Online Reference Notes: 2009-08-30

Bullets

HI there....welcome To test visual acuity, the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without, as appropriate. Fundamental of Nursing Before teaching any procedure to the patient, the nurse must first assess the patient’s willingness to learn and his current knowledge. Fundamentals of Nursing A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure reading. Fundamentals of Nursing When preparing a single injection for a patient who takes regular and NPH insulin, the nurse should draw the regular insulin into the syringe first because it is clear and can be measured more accurately than the NPH insulin, which is turbid. Fundamentals of Nursing Rhonchi refers to the rumbling sounds heard on lung auscultation; they are more pronounced during expiration than during inspiration. Fundamentals of Nursing Gavage refers to forced feeding, usually through a gastric tube (a tube passed into the stomach by way of the mouth). Fundamentals of Nursing According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. Fundamentals of Nursing Checking the identification band on a patient’s wrist is the safest and surest way to verify a patient’s identity. Fundamentals of Nursing A patient’s safety is the priority concern in developing a therapeutic environment. Fundamentals of Nursing The nurse should place the patient with a Sengstaken-Blakemore tube in semi-Fowler’s position. Fundamentals of Nursing The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery; hand and finger spasms during occlusion indicate Trousseau’s sign and suggest hypocalcemia. Fundamentals of Nursing For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Fundamentals of Nursing Pain that incapacities a patient and can’t be relieved by drugs is called intractable pain. Fundamentals of Nursing In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic transmission. Fundamentals of Nursing Decibel is the unit of measurement of sound. Fundamentals of Nursing Informed consent is required for any invasive procedure. Fundamentals of Nursing A patient who can’t write his or her name to give consent for treatment must have his or her X witnessed by two persons, such as a nurse, priest, or doctor. Fundamentals of Nursing The Z-track I.M. injection technique seals medication deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that is 1’’ (2.5 cm) or longer. Fundamentals of Nursing A registered nurse (RN) should assign a licensed vocational nurse (LVN) or licensed practical nurse (LPN) to perform bedside care, such as suctioning and medication administration. Fundamentals of Nursing The therapeutic purposed of a mist tent is to increase hydration of secretions. Fundamentals of Nursing If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention. Fundamentals of Nursing The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. Fundamentals of Nursing To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2” (5 cm) to that measurement. Fundamentals of Nursing Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. Fundamentals of Nursing The appropriate needle size for an insulin injection is 25G and ⅝" (1.5 cm) long. Fundamentals of Nursing Residual urine refers to urine that remains in the bladder after voiding. The amount of residual urine normally ranges from 50 to 100 ml. Fundamentals of Nursing The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Fundamentals of Nursing Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Fundamentals of Nursing Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Fundamentals of Nursing Evaluation refers to the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan, making the nursing process circular. Fundamentals of Nursing In the event of fire, the nurse should (1) remove the patient, (2) call the fire department, (3) attempt to contain the fire by closing the door, and (4) extinguish the fire, if it can be done safely. Fundamentals of Nursing Before administering any as need pain medication, the nurse should ask the patient to indicate the pain’s location. Fundamentals of Nursing Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people. Fundamentals of Nursing When providing oral care for an unconscious patient, the nurse should position the patient on the side to minimize the risk of aspiration. Fundamentals of Nursing During assessment of distance vision, the patient should stand 20’ (6.1 m) from the chart. Fundamentals of Nursing The ideal room temperature for a geriatric patient or one who is extremely ill ranges form 66º to 76º F (18.8º to 24.4º C). Fundamentals of Nursing Normal room humidity ranges from 30% to 60%. Fundamentals of Nursing Hand washing is the single best method of limiting the spread of microorganisms. Hands should be washed for 10 seconds after routine contact with a patient and after gloves are removed. Fundamentals of Nursing To catheterize a female patient, the nurse should place her in the dorsal recumbent position. Fundamentals of Nursing A positive Homan’s sign may indicate thrombophlebitis. Fundamentals of Nursing Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent equals the number of milligrams per 100 milliliters of a solution. Fundamentals of Nursing Metabolism takes a place in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). Fundamentals of Nursing The basal metabolic rate represents the amount of energy needed to maintain essential body functions. It is measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. Fundamentals of Nursing Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains adequate intestinal motility, and helps establish regular bowel habits. Fundamentals of Nursing Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Fundamentals of Nursing Petechiae refers to tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Fundamentals of Nursing Purpura refers to a purple skin discoloration caused by blood extravasation. Fundamentals of Nursing Glucose-6-phosphate dehydrogenase (C6PD) deficiency is an inherited metabolic disorder characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Fundamentals of Nursing According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use because most needle sticks result from missed needle recapping. Fundamentals of Nursing The nurse administers a drug by I.V. push by delivering the dose directly into a vein, I.V. tubing, or catheter with a needle and syringe. Fundamentals of Nursing When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. Fundamentals of Nursing A nurse should have assistance when changing the ties on a tracheostomy tube. Fundamentals of Nursing A filter is always used for blood transfusions. Fundamentals of Nursing A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. Fundamentals of Nursing The patient should carry a cane on the unaffected side to promote a reciprocal gait pattern and distribute weight away from the affected leg. Fundamentals of Nursing A good way to begin a patient interview is to ask “What made you seek medical help?” Fundamentals of Nursing The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. Fundamentals of Nursing Potassium (K+) is the most abundant cation in intracellular fluid. Fundamentals of Nursing In the four-point gait (or alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. Fundamentals of Nursing In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. Fundamentals of Nursing In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch. Fundamentals of Nursing Vitamin B complex, the water-soluble vitamins essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). Fundamentals of Nursing When being weighed, an adult patient should be lightly dressed and shoeless. Fundamentals of Nursing Before taking an adult’s oral temperature, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the past 15 minutes. Fundamentals of Nursing The nurse shouldn’t take a rectal temperature on an adult patient if the patient has a cardiac disorder; anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. Fundamentals of Nursing In a patient with cardiac problems, rectal temperature measurement may stimulate a vagal response, leading to vasodilation and decreased cardiac output. Fundamentals of Nursing When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3 indicates a bounding pulse (readily palpable and forceful); +2, a normal pulse (easily palpable); +1, a thready or weak pulse (difficult to detect); and 0, an absent pulse (not detectable). Fundamentals of Nursing The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit. Fundamentals of Nursing On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water, has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have taken and recorded. Artificial limbs and other prostheses are usually removed. Fundamentals of Nursing Comfort measures, such as positioning the patient, performing backrubs, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness. Fundamentals of Nursing A drug has three names: its generic name, which is used in official publications; its trade name or brand name (such as Tylenol), which is selected by the drug company; and its chemical name, which describes the drug’s chemical composition. Fundamentals of Nursing The patient should take a liquid iron preparation through a straw to avoid staining the teeth. Fundamentals of Nursing The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). Fundamentals of Nursing An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. Fundamentals of Nursing In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. Fundamentals of Nursing To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if indicated; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. Fundamentals of Nursing The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. Fundamentals of Nursing A slight blood pressure difference (5 to 10 mm Hg) between right and left arms is normal. Fundamentals of Nursing The nurse should place the blood pressure cuff 1'' (2.5 cm) above the antecubital fossa. Fundamentals of Nursing When instilling ophthalmic ointments, waste the first bed of ointment and then apply from the inner canthus to the outer canthus; twist the medication tube to detach the ointment. Fundamentals of Nursing The nurse should use a leg cuff to measure blood pressure in an obese patient. Fundamentals of Nursing If the blood pressure cuff is applied too loosely, the reading will be falsely elevated. Fundamentals of Nursing Ptosis refers to eyelid drooping. Fundamentals of Nursing A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. Fundamentals of Nursing To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. Fundamentals of Nursing To move the patient to the edge of the bed for transfer, follow these steps: (1) Move the patient’s head and shoulders toward the edge of the bed. (2) Move the patient’s feet and legs to the edge of the bed (crescent position). (3) Place both the arms well under the patient’s hips and straighten the back while moving the patient toward the edge of the bed. Fundamentals of Nursing When being measured for crutches, a patient should wear his or her shoes. Fundamentals of Nursing The nurse should attach a restraint to a part of the bed frame that moves with the head, not to the mattress or side rails. Fundamentals of Nursing The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern. Fundamentals of Nursing To administer heparin subcutaneously, the nurse should follow these steps: (1) Clean, but don’t rub, the site with alcohol. (2) Stretch the skin taut or pick up a well-defined skin fold. (3)Hold the shaft of the needle in a dart position. (4)Insert the needle into the skin at a right (90-degree) angle. (5)Firmly depress the plunger; but don’t aspirate. (6)Leave the needle in place for 10 seconds. (7)Withdraw the needle gently at the same angle it was inserted. (8)Apply pressure to the injection site with an alcohol pad. Fundamentals of Nursing For a sigmoidoscopy, the nurse should place the patient in a knee-chest or Sims’ position, depending on the doctor’s preference. Fundamentals of Nursing Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort) safety and security, love and belonging, self-esteem and recognition, and self-actualization. Fundamentals of Nursing When caring for patient with a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. Fundamentals of Nursing During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. Fundamentals of Nursing In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage, for example, “10 mm of brown mucoid drainage noted on dressing.” Fundamentals of Nursing To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as thumbnail. Fundamentals of Nursing In a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out. Fundamentals of Nursing When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. Fundamentals of Nursing The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Fundamentals of Nursing Antiembolism stockings decompress the superficial blood vessels, thereby reducing the risk of thrombus formation. Fundamentals of Nursing The most convenient veins for venipuncture in a adult patient are the basilic and median cubital veins in the antecubital space. Fundamentals of Nursing From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify adequate gastric emptying. Fundamentals of Nursing People with type O blood are considered to be universal donors. Fundamentals of Nursing People with type AB blood are considered to be universal recipients. Fundamentals of Nursing Herts (Hz) refers to the unit of measurement of sound frequency. Fundamentals of Nursing Hearing protection is required when the sound intensity exceeds 84 dB; double hearing protection is required if it exceeds 104 dB. Fundamentals of Nursing Prothrombin, a clotting factor, is produced in the liver. Fundamentals of Nursing If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. Fundamentals of Nursing During lumbar puncture, the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. Fundamentals of Nursing A patient who can’t cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of a sample. Fundamentals of Nursing