Binders and bandages applied over or around dressings provide extra
protection and therapeutic benefits by doing what?1) Creating pressure
over a body part
1) Creating pressure over a body
part
2) Immobilizing a body part
3) Supporting a wound
4) Reducing or preventing edem
5) Securing a splint
6) Securing dressings
What bandages are lightweight and inexpensive, mold easily around
contours of the body, and permit air circulation to prevent skin
maceration?
Gauze bandages
What bandage conforms well to body parts but are also for exerting
pressure?
Elastic Bandages
What are binders made of and what are two examples of binders?
Binders are bandages made of
large pieces of material, like
elastic or cotton, to fit a
specific body part. Examples
are abdominal binders and
breast binders.
Before applying a bandage or binder what must a nurse do?
Inspect the skin for abrasions,
edema, discoloration, or
exposed wound edges.
Covering exposed wounds or open abrasions with a sterile dressing
Assessing the condition of underlying dressings and changing if soiled.
Assessing the skin of
underlying areas that will be
distal to bandage for signs of
circulatory impairment
This is an physical, manual, or mechanical method or device attached to a
body to restrict movement.
Physical Restraint
This is any medication used to control behavior and are especially
dangerous in older adults because the increased sedation, drowsiness,
and/or otherwise impaired cognition may increase the risk of Falling.
Chemical Restraints
T/F Use restraints as the first order of frustration towards a noncompliant patient without the necessity of a physicians order.
False:Use restraints only as a
last resort, in consultation with
the PCP, and with an order
stating why the restraint is
necessary and for how long.
T/F The use of restraints without an order is considered a standing order
until a physician writes an order.
False The use of restraints
without an order is considered
false imprisonment and is there
fore illegal.
What are the foundations of good body mechanics?
1) Coordination,
2) Maintenance, and
3) Protection
What provides the framework for all tissue of the body?
Skeletal system.
Coordination is the result of ____, ____, and ____.
Weight, center of gravity and
balance
The cerebellum and the inner ear controls what?
Voluntary movement and
balance
When moving an object you should pull the object towards you. T/F
False: Push objects don't pull.
It is better to use minor
muscles over the major
muscles.
When preparing to lift an object what are the procedures from beginning
to end?
If it is necessary lifting vertically, it is best to stand on tips of the toes for
overhead objects. T/F
When moving patients what are the steps prior to the actual lift of a
patient up in bed?
Assess the weight of the
object, tighten stomach
muscles and tuck pelvis. Bend
at the knees and keep the
object close to your body while
maintaining trunk in erect
position with knees bent. At all
times, avoid Twisting!!!
False: Use a safe step
ladder/stool, stand as close to
the shelf as possible then
transfer the weight of the
object from the shelf to the
arms and bring close the body.
Arrange for adequate help,
encourage client to help as a
dlib, use body mechanic
principles then slide patient
toward you with a draw sheet
coordinating the lift by
counting to three.
____ places body weight fully on each leg in turn.
Normal Gait
What are the steps prior to assisting a patient with ambulation?
Evaluate the environment for
safety, dangle pt if indicated.
Support the pt at his waist,
return pt to chair/bed if c/o
dizziness or experiences
syncopal episodes.
Supporting pt with hemiplegia
or hemiparesis. When in doubt,
get help.
What is the number one step to take before assisting with patient with any
activity?
PATIENT SAFETY!!!
This is the act of posture being in a straight line.
Body Alignment
When should a RN assess, a patients alignment?
When they are least aware of
the observation, while
sitting/lying at the foot of the
bed or while standing.
a position in which the head is low and the body and legs are on an
inclined plane. It is sometimes used in pelvic surgery to displace the
abdominal organs upward, out of the pelvis, or to increase the blood flow
to the brain in hypotension and shock.
Trendelenburg's
a position in which the lower extremities are lower than the body and
head, which are elevated on an inclined plane.
