colour, odour, consistency, thickness 13. DIAGNOSTIC TESTS CBC = complete blood count = hemoglobin and rbcs ABG = arterial blood gas = oxygen and CO2 content in blood ○ Blood tests ○ Oxygen Saturation (O2 Sat): the pulse oximeter measures the amount of oxygen that the hemoglobin is carrying or is saturated with Normal Saturation value is: 95-100% Factors can cause an inaccurate reading = poor circulation, cold fingers, shaking, nail polish, jaundice or artificial nails Other tests: ○ STRESS TEST: tests for activity intolerance ○ SPUTUM CULTURE: tests for presence of bacteria = lung infection ○ CHEST X-RAY ○ Computed Tomography (CT SCAN) ASSESSMENT OF CAUSES 1. Structural Integrity: Airway is intact and patent – no foreign bodies present, positioning to support lung function Musculoskeletal functioning Bone structure and muscles Free of any disease or trauma Pregnancy or obesity Neuro Control Center & Nerve pathway intactness No diseases like multiple sclerosis or muscular dystrophy No trauma to the spinal cord or brain Medications like narcotics and anesthetics decrease the respiratory rate = suppress respirations 2. Presence of Pain ○ When pain is present, especially chest or abdominal pain, there is a decrease in chest expansion = shallow breathing 3. Environment ○ Changes in altitude = decreased oxygen content in air (N=21%) ○ Changes in external temp = increased metabolic rate to meet the demands of heating or cooling the body Increase BMR = increase O2 demands ○ Inhaled toxins Cigarette smoke Carbon monoxide Other irritants 4. Disruptions of other body systems/components Examples of this are: If one body system is not functioning well, it will have an impact on another system. All systems are interconnected. Nutrition: Less iron = less hemoglobin (carries oxygen to the tissues) High fat content in diet = obesity – fat tissue is less vascular – less oxygen can be carried to tissue Fluid and Electrolytes: Dehydration or low blood volume = less circulating rbcs = less oxygen carrying capacity of blood Skin Integrity: Injury/surgery = more risk for infection and fever = more oxygen demands because of increased metabolic demands for tissue repair and ot fight microorganisms Hemorrhage = blood loss leads to decreased oxygen-carrying capacity = increased heart rate and vasoconstriction to maintain perfusion = higher oxygen demands to support vital organs and compensate for reduced blood flow Activity and Rest: As the level of activity goes up the body’s oxygen needs increase Physically fit = stronger heart muscle = more cardiac output or blood flow with less effort than an unfit person Emotional Factors: Anxiety, stress or excitement goes up the respiratory rate – increase O2 demands Medications: ○ Cns depressants: opioids and sedatives ○ Digitalis: more cardiac output = more oxygen supply Age – Aging adult Less muscle strength Costal cartilage (joins the ribs to the sternum) ○ More rigid = calcified More than 50 yrs lung tissue becomes less elastic = harder to inflate lungs = more risk for dyspnea Altered Cardiac Functioning: Less cardiac output = less blood circulation = less oxygen to the tissues Knowledge level re self-care: Understands how to meet oxygen demands Aware of what enhances or what hinders their condition ○ Ex: someone who is diagnosed with asthma and continues to smoke, not understanding/aware of the consequences The Client Interview Pages: Potter and Perry, Canadian Fundamentals of Nursing, 2024 p.191-193, p. 282 box 18.6 and p. 288 box 18.8 Jarvis Physical Examination and Health Assessment Canadian Ed, 2019 Ch. 4 Learning Outcomes: 1. Define the term Interview. 2. Describe the purpose of the nurse-client interview. 3. Describe each phase of the interview and its purpose (pre interaction, introductory, working and termination). 4. Describe the appropriate use of open and closed ended questions during the interview process. 5. Describe factors to consider when planning an interview (physical setting and environment). 6. Describe the relevance of establishing a clear agreement with the person regarding the purpose of the interview and the course of the interview. 7. Describe the factors to consider when interviewing (age, gender, sexual orientation, culture) 8. Describe stra

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