If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. Fundamentals of Nursing When leaving an isolation room, the nurse should remove the gloves before the mask because fewer pathogens are on the mask. Fundamentals of Nursing Skeletal traction is applied to a bone using wire pins or tons. It is the most effective means of traction. Fundamentals of Nursing The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use because delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Fundamentals of Nursing Medication isn’t routinely injected I.M. into edematous tissue because it may not be absorbed. Fundamentals of Nursing When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Fundamentals of Nursing When cleaning dentures, the sink should be lined with a washcloth. Fundamentals of Nursing A patient should void within 8 hours after surgery. Fundamentals of Nursing An EEG identifies normal and abnormal brain waves. Fundamentals of Nursing Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. Fundamentals of Nursing The autonomic nervous system regulates the cardiovascular and respiratory systems. Fundamentals of Nursing When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. Fundamentals of Nursing A low-residue diet includes such as foods as roasted chicken, rice, and pasta. Fundamentals of Nursing A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a loss of sphincter control. Fundamentals of Nursing A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. Fundamentals of Nursing When lifting and moving a patient, the nurse should use the upper leg muscles most to prevent injury. Fundamentals of Nursing Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal. Fundamentals of Nursing During occupied bed changes, the patient should be covered with a black blanket to promote warmth and prevent exposure. Fundamentals of Nursing Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is inevitable. Fundamentals of Nursing The following foods can alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). Fundamentals of Nursing When preparing a patient for a skull X-ray, have the patient remove all jewelry and dentures. Fundamentals of Nursing The fight-or-flight response is a sympathetic nervous system response. Fundamentals of Nursing Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Fundamentals of Nursing Wheezing refers to an abnormal, high-pitched breath sound that is accentuated on expiration. Fundamentals of Nursing Wax or a foreign body in the ear should be gently flushed out by irrigation with warm saline solution. Fundamentals of Nursing If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries. Fundamentals of Nursing The nurse should grade hyperactive biceps and triceps reflexes +4. Fundamentals of Nursing If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. Fundamentals of Nursing In a postoperative patient, forcing fluids helps prevent constipation. Fundamentals of Nursing The nurse must administer care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. Fundamentals of Nursing The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1º C. Fundamentals of Nursing As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. Fundamentals of Nursing The body metabolizes alcohol at a fixed rate regardless of serum concentration. Fundamentals of Nursing In an alcoholic beverage, its proof reflects its percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. Fundamentals of Nursing A living will is a witnessed document that states a patient’s desire for certain types of care and treatment, which depends on the patient’s wishes and views and quality of life. Fundamentals of Nursing The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Fundamentals of Nursing Quality assurance is a method of determining whether nursing actions and practices meet established standards. Fundamentals of Nursing The five rights of medication administration are the right patient, right medication, right dose, right route of administration, and the right time. Fundamentals of Nursing Outside of the hospital setting, only the sublingual and transligual forms of nitroglycerin should be used to relieve acute anginal attacks. Fundamentals of Nursing The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities. Fundamentals of Nursing The Patient’s Bill of Rights offers guidance and protection to patients by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. Fundamentals of Nursing To minimize the omissions and distortion of facts, the nurse should record information as soon as it is gathered. Fundamentals of Nursing When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. Fundamentals of Nursing Drug administration is a dependent activity. The nurse can administer or withhold a drug only with the doctor’s permission. Fundamentals of Nursing The nurse shouldn’t give false assurance to a patient. Fundamentals of Nursing After receiving preoperative medication, a patient isn’t competent to sign an informed consent form. Fundamentals of Nursing When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. Fundamentals of Nursing A nurse may clarify a doctor’s explanation to a patient about an operation or a procedure but must refer questions about informed consent to the doctor. Fundamentals of Nursing The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse of its own and may be confused with the patient’s pulse. Fundamentals of Nursing An inspiration and an expiration count as one respiration. Fundamentals of Nursing Normal respirations are known as eupnea. Fundamentals of Nursing During a blood pressure measurement, the patient should rest the arm against a surface because using muscle strength to hold up the arm may raise the blood pressure. Fundamentals of Nursing Major unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Fundamentals of Nursing Inspection is the most frequently used assessment technique. Fundamentals of Nursing Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a homey atmosphere. Fundamentals of Nursing The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Fundamentals of Nursing Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidosmastoid muscle use during respiration. Fundamentals of Nursing When patients use axillary crutches, their palms should bear the brunt of the weight. Fundamentals of Nursing Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Fundamentals of Nursing Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which that patient’s foot moves forward. Fundamentals of Nursing The phases of mitosis are prophase, metaphase, anaphase, and telophase. Fundamentals of Nursing The nurse should follow standard precautions in the routine care of all patients. Fundamentals of Nursing The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. Fundamentals of Nursing The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president for the United States?” Fundamentals of Nursing Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. Fundamentals of Nursing The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). Fundamentals of Nursing The autonomic nervous system controls the smooth muscles. Fundamentals of Nursing A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It is developed in collaboration with the patient. Fundamentals of Nursing The optic disk is yellowish pink and circular with a distinct border. Fundamentals of Nursing A primary disability results from a pathologic process; a secondary disability, from inactivity. Nurses usually are held liable for failing to keep an accurate count of sponges and other devices during surgery. Fundamentals of Nursing The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Fundamentals of Nursing Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, leafy vegetables, eggs, and whole gains, generally have low water content. Fundamentals of Nursing Collaboration refers to joint communication and decision making between nurses and doctors designed to meet patients’ needs by integrating the care regimens of both professions in one comprehensive approach. Fundamentals of Nursing Bradycardia refers to a heart rate of fewer than 60 beats/minute. Fundamentals of Nursing A nursing diagnosis is a statement of a patient’s actual or potential health problems that can be resolved, diminished, or otherwise changed by nursing interventions. Fundamentals of Nursing During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. Fundamentals of Nursing The patient’s health history consists primarily of subjective data, information supplied by patient. Fundamentals of Nursing The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. Fundamentals of Nursing When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign every entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Fundamentals of Nursing Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. Fundamentals of Nursing The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery, which is compressed against the radius to take the pulse rate. Fundamentals of Nursing The normal pulse rate of a resting adult is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Fundamentals of Nursing Laboratory test results are an objective form of assessment data. Fundamentals of Nursing The measurement systems most often used in clinical practice are the metric system, apothecaries’ system, and household system. Fundamentals of Nursing Before signing an informed consent, a patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phase; the risk involved; and the possible complications. The patient also should have a general idea of the time required from surgery to recovery and should have an opportunity to ask questions. Fundamentals of Nursing A patient must sign a separate informed consent form for each procedure. Fundamentals of Nursing During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds (that helps determine the size, shape, position, and density of underlying organs and tissues), elicit tenderness, or assess reflexes. Fundamentals of Nursing Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. Fundamentals of Nursing A foot cradle keeps bed linen off the patient’s feet, which prevent skin irritation and breakdown, especially in a patient with peripheral vascular disease or neuropathy. Fundamentals of Nursing If the patient is a married minor, permission to perform a procedure can be obtained form the patient’s spouse. Fundamentals of Nursing Gastric lavage is the flushing of the stomach and removal of ingested substances through a nasogastric tube. It can be used to treat poisoning or drug overdose. Fundamentals of Nursing During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy. Fundamentals of Nursing Bruits commonly indicate a life- or limb-threatening vascular disease. Fundamentals of Nursing O.U. means each eye; O.D., right eye; and O.S, left eye. Fundamentals of Nursing To remove a patient’s artificial eye, the nurse depresses the lower lid. Fundamentals of Nursing The nurse should use a warm saline solution to clean an artificial eye. Fundamentals of Nursing A thready pulse is very fine and scarcely perceptible. Fundamentals of Nursing Axillary temperature usually is 1º F lower than oral temperature. Fundamentals of Nursing After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. Fundamentals of Nursing On a medication prescription, the abbreviation p.c. means that the medication should be administered after meals. Fundamentals of Nursing After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Fundamentals of Nursing Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Fundamentals of Nursing Gauge refers to the inside diameter of a needle. The smaller the gauge, the larger the diameter. Fundamentals of Nursing An adult normally has 32 permanent teeth. Fundamentals of Nursing After turning a patient, the nurse should document the position used, time turned, and skin assessment findings. Fundamentals of Nursing PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. Fundamentals of Nursing When purcussing a patient’s chest for postural drainage, the nurse’s hands should be cupped. Fundamentals of Nursing When measuring a patient’s pulse, the nurse should assess the rate, rhythms, quality, and strength. Fundamentals of Nursing Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels. Fundamentals of Nursing When assessing respirations, the nurse should document the rate, rhythm, depth, and quality. Fundamentals of Nursing For a subcutaneous injection, the nurse should use a ⅝" 25G needle. Fundamentals of Nursing The notation “AA & O x 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fundamentals of Nursing Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or stool, and perspiration. Fundamentals of Nursing After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results. Fundamentals of Nursing When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle) with the bevel up. Fundamentals of Nursing To obtain an accurate blood pressure, the nurse should inflate the manometer 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. Fundamentals of Nursing The nurse should count an irregular pulse for 1 full minute. Fundamentals of Nursing A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Fundamentals of Nursing Prophylaxis is disease prevention. Fundamentals of Nursing Body alignment is achieved when the body parts are in proper relation to their natural position. Fundamentals of Nursing Trust is the foundation of a nurse-patient relationship. Fundamentals of Nursing Blood pressure in the force exerted by the circulating volume of blood on arterial walls. Fundamentals of Nursing Malpractice refers to the professional’s wrongful conduct, improper discharge of duties, or failure to meet standers of care, which causes harm to another. Fundamentals of Nursing As a general rule, nurses can’t refuse a patient care assignment; however, they may refuse to participate in abortions in most states. Fundamentals of Nursing A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform. Fundamentals of Nursing States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from such assistance. These laws don’t apply to care provided in a health care