Reverse Trendelenburg
the posture assumed by the patient when the head of the bed is raised 45
to 60 degrees and his or her knees are elevated slightly.
Fowler's Position
placement of the patient in an inclined position, with the upper half of the
body raised by elevating the head of the bed approximately 30 degrees.
Semi-Fowler's Position
A thin gauze that has be saturated in Vaseline.
Vaseline Gauze
What are the different restraints provided for patient safety?
1) 2pt vs 4pt
2) Mitten
3) Posey
4) Belt
What would be the rationale of restraints?
When placing restraints, a nurse should tie restraints to side rail to
prevent patient from harming self or others. T/F
1) Maintains immobilization,
2) Prevents pulling out of
devices,
3) Prevents unintentional harm,
and
4) Prevent scratching of
self/other/
False: One should never secure
a restraint to a moving object.
When side rails are all placed up, they are considered a restraint. T/F
False: Side rails are NOT
considered a restraint.
How long is a restraint order written by a physician good for?
24 hr
When does discharge planning take place?
Admition
What are the 6 Documentation qualities of patient information?
Factual, Accurate, Complete,
Current, Organized, and
Legible
Documentation that states descriptive, objective lingual that avoids vague
terms, quoting subjective remarks is known as ____.
Factual Documentation
Documenting in universal language, spelling correctly, being concise &
easy to understand. Specific to date, time, with signature and credentials
avoiding generalized comments and inappropriate language keeps _____
documentation.
Accurate
In order to keep documentation current one must ....
Document everything on a
flow sheet chronologically
using Military time.
What do I do if I forget to chart something and remember it later?
Write a late entry
What do I do if I need to make a correction?
Draw one line through, no
writing of error or mistake
just initial and that is it.
What do I do if I need to continue to the next page?
Start with date and time and
write..."continued from
What do I do if I have a countersign?
previous page"
If one countersigns, you are
taking full responsibility of
the person you, as an RN, are
countersigning for.
What device supports large abdominal incisions that are vulnerable to
tension or stress as the client moves or coughs?
Abdominal binder
What device support arms with muscular sprains or fractures?
Slings
an abnormal condition characterized by the collapse of alveoli,
preventing the respiratory exchange of carbon dioxide and oxygen in a
part of the lungs.
atelectasis
the secretion of sweat, especially the profuse secretion associated with an
elevated body temperature, physical exertion, exposure to heat, and
mental or emotional stress.
diaphoresis
When should you remove patients abdominal binder to incourage client
to cough and deep breath before reappling binder using less pressure?
When regarding an abdominal binder, what should be recorded for proper
reporting to other shift?
If clent's respiratory rate
decreases.
application of binder
condition of skin,
circulation,
integrity of dressing
client's comfort level
Who should ineffective lung expansion be reported to ultimatly?
Health care provider
immediately
Elastic bandages that reduce swelling are best applied when?
In the morning before getting
out of bed
Current JACHO standards require these assessments of all clients who
are admitted to a health care institution. What are they?
An assessment of:
Phyical, Psycholosocial,
Environmental, Self-Care,
Client Education and
Discharge Planning Needs
Oral/Tympanic temperature:
96.8-100.4
Rectal Temperature:
98.6-100.4
Axilla temperature:
96.6-98.6
Normal Pulse rate is
60-100 beats per minute
Normal Respiration range from
12-20 breaths per minute
A patient with a BP between 120/80 to 139/89 is considered to be what?
Pre-hypertensive
What would a patients blood pressure look like who has hypertension?
140/90
A patient with a systolic blood pressure of <90 is considered...?
Hypotensive
When should we take vital signs?
Per physician order
Any change in patient's
condition
After any major procedure
A 72 year old male s/p open heart surgery comes to the ICU for post op
recovery. Among various medications needed to assist with stabilization
of this patient, a nurse would recognize vital signs like these…
BP: 98/60
Resp: 30
Pulse: 58
Temp: 96.3 orally
As normal or abnormal?