facility. Fundamentals of Nursing A doctor should sign verbal and telephone orders within the time established by institutional policy, usually within 24 hours. Fundamentals of Nursing A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of this refusal. Fundamentals of Nursing Although a patient’s health record or chart is the health care facility’s physical property, its contents belong to the patient. Fundamentals of Nursing Before a patient’s record can be released to a third party, the patient or patient’s legal guardian must give written consent. Fundamentals of Nursing Under the Controlled Substances Act, every dose of a controlled drug dispensed by the pharmacy must be counted for, whether the dose was administered to a particular patient or discarded accidentally. Fundamentals of Nursing A nurse can’t perform duties that violate a rule or regulation established by a state licensing board even if it is authorized by a health care facility or doctor. Fundamentals of Nursing The nurse should select a private room, preferably with a door that can be closed, to minimize interruptions during a patient interview. Fundamentals of Nursing In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followed by potentially life-threatening concerns. Fundamentals of Nursing The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Fundamentals of Nursing Standing orders, or protocols, establish guidelines for treating a particular disease or set of symptoms. Fundamentals of Nursing In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostals space near the apex. Fundamentals of Nursing The S1 sound heard on auscultation is caused by closure of the mitral and tricuspid valves. Fundamentals of Nursing To maintain package sterility, the nurse should open the wrapper’s top flap away from the body, open side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. Fundamentals of Nursing The nurse shouldn’t use a cotton-tipped applicator to dry a patient’s ear canal or remove wax because it may force cerumen against the tympanic membrane. Fundamentals of Nursing A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. Fundamentals of Nursing The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse liability. Fundamentals of Nursing Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Fundamentals of Nursing Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential but have currently accepted medical uses. Their use may lead to physical or psychological dependence. Fundamentals of Nursing Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Fundamentals of Nursing Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Fundamentals of Nursing Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Fundamentals of Nursing Activities of daily living are actions that the patient must perform every day to provide self-care and interact with society. Fundamentals of Nursing Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. Fundamentals of Nursing The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with stethoscope slightly raised from the chest. Fundamentals of Nursing The most important goal to include in a care plan is the patient’s goal. Fundamentals of Nursing Fruits are high in fiber and low in protein and should be omitted from a low-residue diet. Fundamentals of Nursing The nurse should use an objective scale to assess and quantify pain because postoperative pain varies greatly among individuals. Fundamentals of Nursing Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. Fundamentals of Nursing The nurse should provide honest answers to the patient’s questions. Fundamentals of Nursing Milk shouldn’t be included in a clear liquid diet. Fundamentals of Nursing Consistency in nursing personnel is paramount when caring for a child, and infant, or a confused patient. Fundamentals of Nursing The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. Fundamentals of Nursing The three membranes that enclose that brain and spinal cord are the dura mater, pia mater, and arachnoid. Fundamentals of Nursing A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Fundamentals of Nursing Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for medication. Fundamentals of Nursing The area around a stoma should be cleaned with mild soap and water. Fundamentals of Nursing Vegetables have a high fiber content. Fundamentals of Nursing The nurse should use a tuberculin syringe to administer an S.C. injection of less than 1 ml. Fundamentals of Nursing For adults, S.C. injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle. Fundamentals of Nursing Before administering medication, the nurse should identify the patient by checking the identification band and asking the patient to state his name. Fundamentals of Nursing To clean the skin before an injection, the nurse should use a sterile alcohol swab and wipe from the center of the site outward in a circular motion. Fundamentals of Nursing The nurse always should inject heparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. Fundamentals of Nursing If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. Fundamentals of Nursing The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. Fundamentals of Nursing If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops; if bruising occurs, the nurse should monitor the site for an enlarging hematoma. Fundamentals of Nursing When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. Fundamentals of Nursing Frequency of patient hair care depends on the length and texture of the hair, duration of hospitalization, and patient’s condition. Fundamentals of Nursing Proper hearing aid function requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. Fundamentals of Nursing The hearing aid marked with a blue dot is for the left ear; the one with the red dot is for the right ear. Fundamentals of Nursing A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. Fundamentals of Nursing The nurse should instruct a patient not to use hair spray while wearing a hearing aid. Fundamentals of Nursing The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. Fundamentals of Nursing The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Fundamentals of Nursing The purpose of heat application is to promote vasodilation, which reduces pain caused by inflammation. Fundamentals of Nursing A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Fundamentals of Nursing Healing by secondary intention (healing by granulation) is closure of the wound by the granulation tissue filling the defect and allowing reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Fundamentals of Nursing Keloid formation is an abnormality in healing characterized by overgrowth of scar tissue at the wound site. Fundamentals of Nursing The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. Fundamentals of Nursing The ascending colostomy drains fluid feces; the descending colostomy drains solid fecal matter. Fundamentals of Nursing A folded towel (called a scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. Fundamentals of Nursing When giving an injection to the patient with a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Fundamentals of Nursing Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. Fundamentals of Nursing To insert a nasogastric tube, the nurse should first instruct the patient to tilt the head back slightly and then insert the tube. When the tube is felt curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Fundamentals of Nursing According to families whose loved ones are in intensive care units, their four most important needs are to have questions answered honestly, to be assured that the best possible car is being provided, to know the prognosis, and to feel there is hope. Fundamentals of Nursing A double-bind communication when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. Fundamentals of Nursing A nonjudgmental attitude displayed by the nurse demonstrates that she neither approves nor disapproves of the patient. Fundamentals of Nursing Target symptoms are those that the patient and others find most distressing. Fundamentals of Nursing Advise the patient to take aspirin on an empty stomach with a full glass of water and to avoid foods with acid such as coffee, citrus fruits, and cola. Fundamentals of Nursing For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for that specific problem, and then selecting the intervention from the choices provided that will enable the patient to reach that goal. Fundamentals of Nursing Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Fundamentals of Nursing Giving an I.M. injection against the patient’s will and without legal authority is battery. Fundamentals of Nursing An example of a third-party payor is an insurance company. Fundamentals of Nursing On-call medication should be given within 5 minutes of receipt of the call. Fundamentals of Nursing Generally, the best method to determine the cultural or spiritual needs of the patient is to ask him. Fundamentals of Nursing An incident report shouldn’t be made part of the patient’s record but is an in-house document for the purpose of correcting the problem. Fundamentals of Nursing Critical pathways are a multidisciplinary guideline for patient care. Fundamentals of Nursing When prioritizing nursing diagnoses, use this hierarchy: (1) problems associated with airway, (2) those concerning breathing, and (3) those related to circulation. Fundamentals of Nursing The two nursing diagnoses with the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. Fundamentals of Nursing A subjective sign that a sitz bath has been effective is that patient expresses a decrease in pain or discomfort. Fundamentals of Nursing For the nursing diagnosis Diversional activity deficit to be valid, the patient must make the statement that he’s “bored, there is nothing to do” or words to that effect. Fundamentals of Nursing The most appropriate nursing diagnosis for an individual who doesn’t speak English is Communication, impaired, related to inability to speak dominant language (English). Fundamentals of Nursing The family of the patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Fundamentals of Nursing Up to age 3, the pinna should be pulled down and back to straighten the eustachian tube before instilling medication. Fundamentals of Nursing When administering eyedrops, the nurse should waste the first drop and instill the medication in the lower conjunctival sac to prevent injury to the cornea. Fundamentals of Nursing When administering eye ointment, the nurse should waste the first bead of medication and then apply the medication from the inner to the outer canthus. Fundamentals of Nursing When removing gloves and mask, the gloves, which most likely contain pathogens and are soiled, should be removed first. Fundamentals of Nursing Crutches should placed 6" (15 cm) in front of the patient and 6" to the side to assume a tripod position. Fundamentals of Nursing Listening is the most effective communication technique. Fundamentals of Nursing Process recording is a method of evaluating one’s communication effectiveness. Fundamentals of Nursing When feeding the elderly, limit high-carbohydrate foods because of the risk of glucose intolerance. Fundamentals of Nursing Passive range of motion maintains joint mobility whereas resistive exercises increase muscle mass. Fundamentals of Nursing Isometric exercises are performed on an extremity in a cast. Fundamentals of Nursing A back rub is an example of the gate-control theory of pain. Fundamentals of Nursing Anything below the waist is considered unsterile, a sterile field becomes unsterile when it comes in contact with nay unsterile item, a sterile field must be continuously monitored, and the 1" (2.5 cm) border around a sterile field is considered unsterile. Fundamentals of Nursing A “shift to the left” is evident when there is an increase in immature cells (bands) in the blood to fight an infection. Fundamentals of Nursing A “shift to the right” is evident when there is an increase in mature cells in the blood as seen in advanced liver diseases and pernicious anemia. Fundamentals of Nursing Before administering preoperative medication, make sure that an informed consent form has been signed and attached to the patient’s record. Fundamentals of Nursing The nurse should spend no more than 30 minutes per 8-hour shift in providing care to the patient with a radiation implant. Fundamentals of Nursing The nurse should stand near the patient’s shoulders for cervical implants and at the foot of the bed for head and neck implants. Fundamentals of Nursing The nurse should never be assigned to care for more than one patient with radiation implants. Fundamentals of Nursing Long-handled forceps and a lead-lined container should be in the room of the patient who has a radiation implant. Fundamentals of Nursing Generally, patients who have the same infection and are in strict isolation can share the same room. Fundamentals of Nursing Diseases requiring strict isolation include chickenpox, diphtheria, and viral hemorrhagic fever such as Marburg virus disease. Fundamentals of Nursing For the patient abiding by Jewish custom, milk and meat shouldn’t be served in the same meal. Fundamentals of Nursing Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domain of learning). Fundamentals of Nursing Developmental stages according to Erik Erikson are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to 3 years), initiative versus guilt (3 to 5 years), industry versus inferiority (5 to 12 years), identity versus identity diffusion (12 to 18 years), intimacy versus isolation (18 to 25 years), generativity versus stagnation (25 to 60 years), and ego integrity versus despair (older than 60 years). Fundamentals of Nursing Face the hearing impaired patient when communicating with him. Fundamentals of Nursing A proper nursing intervention for the spouse of the patient who has suffered a serious incapacitating disease is to assist him in mobilizing a support system. Fundamentals of Nursing Hyperpyrexia refers to extreme elevation in temperature above 106º F (41.1º C). Fundamentals of Nursing

Terms: Physical Assessment

1. Auscultation
an assessment technique in which an examiner listens to sounds produced from within an area of the body
2. Bell
the end of the amplifying device of a diaphragm that is small, with a hollow, cuplike shape that is best for auscultating soft, low-pitched sounds such as extra heart sounds and murmurs and, when used, should be held lightly against the patient's skin just hard enough that it forms a perfect seal
3. Bimanual deep palpation
palpation technique in which the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated, places the fingerpads of the nondominant hand on the dorsal surface of the distal interphalangeal joints of the middle three fingers of the dominant hand, and presses down gently 1" (2 centimeters) with the top hand while the lower hand remains relaxed to perceive the tactile sensations
4. Cephalocaudal
head to toe
5. Cervical broom
a paint-type brush used for collecting both ectocervical and endocervical cells as part of a Pap smear
6. Cervical brush
a brush used for collecting endocervical cells as part of a Pap smear
7. Cervical scrape
an assessment apparatus used to collect ectocervical cells and cells in the transformation zone as part of a Pap smear
8. Diaphragm
the end of the amplifying device of a stethoscope that is large, with a flat edge and is best for auscultating high-pitched sounds such as breath, bowel, and normal heart sounds and, when used, should be held firmly against the patient's skin to leave a slight ring afterwards
9. Direct auscultation
auscultation technique in which the examiner listens to sounds produced within an area of the body by use of the unaided ear
10. Direct percussion
percussion technique in which the examiner strikes an area of the body to be percussed directly with the pads of two, three, or four fingers or with the pad of the middle finger
11. Dorsal recumbent position
position in which the patient lies on the back with the legs separated, knees bent, and soles of the feet flat on the bed; used to examine the head and neck, anterior thorax and lungs, breasts, heart, extremities, peripheral pulses
12. Dullness
a medium, medium-pitched, "thudlike" percussion sound of moderate duration typically found over the liver, heart
13. Duration
length of an auscultated sound
14. Flatness
a soft, high-pitched, "dead stop of sound, absolute dullness" percussion sound of short duration typically found over muscle, bone
15. Genupectoral (knee-chest) position
position in which the patient kneels, using the knees and chest to bear the weight of the body; used to examine the rectum
16. Goniometer
an assessment apparatus used to measure joint movements and angles
17. Hyperresonance
a very loud, very low-pitched, "booming" percussion sound of very long duration typically found over the emphysematous lung
18. Indirect auscultation
auscultation technique in which the examiner listens to sounds produced within an area of the body by use of a stethoscope
19. Indirect percussion
percussion technique in which the examiner places the middle finger of the nondominant hand, referred to as the pleximeter, firmly on the patient's skin over the area of the body to be percussed and then strikes the distal interphalangeal joint of the pleximeter with the tip of the flexed middle finger of the dominant hand, referred to as the plexor
20. Inspection
an assessment technique in which the examiner deliberately, purposefully, and systematically observes an area of the body
21. Intensity (amplitude)
loudness or softness of an auscultated sound
22. Light (superficial) palpation
palpation technique in which the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated and presses down gently 1/2" (1 centimeter) while moving the hand in a circle
23. Lithotomy position
position in which the patient is in the dorsal recumbent position with the buttocks at the edge of the examining table and the feet supported in stirrups; used to examine the rectum and female genitalia
24. Nasal speculum
an assessment apparatus with two opposing portions that, after being inserted, can be pushed apart for examination of the nose
25. Ophthalmoscope
an assessment apparatus used for examining the interior of the eye
26. Otoscope
an assessment apparatus used for examining the external auditory ear canal and tympanic membrane
27. Percussion
an assessment technique in which the examiner strikes an area of the body with the fingers
28. Percussion (reflex) hammer
an assessment apparatus used for tapping body parts such as a muscle, tendon, or nerve in order to test nerve function
29. Pitch
the frequency of the vibrations of an auscultated sound
30. Platform scale
an assessment apparatus used for weighing
31. Prone position
position in which the patient lies on the abdomen, flat on the bed, with the head turned to the side; used to examine the posterior thorax, hip joint movement
32. Quality
subjective description of an auscultated sound, e.g. whistling, gurgling, snapping
33. Resonance
a loud, low-pitched, "hollow" percussion sound of long duration typically found over the lung
34. Rosenbaum Pocket Vision Screener
one of several charts used in testing visual acuity that consists of a card that can be held which has letters, numbers, or symbols arranged in decreasing size from top to bottom on the card
35. Sims' position
position in which the patient lies on either the right or left side with the lower arm behind the body, the upper arm bent at the shoulder and elbow, both knees bent, and the uppermost leg more acutely bent than the lowermost leg; used to examine the rectum, vagina
36. Single manual deep palpation
palpation technique in which the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated and presses down gently 1" (2 centimeters) while moving the hand in a circle and uses the nondominant hand to support a mass or organ from below
37. Sitting position
position in which the patient sits upright in a chair or on the side of an examining table or bed or, if physically unable to maintain an upright position, may be supine in bed with the head elevated; used to examine the head and neck, posterior and anterior thorax, lungs, breasts, heart, upper extremities, and to take vital signs
38. Skinfold caliper
an assessment apparatus used to measure the thickness of a fold of skin at defined body sites, typically the upper arm or triceps, subscapular region, and upper abdomen, in estimation of the amount of body fat
39. Snellen Chart
one of several charts used in testing visual acuity that consists of a chart which has letters, numbers, or symbols arranged in decreasing size from top to bottom on the chart
40. Sphygmomanometer
an assessment apparatus used to indirectly measure arterial blood pressure
41. Stethoscope
an assessment apparatus used to indirectly listen to sounds produced within an area of the body
42. Supine position
position in which the patient lies flat on the back with the legs together but extended and slightly bent at the knees; used to examine the head and neck, anterior thorax and lungs, breasts, heart, abdomen, extremities, peripheral pulses
43. Thermometer
an assessment apparatus used to measure temperature
44. Transilluminator
an assessment apparatus used to inspect a cavity organ by passing a light through its walls
45. Tympany
a loud, high-pitched, "musical" percussion sound of moderate duration typically found over the stomach filled with gas
46. Vaginal speculum
an assessment apparatus with two opposing portions that, after being inserted, can be pushed apart for examination of the vagina and cervix
47. Woods' lamp
an assessment appratus used to detect fluorescent materilal in the skin and hair in certain disease states, such as tinea capitis

Instruments, equipment, and supplies used during the physical examination

1. instruments
  1. goniometer
  2. nasal speculum
  3. opthalmoscope
  4. otoscope
  5. reflex hammer
  6. platform scale with heigh attachment
  7. Snellen chart
  8. sphygmomanometer and cuff
  9. stethoscope
  10. transilluminator
  11. tuning fork
  12. vaginal speculum
2. equipment and supplies
  1. alcohol swabs
  2. assorted containers and slides
  3. assorted familiar items
  4. ayre (cervical) spatula
  5. cervical brush
  6. cotton-tipped applicators
  7. cotton balls
  8. culture media
  9. dental mirror
  10. disposable pad
  11. drape or sheet
  12. gauze dressing (4 x 4)
  13. fecal occult blood test materials
  14. flashlight or penlight
  15. gloves (sterile and unsterile)
  16. lubricant
  17. Rosenbaum Pocket Vision Screener
  18. ruler marked in centimeters
  19. skin-marking pen
  20. skinfold caliper
  21. smells
  22. sterile safety pins
  23. tape measure marked in centimeters
  24. test tubes of hot/cold liquid
  25. thermometer
  26. tongue blades (depressors)
  27. watch with second hand
  28. Wood's Lamp

Auscultation

1. an assessment technique in which an examiner listens to sounds produced from within an area of the body
2. uses of auscultation
  1. to determine the absence or presence of normal and/or adventitious sounds produced from within an area of the body
3. types of auscultation
  1. direct auscultation
    1. the examiner listens to sounds produced within an area of the body by use of the unaided ear
  2. indirect auscultation
    1. the examiner listens to sounds produced from within an area of the body by use of a stethoscope
    2. parts of a stethoscope
      1. earpieces
        should fit snuggly into your ear canal
        should slope forward toward your nose
      2. tubing
        should have the appropriate internal diameter
        about 4 millimeters (1/8 inch) thick
        
        should be the appropriate length
        about 30 - 36 centimeters (12 - 14 inches) long
      3. amplifying devices
        diaphragm
        end of the amplifying device that is large, with a flat edge
        best for auscultating high-pitched sounds
        e.g., breath, bowel, and normal heart sounds
        
        when used, should be held firmly against the patient's skin
        e.g., firm enough to leave a slight ring afterwards
        
        bell
        end of the amplifying device that is small, with a hollow, cuplike shape
        best for auscultating soft, low-pitched sounds
        e.g., extra heart sounds and murmurs
        
        when used, should be held lightly against the patient's skin
        e.g., just hard enough that it forms a perfect seal
    3. preparation for using a stethoscope
      1. eliminate any extra sounds in the patient's room, e.g.:
        turn off patient's or neighbor's radio, television
        turn off noisy patient equipment that can safely be turned off for a short period of time
        e.g., pneumatic compression boots, continuous nasogastric suction equipment
      2. warm the stethoscope between your hand before placing it on the patient's skin
      3. male patient's chest hair
        may cause a crackling sound that mimics an abnormal breath sound called crackles or rales
        if occurs, wet his chest hair before auscultating the area
      4. avoid your own extra sounds, e.g.:
        breathing on the tubing
        thumping from bumping the tubing together
4. description of auscultated sounds
  1. pitch
    1. the frequency of the vibrations of an auscultated sound
  2. intensity (amplitude)
    1. loudness or softness of an auscultated sound
  3. duration
    1. length of an auscultated sound
  4. quality
    1. subjective description of an auscultated sound, e.g.:
      1. whistling, gurgling, snapping