For the body temperature to stay constant & within an acceptable range,
body mechanisms must maintain the relationship between ____ ____ and
____ ____.
Abnormal
Heat Production
Heat Loss
Physiological and behavioral mechanisms regulate the balance between
heat lost and heat produced,also known as ____.
Thermoregulation
What is believed to be the most reliable measure of core temperature?
Rectal Temperature
Placement of a thermometer into feces may give what kind of reading?
Inaccurate Readings indicating a high reading due to heat loss from feces.
What are the differences in rectal thermometer insertions for Adult, child,
and infants?
Celsius=(F-32)x5/9
Adult: 1 1/2 in
Child: 1 in
Infant: 1/2 in
Fahrenheit=(9/5xC)+32
What is the safest temperature site to check?
What is one of the most rapid means of measuring temperature?
Axillary Temperature:
5-10minutes, make sure it's dry
surface
Tympanic
This is the transfer of heat from one surface of an object to another
surface of an object by direct contact.
Heat Loss
Losing heat by removing clothing is considered what form of heat loss?
Radiation
The Transfer of heat from one object to another by direct contact is what
form of heat loss?
Conduction
The patient has just finished a hot cup of coffee when you enter the room
to take an oral temperature. What should you do?
What 20-30 minutes to retrieve
an accurate temperature.
This is the visible presence of earwax.
Cerumen
The transfer of heat away from a surface by the movement of air or fluid
is what form of heat loss?
Convection
The heat loss from the energy required to change a liquid into a gas is
called what?
Evaporation
The visible perspiration primarily occurring on the forehead and upper
thorax, though you can see it in other places on the body is known as
_____.
Diaphoresis
What occurs because heat-loss mechanisms are unable to keep pace with
excess heat production, resulting in an abnormal rise in body temperature.
Pyrexia
This is a substance which can cause a rise in body temperature.
Pyrogens
When does a fever become harmful to the human body?
102.5 F
FUO?
Fever of Unkown Origin
What is an elevated body temperature related to the body's inability to
promote heat loss or reduce heat production?
Hyperthermia
Heat loss during prolonged exposure to cold overwhelms the body's
ability to produce heat causing what?
Hypothermia
When temperatures become extremely hot or cold, health-promoting
behaviors, such as removing or adding clothing, have a limited effect on
controlling temperature are factors for high risks for ___ ___.
You walk into a patients room and notice the patient has increased
perspiration and pulse rate is 120. You find the patients temperature is
102.0. What are some nursing interventions to reduce temperature?
Ineffective Thermoregulation
Monitor VS, assess skin color,
temperature, turgor and lab
work
This is profuse diaphoresis resulting in excess H2O and electrolyte loss.
Heat Exhaustion
This dangerous heat emergency has a high morality rate.
Heat Stroke
Sub-normal temperature exposure to the body substantially causing
possible this?
Frostbite
A group of football players are out scrimmaging on the field. One player
shows signs of Hot dry skin. What is this a sign of?
Heat stroke
The palpable bounding blood flow in a peripheral artery noted at various
points on the body is the _____.
pulse
The pulse is an indirect measure of ___ ____.
Cardiac Output
Your friend displays a pulse of 134 per minute. Is this normal
Abnormal (60-100 normal)
What are the sites for assessing the pulse of a client?
Radial(thumb side of forearm
of wrist), Apical (5th-4th
intercostal space at left of
mid-clavicular line),
Carotid (along medial edge of
sternocleidomastoid muscle)
Rate of pulse, rhythm, strength, and equality are all _____ __ ____.
Character of pulse
This is the mechanism the body uses to exchange gases between the
atmosphere to the blood and the blood to the cells.
Respiration
This is the movement of gases in and out of the lungs.
Ventilation
This is the movement of oxygen and carbon dioxide between the alveoli
and the red blood cells.
Diffusion
This is the distribution of red blood cells to and from the pulmonary
capillaries.
Perfusion
The most important factor in the control of ventilation is ?
The level of CO2 in the arterial
blood
This is normal rate and depth of ventilation.
Eupnea
What should one assess when checking patients respiration?
Rate, Rhythm, and Depth
You note, after checking a patients O2 saturation, a level of 89%. Is this
acceptable?
NO! Acceptable range
95%-100%
What device can indirectly measure oxygen saturation using the light
absorption with photo detector checking pulse saturation (SpO2)
estimates arterial saturation (SaO2)?
Pulse Oximetry
This is the absence of respirations.
Apnea
Slow breath is known as ____.
Bradypnea
Rapid Breathing is known as ____.
Tachypnea
This is an abnormal pattern of respiration, characterized by alternating
periods of apnea and deep, rapid breathing.
Cheyne-Strokes Respiration
This is an abnormal condition in which the client uses multiple pillows
when lying down or must sit with the arms elevated and leaning forward
to breathe.
Orthopnea
This is a clinical sign of hyoxia displaying a shortness of breath usually
associated with exercise or excitement, but in some clients is present
without any relation to activity or exercise.
Dyspnea
The force exerted against the blood vessels by the blood is what?
Blood Pressure
A patient displays no signs of heart problems but on assessment you find
the patients has high blood pressure. What is this patient at risk for?
16 year old boy displays mottling skin, signs of clamminess, confusion,
increased heart rate and mother states boy has had a decrease in urination.
What would you expect upon assessment of vitals?
Hypertension is a major factor
underlying stroke and
contributing factor to heart
attacks.
Low blood pressure?
(Hypotension)
John's BP has been ranging around 108/62 6am every morning. One day
he decides to take his BP 4:20 in the afternoon but is shocked at the
results. Why was he shocked at his BP?
A patient just returned from smoking a couple of cigarettes when you
enter their room for vitals. What do you do next?
He saw an increase in his BP
because between 10am-6pm
BP is the highest
Return in about 15 minutes
because smoking increases
vasoconstriction.
The thickening of arterial walls and loss of elasticity can increase the risk
for...
Hypertension
Dilation of arteries, loss of blood volume and decreased blood flow to
vital organs can increase the risk for....
Hypotension
The First Korotkoff sound is known as what when taking vitals?
Systolic Reading
The absence of sound when taking BP is known as ____.
Diastolic Reading
Talking with patient during BP reading can cause what?
Increase by 10%-40%
When taking the blood pressure how should the patient be positioned, and
what is the difference in readings?
A catheter inserted in an artery that monitors the BP electronically is
what known as a/an ____.
What are the 5 vital signs?
When assessing pain what should be factored as a means of
understanding pain intensity?
Patient should be in prone
position
Systolic pressure usually
higher by 10-40mmHg
Diastolic the same
Arterial Line
Temperature
Blood Pressure
Respiration
Pulse
Pain
Provokes/palliates
Quality
Region/radiation
Severity & setting
Timing
Pain SCALE
0----5----10
the separation and restriction of movement of ill persons with contagious
diseases is ...
Why is the risk for infection transmission possible in a hospital?
This tier of precaution is designed for the care of all clients in hospitals
regardless of their diagnosis or presumed infection status.
This tier of precaution is designed only for the care of clients who have
known or suspected infections or have been colonized with transmissible
pathogens.
What should one take standard precautions against?
A student nurse prepares to enter a droplet Isolation room. He donns on
the PPE by first placing his gown, than mask, Finally he donns gloves
than enters. Did you take the proper precautions prior to entering room?
What is the proper sequence for removing PPE equipment before leaving
patients room?
A tier two expanded precaution does not require a physicians order. Only
standard precautions T/F
Patient Jane in on airborne isolation. You wash your hands and take
proper precautions equipping yourself with what?
Isolation
Because every client has the
potential to transmit infection
via blood and body fluids.