Percussion

1. an assessment technique in which the examiner strikes an area of the body with the fingers
2. uses of percussion
  1. to determine the borders of an underlying structure of the body by establishing the difference between tissue that is fluid-filled, air-filled, or solid
  2. to determine the absence or presence of normal and/or adventitious sounds elicited while percussing over an area of the body
3. types of percussion
  1. direct percussion
    1. the examiner strikes an area of the body to be percussed directly with the pads of two, three, or four fingers or with the pad of the middle finger
  2. indirect percussion
    1. first, the examiner places the middle finger of the nondominant hand, referred to as the pleximeter, firmly on the patient's skin over the area of the body to be percussed
    2. second, the examiner strikes the distal interphalangeal joint of the pleximeter with the tip of the flexed middle finger of the dominant hand, referred to as the plexor
4. sounds elicited by percussion
  1. flatness
    1. a soft, high-pitched, "dead stop of sound, absolute dullness" sound of short duration
    2. where found
      1. typically over muscle, bone
  2. dullness
    1. a medium, medium-pitched, "thudlike" sound of moderate duration
    2. where found
      1. typically over the liver, heart
  3. resonance
    1. a loud, low-pitched, "hollow" sound of long duration
    2. where found
      1. typically over the lung
  4. hyperresonance
    1. a very loud, very low-pitched, "booming" sound of very long duration
    2. where found
      1. typically over the emphysematous lung
  5. tympany
    1. a loud, high-pitched, "musical" sound of moderate duration
    2. where found
      1. typically over the stomach filled with gas

Palpation

1. an assessment technique in which the examiner feels an area of the body with the palmar surface of the pads of the fingers and/or the dorsum of the hand
2. uses of palpation
  1. to determine texture (e.g., hair)
  2. to determine temperature (e.g., of a skin area)
  3. to determine vibration (e.g., of a joint)
  4. to determine the position, size, consistency, and mobility of organs or masses
  5. to determine distention (e.g., the urinary bladder)
  6. to determine the presence and rate of peripheral pulses
  7. to determine tenderness or pain
3. types of palpation
  1. light (superficial)
    1. the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated and presses down gently 1/2" (1 centimeter) while moving the hand in a circle
  2. bimanual deep palpation
    1. first, the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated
    2. second, the examiner places the fingerpads of the nondominant hand on the dorsal surface of the distal interphalangeal joints of the middle three fingers of the dominant hand
    3. third, the examiner presses down gently 1" (2 centimeters) with the top hand while the lower hand remains relaxed to perceive the tactile sensations
  3. single manual deep palpation
    1. first, the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated and presses down gently 1" (2 centimeters) while moving the hand in a circle
    2. second, the examiner uses the nondominant hand to support a mass or organ from below
4. helping a patient relax to facilitate palpation
  1. gowning and/or draping to prevent unnecessary exposure, provide privacy, and keep the patient warm
  2. positioning the patient comfortably
  3. ensuring that your hands are warm before beginning
  4. commencing palpation with areas that are not painful first
5. characteristics of masses determined by palpation
  1. shape (round, ovoid, tubular, irregular)
  2. size (measured in centimeters)
  3. consistency (firm, edematous, spongy, cytic)
  4. surface (smooth, nodular, granular)
  5. mobiity (fixed or immobile, mobile)
  6. tenderness (amount of tenderness to touch)
  7. pulsatile (pulsations can or cannot be felt in the mass)

Inspection

1. an assessment technique in which the examiner deliberately, purposefully, and systematically observes an area of the body
2. uses of inspection

1. to determine the presence of normal and/or abnormal size, shape, color, symmetry, and/or position of an area of the body

3. when inspecting, need to take into consideration:

1. normal variations as a result of developmental age
2. normal variations as a result of race

Physical preparation

1. emptying the bowel and bladder
2. changing into a gown
3. draping to prevent unnecessary exposure, provide privacy, and to keep the patient warm
4. assuming a special position

Positions during Assessment

dorsal recumbent
1. the patient lies on the back with the legs separated, knees bent, and soles of the feet flat on the bed
2. areas examined
  1. head and neck, anterior thorax and lungs, breasts, heart, extremities, peripheral pulses
supine
1. the patient lies flat on the back with the legs together but extended and slightly bent at the knees
2. areas examined
  1. head and neck, anterior thorax and lungs, breasts, heart, abdomen, extremities, peripheral pulses
sitting
1. the patient sits upright in a chair or on the side of an examining table or bed or, if physically unable to maintain an upright position, may be supine in bed with the head elevated
2. areas examined
  1. head and neck, posterior and anterior thorax, lungs, breasts, heart, upper extremities, and to take vital signs
lithotomy
1. the patient is in the dorsal recumbent position with the buttocks at the edge of the examining table and the feet supported in stirrups
2. areas examined
  1. rectum and female genitalia
genupectoral (knee-chest)
1. the patient kneels, using the knees and chest to bear weight of the body
2. areas examined
  1. rectum
Sims'
1. the patient lies on either the right or left side with the lower arm behind the body, the upper arm bent at the shoulder and elbow, both knees bent, and the uppermost leg more acutely bent than the lowermost leg
2. areas examined
  1. rectum, vagina
prone
1. the patient lies on the abdomen, flat on the bed, with the head turned to the side
2. areas examined
  1. posterior thorax, hip joint movement

Verbal explanations

#

1. when the exam will take place
2. where the exam will take place
3. why the exam is necessary
4. who will conduct the exam
5. what will happen during the exam
6. that privacy will be provided at all times during the exam
7. that confidentiality about the exam and results will not be breached

Components of the physical health examination

1. verbal explanations
2. physical preparation

Purposes of the physical health examination

1. to obtain baseline data about the patient's functional abilities
2. to supplement, confirm, or refute data obtained in the nursing health history
3. to obtain data that will help the nurse establish nursing diagnoses and plan the patient's care
4. to evaluate the physiologic outcomes of health care and thus the progress of a patient's health problem
5. to screen for the presence of cancer