Tier One: Standard Precaution
Tier Two: Expanded
Precaution
Blood
Body Fluids
Non-intact Skin
Mucous Membrane
NO. #1 thing everyone must
do before placing PPE
equipment and after removing
them is WASH HANDS!!!
Remove gloves, then goggles,
next gown, and then mask.
Finally always wash HANDS!!!
False: Tier Two is based on
mode of transmission and
requires a physicians Order
followed by an isolation cart,
door signage, and patient
restrictions.
N-95 mask, gown and gloves.
Patient Ace has pneumonia and the physician orders for an isolation cart.
What isolation precaution is this?
A patient with MRSA is admitted into your unit and placed on isolation.
You noticed your coworker entering the room with gloves, gown, and
mask on. What should you educate him on?
You just got done getting a patient situated after getting them off the bed
pan. Patient was positive for C-Diff and on isolation. You remove all
equipment and use a hand sanitizer soap to cleanse hands. What is wrong.
A kidney transplant patient is in a reverse Isolation room. Family ask if
its alright to bring some flowers for them. What would be your response?
You have just been notified that your patient, who is on isolation, has had
an accident and needs to be cleaned. Before donning PPE you want to
make sure ____.
Droplet Isolation (requires a
face-shield)
MRSA is a contact isolation,
gloves and gown are the only
things necessary in room
unless there is a possibility of
becoming exposed to an open
wound with drainage.
C-Diff is only killed with soap
and water.
Because the patient's fully
strong yet, it would be best to
not bring any Fresh fruits
vegetables or fresh plants.
You have all supplies (extra)
before entering room
Then PROPER hand hygiene.!!!
What type of PPE will you wear when changing an MRSA dressing?
Gloves, mask w/face shield or
goggles, and gown.
What type of PPE will you wear when suctioning oral secretions?
Sx Mask
What type of PPE will you wear when transporting a patient Dx with TB?
Gloves, fluid-resistant gown,
mask/goggles or face shield
What type of PPE will you wear when responding to an emergency where
blood is spurting?
Gloves
What type of PPE will you wear when drawing blood?
Gloves, gown
What type of PPE will you wear when cleaning an incontinent patient
with diarrhea?
Gloves, w/wo gown
What type of PPE will you wear when taking vital signs on a patient Dx
with influenza?
Gloves, gown, mask with eye
shield
What type of PPE will you wear when irrigating a wound?
Gloves, gown, mask w/shield goggles
You receive the order from the physician to place a patient on isolation.
You noticed the family and the patient have a concerned look on their
face. What should you do?
The process or methods of bringing about a condition in which no
disease-causing micro-organisms are present.
The purpose of asepsis is ...
Explain the situation
Explain the Basic
understandings of isolation
Ease their concerns
Comfort and Reassure
Asepsis (elimination of germs)
Destroying the number of
microbes to an irreducible
number.
The purposeful prevention of
the transfer of microbes from
one person to another
Calculated effort to keep the
patient's environment from
contamination & colonization
This occurs when a patient has an organism in or on a body site but has
no clinical signs or symptoms of disease.
Colonization (Staph)
What is the single most important procedure for preventing nosocomial
infections?
Handwashing
The absense of pathogenic microorganisms.
Asepsis
Medical Asepsis is ____ technique where as Surgical Asepsis is ____
technique.
Clean/Sterile
This type of Asepsis technique reduces number of organisms present,
lowers risk of transmission by good hand hygiene, using barrier
techniques and antiseptics/disinfection.
Medical Asepsis
This type of Asepsis using sterile techniques destroying all microorganisms and their spores. These techniques are held to a very rigid
standard.
Surgical Asepsis
When starting an IV or cleaning a central line you would want to use this
technique.
Surgical Asepsis
Antiseptics are used ____ where as disinfectants are used ____.
Used on skin/ inanimate objects
This method of infection control is the process to remove all organisms.
Sterilization
This method of infection control kills or reduces growth and replication
of micro-organisms.