Physical Assessment

Loss,Grieving,Dying and Death

Loss
1. an actual or potential situation in which something that is valued is changed, no longer available, or gone
2. types of loss
  1. actual loss
    1. a loss that can be identified by others
      1. e.g., loss of the ability to move legs due to paralysis
  2. perceived loss
    1. a loss that is perceived by one person but cannot be verified by another
      1. e.g., loss of financial independence when a woman leaves employment to care for her child at home
  3. anticipatory loss
    1. a loss that is experienced before the loss really occurs
      1. e.g., anticipation of the loss of a foot due to gangrene toes
3. categories of loss
  1. loss of external objects
    1. e.g., loss of a home in a fire
  2. loss of a known environment
    1. e.g., a 6-year-old boy losing spending most of his day in his home environment when he begins attending kindergarten
  3. loss of significant others
    1. e.g., a wife losing her husband
  4. loss of an aspect of self
    1. e.g., a paraplegic man losing the function of his legs
  5. loss of life
Grief
1. grief
  1. the totality of the subjective response and behavioral process experienced related to a loss
    1. bereavement is the subjective response experienced related to a loss
    2. mourning is the behavioral process experienced related to a loss
      1. mourning is often influenced by culture, religious experience, and custom
        e.g., a widow wears black at a funeral, Irish have wakes after a funeral
2. types of grief reactions
  1. conventional
    1. abbreviated
      1. a grief reaction that is brief, but genuinely felt
    2. anticipatory
      1. a grief reaction that is experienced in advance of a loss
  2. dysfunctional
    1. unresolved
      1. a grief reaction that is extended in length and severity
    2. inhibited
      1. a grief reaction in which many of the normal symptoms of grief are suppressed
3. stages of grief reactions
  1. Engel (1964)
    1. shock and disbelief
      1. the survivor either refuses to accept the loss or demonstrates intellectual acceptance of the loss but denies the emotional impact
    2. developing awareness
      1. the survivor becomes consciously aware of the reality and meaning of the loss
    3. restitution
      1. the survivor performs the work of mourning, which is accomplished by observing rituals dictated by religion and/or culture
    4. resolving the loss
      1. the survivor focuses energy on thoughts of the deceased
    5. idealization
      1. the survivor represses all negative feelings toward the decreased and, then, through identification, incorporates certain characteristics of the deceased into his or her own personality
    6. outcome
      1. the survivor diminishes psychological dependence on the deceased and becomes interested in developing new relationships
  2. Kubler-Ross (1969)
    1. denial
      1. the individual refuses to believe that the loss is happening
        serves as a buffer in helping the client mobilize defenses to cope with the situation
    2. anger
      1. the individual resists the loss
        anger, behaviorally described as "acting out", is often directed at family and health care providers
    3. bargaining
      1. the individual attempts to postpone the reality of the loss
        serves as a plea for an extension of life or the chance to "make everything right"
    4. depression
      1. the individual realizes the full impact of the loss
        serves as the preparation for the impending loss by working through the struggle of separation
    5. acceptance
      1. the individual comes to term with the loss
        serves as a form of detachment exemplified by a void of emotion or interest in worldly activities
4. signs of grief
  1. repeated somatic distress
  2. tightness in the chest
  3. choking or shortness of breath
  4. sighing
  5. empty feeling in the abdomen
  6. loss of muscular control
  7. uncontrolled trembling
  8. loss of appetite
  9. sleep disturbance
  10. intense subjective distress
5. common interventions for grieving clients
  1. plan time to be available for the client
  2. listen to the client’s grieving process
    1. utilize therapeutic communication skills
    2. utilize attentive listening skills
  3. respect racial, cultural, religious, and personal values of the client and significant others in their expressions of grief
  4. assure the client that intense feelings and reactions are normal initially
  5. provide information about the grieving process and what to expect
  6. encourage the client to express grief with significant others
  7. acknowledge significant others in their own grief and desire to help the client
  8. encourage the development of new relationships
  9. encourage the client to explore available resources
  10. encourage the client to explore support groups for individuals who have experienced a similar loss
  11. assess client well-being
  12. suggest that the client resume normal activities on a schedule that promotes physical and psychologic health
Dying and death
1. stages of dying and death
  1. Kubler-Ross (1969)
    1. denial
      1. the individual refuses to believe the reality of his/her eventual death
    2. anger
      1. the individual resists his/her eventual death
    3. bargaining
      1. the individual attempts to postpone the reality of his/her eventual death
    4. depression
      1. the individual realizes the full impact of his/her eventual death
    5. acceptance
      1. the individual comes to term with the reality of his/her eventual death
2. signs of impending death
  1. loss of muscle tone, e.g.:
    1. relaxation of facial muscles
    2. difficulty speaking
    3. difficulty swallowing
    4. gradual loss of the gag reflex
    5. decreased activity of the gastrointestinal tract
    6. possible urinary and rectal incontinence
    7. diminished body movement
  2. slowing of circulation, e.g.:
    1. diminished sensation
    2. mottling and cyanosis of extremities
    3. cold skin
  3. changes in vital signs, e.g.:
    1. decelerated and weaker pulse
    2. decreased blood pressure
    3. rapid, shallow, irregular, or abnormally slow respirations
    4. Cheyne-Stokes respirations
    5. death rattle
  4. sensory impairment, e.g.:
    1. blurred vision
    2. impaired senses of taste and smell
3. definitions of death
  1. heart-lung death
    1. the irreversible cessation of spontaneous respiration and circulation
    2. emerged from the historical idea that the flow of body fluids was essential for life
    3. manifestations of heart-lung death:
      1. no spontaneous respirations
      2. no spontaneous heart beat
  2. whole brain death
    1. the irreversible cessation of all functions of the entire brain, including the brain stem
    2. emerged in the 1960s from the belief that neocortical functioning is the key to the definition of a human being
    3. manifestations of whole brain death:
      1. unreceptive and unresponsive to external stimuli
      2. no muscular movement
      3. no spontaneous respirations
      4. no relfexes
      5. flat electroencephalogram (EEG) for 24 hours
      6. no circulation to or within the brain evidenced by Doppler ultrasound for 24 hours
      7. positive apnea test
        apnea when off the respirator for four minutes with a PaCO₂ of at least 60 mm Hg
  3. higher brain death
    1. the irreversible loss of all "higher" brain functions, of cognitive function
    2. emerged in the 1970s from the belief that the brain is more important than the spinal cord and that the critical functions are the individual’s personality, conscious life, uniqueness, capacity for remembering, judging, reasoning, acting, enjoying, and worrying
4. changes in the body after death
  1. rigor mortis
    1. stiffening of the body
    2. occurs about 2 - 4 hours after death
  2. algor mortis
    1. gradual decrease of body temperature after death
    2. body temperature falls about 1° C (1.8° F) per hour until it reaches room temperature
  3. livor mortis
    1. discoloration of the skin due to breakdown of red blood cells and release of their hemoglobin
    2. appears in the lowermost, or dependent, areas of the body
Factors influencing loss, grief, death, and dying
1. developmental state
  1. e.g., a 4-year girl, who would typically believe that death is reversible, may assume that her dead grandfather will "wake-up" and come back to life
2. significance of the loss
  1. e.g., a woman may view menopause not as a loss, but as providing more sexual spontaneity due to freedom from unplanned pregnancies
3. culture
  1. e.g., in Western society, the prevalent attitude seems to be to view loss and death as dreaded enemies to be fought and postponed
4. spiritual beliefs
  1. e.g., in the Jewish religion, family and friends sit Shiva with the survivors and the survivors unwrap the deceased’s headstone one year after burial (Jarhzeit)
5. sex-role
  1. e.g., men are socialized to "be strong" and show very little emotion during grief
6. socioeconomic status
  1. e.g., a wife, whose husband has an adequate pension plan or insurance, will have more options for coping with widowhood
7. cause of death
  1. e.g., a gay man’s mother and father may view their son’s death as a the result of acquired immunodeficiency syndrome (AIDS) as punishment for his homosexuality
Common interventions for dying clients
1. develop a trusting nurse-client relationship with client and significant others
2. explain the client’s condition and treatment to both the client and significant others
3. if desired, teach client’s significant others how to assist in his/her care
4. meet physiologic needs of dying clients
  1. provide personal hygiene measures, e.g.:
    1. mouth care
    2. clean, dry, wrinkle-free linen
    3. frequent changes of gown if diaphoretic
  2. relieve respiratory difficulties, e.g.:
    1. Fowler’s position
    2. pharyngeal suctioning
    3. oxygen as needed
  3. assist with movement, nutrition, hydration, and elimination, e.g.:
    1. frequent changes of position
    2. antiemetics to stimulate appetite
    3. encourage fluids
    4. skin care if incontinent
  4. provide measures related to sensory changes, e.g.:
    1. touch
    2. speak clearly and do not whisper (hearing is the last to go)
    3. brightly lit room
  5. relieve pain, e.g.:
    1. provide pharmacologic, nonpharmocologic, and/or cognitive-behavioral pain management
5. meet spiritual needs of dying clients
  1. if comfortable, a nurse can directly provide spiritual care for the dying client
    1. e.g., pray with the client, read scripture with the client, meditate with the client
  2. if uncomfortable, a nurse should arrange access to individual(s) who can provide spiritual care for the dying client
    1. e.g., priest, minister, rabbi
6. meet pyschologic needs of dying clients
  1. prevent loss of control and dependency
    1. encourage the client to make as many decisions as possible about his/her care
  2. prevent social isolation, e.g.:
    1. help the client maintain involvement in established, significant relationships
    2. provide meaningful environmental stimulation
    3. encourage significant others to stay in communication through caring, silence, touch, and telling the client of their love
  3. life review and framing memories, e.g.:
    1. encourage the client and significant others to talk about past accomplishments, pleasures, and hardships
    2. ask the client to give significant others meaningful information to pass on to future generations
    3. have significant others share with the client what he/she means to them and their future aspirations
  4. guided imagery, e.g.:
    1. self-chosen or instructor-suggested images of the hospital room as a safe, comfortable place to die
    2. death as a state of eternal peace
    3. heaven as a garden of flowers eternally in bloom
  5. final wishes and saying good-bye, e.g.:
    1. preferences for the funeral
    2. burial arrangements
    3. wish to offer body to science or organs for transplantation
7. meet needs of the significant others of dying clients
  1. listening to significant others’ concerns, e.g.:
    1. utilize therapeutic communication skills
    2. utilize attentive listening skills
  2. remind significant others to care for themselves, e.g.:
    1. get rest
    2. eat nutritiously
  3. prepare significant others for the reality of death, e.g.:
    1. explain the signs of impending death
    2. explain changes in the body after death
    3. explain the grieving process
8. provide postmortem care
  1. care of the client’s body
    1. remove or cut all tubes and lines according to health care agency policy
    2. close the client’s eyes
    3. replace dentures or other dental appliances, if worn
    4. straighten the client and lower the bed to a flat position
    5. place a pillow under the client’s head
    6. wash the client if needed, honoring any religious or cultural rituals
    7. comb and arrange the client’s hair
    8. place pads under the client’s hips and around the perineum to absorb feces and urine
    9. clean up the client’s room or unit
    10. prepare the client for transfer to either a morgue or funeral home
      1. wrap the client in a shroud
      2. attach identification tags per agency policy
  2. care of the client’s significant others
    1. listening to significant others’ grieving process
      1. utilize therapeutic communication skills
      2. utilize active listening skills
    2. if desired, allow significant others to see the body in private and perform any religious or cultural custom they wish
    3. provide a private place for significant others to begin the grieving process
    4. if requested, notify the hospital chaplain or appropriate community religious leader
  3. care of other clients
    1. listening to other clients’ grieving processes who were aware of the death of the client
  4. care of other nurses
    1. listening to other nurses’ grieving processes who were involved in the client’s care
9. hospice care
  1. focuses on support of the dying client and family with the goal of facilitating a peaceful and dignified death
  2. based on holistic concepts that emphasize care to improve the quality of remaining life rather than cure
  3. four key features of hospice:
    1. interdisciplinary team
    2. inclusion of family as defined by the client
    3. pain management and symptom control, or palliation (lessening)
    4. individuality and dignity

Nursing Process

Definition:

It is a systematic, rational method of planning and providing individualized nursing care.

a process that seeks to identify a client's healthcare status, actual or potential health problems, to establish plans to meet the client's identified needs, and to deliver specific nursing interventions to address those needs
In 1955,Lydia Hall originated the term

Five Components:

1. assessing
1. the systematic and continuous collection, validation, and communication of patient data
2. during assessing, the nurse:

1. establishes a data base
2. continuously updates the data base
3. validates data
4. communicates data

2. diagnosing
1. the analysis of patient data to identify data clusters that indicate actual or potential health problems, factors that contribute to or cause these problems, and coping pattern or strengths of the patient
2. during diagnosing, the nurse:

1. interprets and analyses patient data
2. identifies patient strengths and patient health problems
3. formulates and validates nursing diagnoses
4. develops a prioritized list of nursing diagnoses

3. planning
1. the establishment of patient goals/expected outcomes by the nurse, working with the patient, that prevent, reduce, or resolve problems identified in the nursing diagnoses, and the determination of related nursing interventions most likely to assist the patient in achieving the goals
2. during planning, the nurse:

1. establish priorities
2. writes patient goals/expected outcomes and develops an evaluative strategy
3. selects nursing interventions
4. communicates the plan of nursing care

4. implementing
1. the nurse carries out of the plan of care
2. during implementing, the nurse:
1. carries out the plan of nursing care
2. continues data collection and modifies the plan of care as needed
3. documents care

5. evaluating
1. the measuring of the extent to which patient goals have been met
2. during evaluating, the nurse:

1. measures the patient's achievement of desired goals/expected outcomes
2. identifies factors that contribute to the patient's success or failure
3. modifies the plan of care, if indicated

Characteristics of the Nursing Process
 cyclical and dynamic--> components follow a logical sequence but more than once component may be involved at one time; responds to the changing health status of the client so there is no absolute beginning or end
 open and flexible--> meets the unique needs of the client, family, group, or community
 client-centered--> the plan of care is organized according to the client’s health problems rather than nursing goals
 interpersonal and collaborative--> to ensure delivery of quality nursing care, the nurse shares concerns and problems regarding the client’s health status; rapport is developed and an open communication is established between the client and the nurse to carry out the nursing process effectively
 planned
 goal directed
 allows client and nurse to devise ways to solve identified health problems--> decision-making is involved in every step of the nursing process and nurses are not bound by standard responses; nurses can use their skills and knowledge to assist the client attend to health-related goals
 emphasizes feedback--> determines if there is a need to revise the nursing care plan
 universally applicable--> it can be used with clients at any age and at any point in the wellness-illness continuum and can be used in a variety of settings.
 utilizes problem-solving techniques and the systems theory--> decision-making is involved in every component of the nursing process

Points to remember

About Insulin
• In the pancreas's islets of Langerhans, beta cells secrete insulin-the islet-cell hormone of major physiological importance;
• Without sufficient insulin, the body develops diabetes mellitus.
• Exploration of a number of new delivery systems for insulin is ongoing.
• Implanted insulin delivery systems, in combination with a glucose sensor may create an "artificial pancreas."
• Exercise increases the body's metabolic rate to result in a decrease in blood sugar and an increase in insulin sensitivity. Signs of hypoglycemia often occur.
• Illness can disrupt metabolic control and raise blood sugar, which results in an increased need for insulin.
• Insulin-dependent clients should be well controlled for at least one week prior to any surgery.
• Special care for any client with either type of diabetes mellitus should be taken to monitor blood glucose during and after surgery and adjust insulin accordingly.

About the Thyroid
• Following neck surgery, potentially life-threatening complications such as laryngeal edema and tracheal obstruction can occur. Monitor for respiratory distress.
• Following thyroid surgery, many clients suffer transient hypocalcemia from hyporfunction or removal of the parathyroids. Monitor for signs of tetany for up to three days after surgery.

About the Parathyroid
• Positive Chvostek's sign: contraction of facial muscle near mouth occurs when light tap is given over facial nerve in front of ear.
• Positive Trousseau's sign: carpopedal spasm results during the deflation of a blood pressure cuff that has been inflated for at least one minute.

Disorders of the Pancreas

Diabetes mellitus
1. Definition - a condition in which the pancreas produces too little insulin, or cells stop responding to insulin; results in hyperglycemia
A. type 1 diabetes mellitus: genetic, auto-immune respones; severe insulin deficiency from beta cells stop production of insulin
B. type 2 diabetes mellitus: obesity; cells stop responding to insulin

2. Diagnostics
a. history and physical exam
b. fasting blood sugar: elevated serum glucose levels
c. oral glucose tolerance test (GTT)
d. after meal, serum glucose is elevated - post-prandial glucose
e. glycosylated hemoglobin test (A1c test)

3. Data collection
a. hyperglycemia
b. the 3 "polys" of diabetes mellitus: polydipsia, polyuria, polyphagia
c. additional findings: fatigue, hunger, weight loss
d. blurred vision
e. slow wound healing

4.Management
1. diet therapy and weight loss

1. the total number of calories is individualized according to the client's weight
2. as prescribed by the care provider, the client may be advised to follow dietary guidelines for Americans (food guide pyramid) or individualized food exchanges from the American Diabetic Association

2. exercise

1. lowers glucose level and improves circulation
2. decreases total cholesterol and triglycerides
3. instruct client to monitor glucose before exercising
4. before exercise, clients who require insulin should eat a carbohydrate snack with protein to prevent hypoglycemia

3. insulin

1. used in type 1 diabetes mellitus (DM) and type 2 DM, if needed for better control of blood glucose levels
2. regular insulin, the only insulin that is given IV, is used for ketoacidosis
3. check other medications the client is taking
4. illness, infections, and stress increase the need for insulin
5. instruct client about the importance of rotating injection within one region (the abdomen absorbs insulin the most rapidly)
6. insulin administration: see Pharmacology section of this course
7. insulin pens, jet injectors, and insulin pumps are used to administer insulin

4. oral antidiabetic medications

1. prescribed for clients with type 2 DM
2. monitor blood glucose levels
3. check other medications the client is taking
4. instruct the client to recognize manifestations for hypoglycemia and hyperglycemia
5. pancreas transplant
6. islet cell transplant
7. blood glucose monitoring - with different self-check systems

5. Medications
1. type 1 DM: insulin therapy
2. type 2 DM: oral hypoglycemic agents

6. Complications
a. hypoglycemia (insulin shock)
i. blood sugar falls below 50 mg / dl
ii. caused by too much insulin, too little food, or excessive physical activity
iii. may result from delayed meals, exercise, or vomiting
iv. rapid onset
v. findings of insulin shock
• diaphoresis; cold, clammy skin
• anxiety, tremor, slurred speech
• weakness
• nausea
• mental confusion, personality changes, altered LOC
• headache
vi. management of hypoglycemia
• if client is conscious, give oral sugar: hard candy, honey, Karo syrup, jelly, cola
• if unconscious: give one mg glucagon IM, IV or subcutaneous (SC); or 20 to 50 ml 50% dextrose IV push

b. diabetic ketoacidosis (DKA) - an acute complication
i. results from severe insulin deficiency
ii. findings
• blood sugar levels > 350 mg/dl
• elevated ketone levels: sweet odor to breath may also have odor of someone drinking alcohol
• metabolic acidosis: Kussmaul's respirations, flushed appearance, dry skin
• thirst
• polyuria
• drowsiness
• anorexia, vomiting
• may lead to shock and coma
• usual causes:
o undiagnosed diabetes mellitus
o inadequacy of prescribed therapy for diabetes mellitus
o physical stress such as surgery, illness, or trauma in person with diabetes mellitus
o caused by increased gluconeogenesis from amino acids and glycogenolysis in the liver
• management:
o correct fluid depletion - IV fluids
o correct electrolyte depletion - replacement particularly of potassium
o correct metabolic acidosis - insulin IV

c. hyperglycemic, hyperosmolar nonketotic coma (HHNKC)
i. potentially fatal
ii. findings
• severe hyperglycemia; usually > 600 mg/dl
• plasma hyperosmolarity
• dehydration
• altered LOC - decreased
• absence of ketoacidosis
iii. usually precipitated by physical stress such as an infection;
iv. in non-diabetics can be due to tube feedings without supplemental water, or too rapid rate of infusion for parenteral nutrition
v. occurs more often in the elderly, typically
vi. expected: to correct fluid depletion, insulin deficiency, and electrolyte imbalance
d. other chronic complications
i. diabetic triopathy
• retinopathy
• nephropathy
• neuropathy
ii. macrovascular disease in the
• coronary artery
• peripheral vascular

6. Nursing interventions
a. give medications as ordered
b. monitor for findings of hyperglycemia or hypoglycemia
c. help client monitor blood glucose
d. refer client to dietician for planing of meals
e. support client emotionally
f. teach client
i. the importance of balanced, consistent daily focus of diet, medication and exercise
ii. self blood-glucose monitoring
iii. dietary exchange system or refer to appropriate resources
iv. about medications and side effects
v. foot care
vi. early reporting of complications of
• ketoacidosis
• insulin shock
• long term issues
vii. about insulin administration
viii. about the need to:
• eat more before strenuous exercise
• carry extra rapid-absorbing carbohydrate on person at all times
• wear medical-alert jewelry
• have regular eye exams
• consider emergency care for insulin shock

Disorders of the Adrenal Gland

Addison's disease
1. Definition

1. adrenal cortex secretes too little adrenocorticotropic hormone (ACTH)
2. decreases secretion of other adrenal products: mineralocorticoid, glucocorticoids, and sex hormones
3. relatively rare

2. Etiology - autoimmune adrenalitis

3. Findings
1. acute adrenal insufficiency (Addisonian crisis)

1. severe headache or back pain
2. severe generalized muscle weakness
3. diarrhea or constipation
4. confusion
5. lethargy
6. severe hypotension
7. circulatory collapse

2. adrenal insufficiency

1. vague complaints or findings
2. fatigue
3. muscle weakness
4. vague abdominal complaints: anorexia, nausea, vomiting
5. personality changes
6. skin pigmentation

4. Diagnostics
a. history and physical exam
b. ACTH stimulation test: low cortisol level
c. low blood levels of sodium and glucose and high levels of potassium
d. 24-hour urine collection: decreased levels of free cortisol

5. Management
a. expected outcome: to return to hormonal balance
b. Addisonian crisis

i. emergency management of circulatory collapse
ii. intravenous hydrocortisone

c. chronic insufficiency
i. glucocorticoid replacement therapy: hydrocortisone (cortef)
ii. mineralocorticoid replacement therapy: fludrocortisone acetate (florinef acetate)
iii. diet high in protein, carbohydrates, and sodium

6. Nursing interventions during hospitalization
a. administer medications as ordered
b. manipulate the environment to reduce stressors
c. preserve the client's energy by assisting with ADL as indicated
d. monitor diet therapy
e. measure intake and output and observe for signs of hyponatremia, hyperkalemia, and hypoglycemia.
f. teach client
i. about medications and side effects
ii. the need for lifelong hormone-replacement therapy
iii. the need for medical-alert jewelry
iv. how to conserve energy
v. how to avoid or minimize stress
vi. guidelines for diet: high sodium

Cushing's syndrome

1. Definition: adrenal gland secretes too much cortisol

2. Etiology
a. average age of onset 20 to 40 years of age
b. affects women more often than men
c. primary syndrome caused by tumor of adrenal cortex
d. secondary syndrome caused by an ACTH-producing tumor of pituitary
e. long term steroid therapy

3. Findings
a. personality changes
b. hypertension
c. metabolic alkalosis
d. weight gain, buffalo hump, truncal obesity
e. change in libido
f. moon face
g. muscle weakness
h. virilization in women, amenorrhea, or menstrual irregularities
i. osteoporosis
j. acne or hyperpigmentation

4. Diagnostics
a. history and physical exam
b. blood tests show
i. increased levels of cortisol,
ii. increased sodium and glucose,
iii. decreased potassium
c. 24-hour urine collection:
i. elevated free cortisol
ii. elevated 17-ketosteroids
iii. elevated 17-hydroxycorticosterone

5. Management
a. expected outcome: to restore hormonal balance
b. surgery for adrenal or pituitary tumor
c. irradiation therapy
d. pharmacologic
e. adrenal enzyme inhibitors that block enzymes needed for cortisol synthesis
i. aminogluthemide
ii. metyrapone
iii. mitotane
f. potassium supplements
g. high protein diet with sodium restriction

6. Nursing interventions
a. administer medications as ordered
b. monitor diet therapy
c. monitor for signs of hypokalemia, hypernatremia
d. teach client
i. the need for lifelong treatment
ii. about medications and side effects
iii. the need for medical alert jewelry
e. surgical treatment may cause adrenal or pituitary insufficiency

Pheochromocytoma

1. Definition
Adrenal medulla secretes too much epinephrine and norepinephrine (called the catecholamines). Causes excessive stimulation of the sympathetic nervous system

2. Etiology
1. generally benign tumor of the adrenal medulla
2. curable, but fatal if untreated

3. Findings
1. severe stress response
2. panic metabolic state
3. hypertensive crisis
4. headache, usually severe
5. orthostatic hypotension
6. tachycardia
7. pallor or flushing
8. diaphoresis
9. palpitations
10. anxiety, high and sustained
11. hyperglycemia
12. dysrhythmias

4. Diagnostics
a. increased BMR
b. computerized tomogram (CT) scan
c. 24-hour urine collection: increased urinary catecholamines

5. Management
a. expected outcomes: to remove the tumor and correct the imbalance
b. surgical removal of the tumor: scheduled only after client has been normotensive for at least one week
c. antihypertensive agents as needed preop
d. alpha-adrenergic blocking agent and beta adrenergic blocking agent (beta blockers): phentolamine (regitine), nitroprusside (nitropress), propranolol (inderal)
e. tyrosine inhibitors: alphamethylparatyrosine decreases circulating catecholamines
f. antidysrhythmic agents as needed preop

6. Nursing interventions
a. monitor vital signs, especially blood pressure
b. administer medications as ordered
c. provide care of the client undergoing surgery
d. if bilateral adrenalectomy performed, lifelong steroid therapy required
e. teach client
i. about medications and side effects
ii. need for lifelong followup

Disorders of the Parathyroid Gland

A. Hypoparathyroidism
1. Definition - parathyroid produces too little parathormone; results in hypocalcemia

2. Etiology unknown
a. possibly an autoimmune disorder
b. most often results from surgical removal of parathyroid glands

3. Findings (mild to severe order)
a. neuromuscular
i. irritability
ii. personality changes
iii. muscular weakness or cramping
iv. numbness of fingers
v. tetany
vi. carpopedal spasms
vii. laryngospasms
viii. seizures
b. dry, scaly skin
c. hair loss
d. abdominal cramping

4. Diagnostics
a. history and physical exam
b. positive Chvostek's sign
c. positive Trousseau's sign (carpopedal spasm as inflated BP cuff is released)
d. decreased serum calcium
e. increased serum phosphate

5. Management
a. expected outcomes: to restore hormonal balance and prevent complications
b. calcium replacement therapy: ideal serum calcium level 8.6mg/dl
c. vitamin D preparations facilitate uptake of calcium
d. calcium-rich diet

6. Nursing interventions
a. monitor carefully for signs of tetany
b. place airway, suction and tracheotomy tray at bedside
c. institute seizure precautions
d. administer medications as ordered
e. teach client
i. about medications and side effects
ii. signs of vitamin D toxicity
iii. to consume more calcium and get vitamin D from sun exposure to skin
iv. to reduce phosphorus intake: minimize intake of fish, eggs, cheese and cereals

B. Hyperparathyroidism

1. Definition - parathyroid secretes too much parathormone; results in increased serum calcium (hypercalcemia)

2. Etiology
1. benign growth in parathyroid
2. secondarily as result of kidney disease or osteomalacia
3. incidence increases dramatically in both sexes after age 50

3. Findings
1. many clients are asymptomatic
2. gastrointestinal: constipation, nausea, vomiting, anorexia
3. skeletal: bone pain and demineralization
4. irritability
5. muscle weakness and fatigue

4. Diagnostics
a. history and physical exam
b. elevated serum calcium
c. decreased serum phosphate level
d. x-rays reveal bone demineralization

5. Management
a. expected outcomes: to restore hormonal balance and prevent complications
b. surgery: removal of parathyroid glands - parathyroidectomy

6. Nursing interventions
a. care of the client undergoing surgery
b. after surgery observe for signs of hypocalcemia
c. after surgery, teach client to consume diet rich in calcium

Disorders of the Thyroid Gland

A. Hypothyroidism
1. Definition - an underactive thyroid resulting in a lessened secretion of thyroid hormone
a. deficiency of thyroid hormones causing decreased metabolic rate
i. affects more women
ii. age group: 30 to 50 years of age
b. classifications
i. cretinism: hypothyroidism in children
ii. hypothyroidism without myxedema: mild thyroid failure
iii. hypothyroidism with myxedema: severe thyroid failure; usually seen in older adults
iv. myxedema coma
• most severe type of hypothyroidism
• precipitated by stress
• findings include:
o hypothermia
o bradycardia
o hypoventilation
o altered LOC leading to coma
• potentially life threatening condition

2. Etiology
a. thyroid surgery
b. treatment for hyperthyroid condition
c. overdosage of thyroid medications
d. deficiency in dietary iodine

3. Findings
a. cognitive impairment
b. constipation, fatigue, depression
c. intolerance to cold
d. coarse, dry skin; periorbital edema; thick, brittle nails
e. bradycardia; increased diastolic pressure
f. menstrual changes - increased menstrual flow
g. loss of the outer one-third of eyebrows
h. weight gain
i. fluid retention

4. Diagnostics
a. history and physical exam
b. increased TSH
c. decreased serum T3 and T4
d. anemia
e. decreased basal metabolic rate (BMR)
f. elevated cholesterol and triglycerides
g. hypoglycemia

5. Management
a. expected outcomes: to restore hormonal balance and prevent complications
b. administer synthetic thyroid hormone: levothyroxine sodium (levothroid)
c. myxedema coma:
i. IV fluids as ordered
ii. correct hypothermia
iii. give synthetic thyroid hormone

6. Nursing interventions
a. give medications as ordered
b. watch client for signs of myxedema
c. provide restful environment
d. teach client
i. how to conserve energy
ii. how to avoid stress
iii. about the medications and side effects - synthyroid is to be taken in the morning on an empty stomach at least one hour before any other medications or vitamins or ingestion of milk
iv. the importance of lifelong therapy
e. protect client from cold

B.Hyperthyroidism (Graves' disease, thyrotoxicosois)

A. Definition - overactive thyroid over secretes hormones, and causes increased basal metabolic rate or hyperactivity of thyroid as a primary disease state

B. Etiology - considered autoimmune response

A. women affected more than men
B. age group: 30 to 50 years

C. Findings
A. hyperphagia, weight loss, diarrhea
B. heat intolerance
C. exophthalmos
D. tachycardia
E. palpitations
F. increased systolic BP
G. difficulty concentrating
H. irritability
I. hyperactivity
J. thin, brittle hair, pliable nails: plummer's nails
K. diaphoresis
L. insomnia
M. reduced tolerance for stress

D.Diagnostics
a. history and physical exam: palpable thyroid enlargement: (goiter)
b. elevated serum T3 and T4 levels
c. elevated radioactive iodine uptake
d. presence of thyroid autoantibodies
e. decreased TSH (thyroid-stimulating hormone; comes from pituitary) levels

E. Complication: thyrotoxic crisis (thyroid storm)
a. rare but potentially fatal
b. breakdown of body's tolerance to chronic hormone excess
c. state of extreme hypermetabolism
d. precipitating factors: stress, infection, pregnancy
e. findings include:
i. systolic hypertension
ii. hyperthermia
iii. angina
iv. infarction or heart failure
v. extreme anxiety
vi. even psychosis

F. Management
a. expected outcomes: to reduce the excess hormone secretion and to prevent complications
b. pharmacologic
i. sodium131I
ii. antithyroid agents: propylthiouracil (PTU)
iii. beta-adrenergic blocking agents: propranolol (inderol)
iv. iodides: useful adjunct
c. surgical: thyroidectomy: partial or total removal of thyroid gland
d. diet high in calories, protein, carbohydrates
7. Nursing interventions
a. monitor vital signs, especially blood pressure and heart rate
b. provide quiet, restful, cool environment
c. monitor diet therapy
d. provide extra fluids
e. provide emotional support
f. administer medications as ordered
g. teach client
i. about medications and side effects
ii. stress avoidance measures
iii. energy conservation measures
h. care of the client undergoing surgery

Online Reference Notes