Germicides
Best Practice equals
Best Care
An illness produced by the invasion and multiplication of an infectious
pathogen in the body.
Infection
This is an infection that was developed after admitting patient into the
hospital.
Hospital-acquired infection
This is an acquired infection that is present when the patient entered the
hospital.
Community-acquired infection
This infection comes from the microorganism outside the body.
Exogenous Infection
This is an infection that occurs when the part of the body's normal
resistant level is abnormal.
Endogenous Infection
Infection acquired due to medical treatment
Latrogenic Infection
What factors increase nosocomial infections?
Antibiotic Resistance
Bad Hygiene
Basic Procedures
Aging/Immunocompromised
Acute illness
What are some defenses against infections?
Normal Flora
Body defense mechanisms
Inflammation
Vascular and cellular response
Inflammatory exudate
Tissue repair
A patient that is receiving a broad spectrum antibiotic is at an increased
risk for ___
infection: because this
antibiotic upset the balance of
normal flora.
What is the chain of infection?
Causative Agent
Reservior
Portal of Exit
Mode of Transmission
Portal of Entry
Susceptible Host
These are parasites that can be carried by mosquitos, contaminated water,
food or soil, and also in ticks.
Protozoans
These are microorganisms that attach to the skin when a person has
contact with another person or object during normal activities. Hand
hygiene can remove these.
Helmithes
This is a place where a pathogen can survive but may or may not
multiply.
Reservoir
Portal of exit for pathogens from a human host can happen in 4
generalized ways.
Respiratory tract
Skin/Wound
Urinary Tract
GI tract
Repro Tract
The physical contact between source and susceptible host is what mode
of transmission?
Direct
The personal contact of susceptible host with contaminated inanimate
object is what means of transmission?
Indirect
Large particles that travel up to 3 feet and come in contact with
susceptible host is what means of transmission?
Droplet
Droplet nuclei, or residue or evaporated droplets suspended in air or
carried on dust particles is what mode of Transmission?
Airborne
The mode of transmission that uses food is called.
Ingestion
A vector can transmit a pathogen in two ways. What are they?
External transmission:
flies-V. Cholerae
Internal transmission between
vector and host:
mosquito-malaria, West Nile
virus.
Portal of Entry can spread by:
Breaks in skin: even
microscopic breaks
Mucous membranes
Respiratory
Blood
GU, GI, Reprod Track
The very young, elderly and immunocompromised, multiple dx prcesses
are all ____ to pathogens.
Susceptible hosts
This stage of infection is between entrance of pathogen into body and
appearance of the first symptoms.
Incubation Period
This stage of infection from onset of nonspecific signs and symptoms
(malaise, low-grade fever, fatigue) to more specific symptoms.
Prodromal Stage
This stage of infection is when client manifest signs and symptoms
specific to type of infection.
Illness Stage
This stage of infection is interval when acute symptoms of infection
disappear.
Convalescence
When your skin encounters any drainage, dried secretions or excess
perspiration, use alcohol gel every time. T/F
False Use soap and Water
You find a patients dressing has become wet and soiled but it is not due
for a dressing change until tomorrow. What do you do?
Change dressing
You find contaminated articles (soiled dressings/linen) in a patients room.
What do yo do?
You have just contaminated your needle prior to attempting to give
insulin. What do you do?
You walk into patients room and noticed an open bottle of normal saline.
What do you do?
Place contaminated articles in
red biohazard bag. and
dispose of it properly
Engage safety features of all
sharp devices and dispose in
puncture-proof container.
Dispose of it. DO not leave
bottled solutions open for
prolonged periods of time.
Keep bottled tightly capped,
date and time should be written
on all solution from time of
open.
Empty and dispose of drainage suction bottles according to facility
policy. Empty all drainage systems on each shift unless otherwise ordered
by a physician.
Never raise a drainage system
(e.g., urinary drainage bag)
above the level of the site
being drained unless it is
clamped off.
Drainage Bottles and Bages
Surgical wounds
Keep drainage tubes and
collection bags patent to
prevent accumulation of
serous fluid under the skin
surface. Strict asepsis with
wounds/care.
At portal of exit
cover mouth when coughing,
sneezing, teach pt/family to do
this, gloves, gown, eye wear if
possibility of contact with
body fluid
The principles and science of preservation and science of healing and
prevention of disease.
Promotion of Well-being
What is the purpose of hygiene?
Cleanse
Comfort, relax
Promote healing
Safety
The Nursing Process?
Assessment (data-subjective
& objective)
Nursing Diagnosis (plan)
Implementation (action)
Evaluate (response)
Document
Epidermis, dermis, and subcutaneous tissue consist of what?
The Skin
What is the function of the three parts of the skin?
Epidermis (protection)
Dermis (support)
Subcutaneous (temperature
regulation)
The purpose of this is to protect, sensory perception, temperature,
regulation, and excretion/secretion.
Skin
The base or edge of a nail, that could be a portal of infection, is called
____.
Cuticle
The white area on the visible nail area is known as the ____.
Lunula
What is the pink, moist, mucous membrane, which includes tongue, teeth,
gums?
Oral/Buccal Cavity
This maintains hygiene comfort within the oral cavity.
Buccal Glands
The process of chewing
Mastication
The disease of the gum is called
Gingivitis
When assessing the sclera and the conjuctivae, what should you see
ideally?
sclera: white, moist
Conjuctivae- pink, moist, free
of lesions
When assessing a patients ears what should you note?
The auricles symmetry, color
and position. The outer ear
canal free form excess
cerumen.
What should be considered when assisting with patient hygiene?
Social practice
Personal Preferences
Body Image
Socioeconomic Status
Health Beliefs and Motivation
Cultural Beliefs
Physical Condition
When assessing patients skin, what should you note?
Any risks in impairment of
skin such as dryness, acne,
rashes, inflammation, open
lesions or abrasions.
The loss of hair (thins with age) is known as?
Alopecia
Head lice is known as?
Pediculus Capitis
Body lice is known as?
Pediculus Corporis
Crab lice (perineal) is known as?
Pediculus Pubis
What is are glands that assist in perspiration of the palms, soles, and
forehead.
Eccrine Glands
What is are glands that assist in perspiration of the axillae, scalp, face,
abdomen, and genital area?
Apocrine Glands
These glands are more active in adolescent which leads to acne
(thermoregulation).
Sebaceous Glands
Who loses elasticity of skin, skin becomes thin and sweat glands decrease
in secretions?
Elderly
With increased age what happens with the feet, hair and nails?
Feet-↑age=loss of balance &
↑pain,
Hair-↑age=loss of hair,
alopecia; adolescence are more
aware of body image
Nails-↑age=more brittle
Oral cavities are found in what ages groups?
The young and elderly.
High sugar intake and
teeth become brittle.
How does one keep accountability of the nursing process?
Evaluation of the Nursing
process
This is a technique used in physical examination in which the examiner
feels the texture, size, consistency, and location of certain body parts with
the hands.
Palpation
A technique in physical examination of tapping the body with the
fingertips or fist to evaluate the size, borders, and consistency of some of
the internal organs to discover the presence and evaluate the amount of
fluid in a body cavity.
Percussion
This is the act of listening for sounds within the body to evaluate the
condition of the heart, blood vessels, lungs, pleura, intestines, or other
organs or to detect the fetal heart sound.
Auscultation
This is the act of smelling.
Olfaction
Techniques for physical assessment includes all sense such as: seeing,
feeling, listening, smelling and tasting. T/F
False:Techniques for
assessment includes all senses
except taste!!!
When performing a proper inspection, what can you do to promote
favorable conditions for visual inspection of the patient?
When performing a visual examination, what are some characters a nurse
should observe for?
When examining the patients' symmetry, it is best to have the patient in a
standing anatomical position. T/F
Make sure there is Good
Lightning. (Use additional
lighting/devices for some
areas of body such as eyes,
ears, throat)
Color: eyes, skin, nail bed,
wounds
Shape/symmetry:
Movement: jerky, trimmers,
steady gait
Position: posterior, anterior,
distal
False: It is best with the
patient in a sitting position
A nurse is assessing a new admit. You notice the nurse checking the
consistency of the patient's neck, the texture and resilience of the
abdomen and the temperature of an immobile extremity. All with the use
of her hand. What tactic did you just see implemented?
Assessment with palpation
Tympany, resonance, hyper-resonance, dullness, and flatness are all
____.
Sounds of Percussion
Percussion between the intercostal space over the lungs and over the
trapezoid muscle will generate this type sound?
Resonance
Percussion over the area above the stomach will generate this type
sound?
Tympany
Percussion over the area above the liver and heart generates this type
sound?
Dullness.
Percussion over the surface of muscle and bones generates this type
sound?
Flatness
When assessing auditory auscultation what characteristics should you be
aware of?
Frequency, Loudness, Quality,
& Duration of the sound
When assessing a patient using the stethoscope for auscultation of the
heart, it is alright to place the diaphragm (of scope) over clothing for
better hearing. T/F
False: Always bet directly
placed on skin
What is the bell of the stethoscope best used to auscultate for?
Low pitched sounds (vascular
& some heart sounds)
What is the diaphragm best used to auscultate for?
High pitched sounds (bowel
and lung sounds)
In which case should you initiate the use of the olfaction to test what is
abnormal vs normal?
How do you prepare for Assessment?
A 13yr old boy is brought to the ER, by his step-father, with a broken
right femur. During your Assessment on the unit, the patient states his
accident was caused by falling off a tree. You notice on the ER report, it
states "patient broke femur falling from the stairs." What is this a possible
indication of?
Alcohol on breath. Foul
smelling odor from wound.
USUALLY DESCRIPTIVE
IN NATURE
1) Gather equipment
2) Introduce self
3) Use standard precaution
4) Wash hands before & after
5) Clean stethoscope and cuff
6) Make client comfortable and
offer privacy and protect
confidentiality
Possible sign of Abuse.
(behavior issues: insomnia,
anxiety, isolation)
Responsive eye movement is an indication of what level of
consciousness?
Alert
A state of dullness, sleepiness, and drowsiness is what level of
consciousness?
Lethargic
Being in a state of reduced consciousness and diminished spontaneous
movement is what LOC?
Stuporous
The state of profound unconsciousness, no response to eye movement,
vocalization, or physical movement is what LOC?
Comatose
When assessing a patient's orientation it is always best to use open ended
questions. T/F
This is an additional Neuro check that is tested by coarsely running a
tongue blade or reflex hammer up the lateral aspect of the foot from heel
to big toe.
You are apply the Babinski Reflex on a patient and notice the toes extend
and separate. What is the result of the Babinski test?
False: Question like "Is your
name Jim Bob?" is an open
ended question and should
never be asked.
Questions that require
oriented responses such as
"Can you tell me your name?"
is best
Babinskie Reflex (aka plantar
relfex)
Positive Babinski sign= Abnorm
Reflex
(Reflex is normal in newborns
but abnormal in children and
adults, in whom it may
indicate a lesion in the
pyramidal tract)
a pathway composed of groups of nerve fibers in the white matter of the
spinal cord through which motor impulses are conducted to the anterior
horn cells from the opposite side of the brain. These descending fibers,
the nerve cell bodies of which are found in the precentral cortex, regulate
the voluntary and reflex activity of the muscles through the anterior horn
cells.
Pyramidal tract
The absent of the Babinski sign, as evidence by flexion of the foot is
known as?
Normal reflex
The hair on the scalp, axillae, pubic and beard are known as...
Terminal hair
Soft tiny hairs covering the body except palms and soles are known as?
Vellus hair
What are some characteristics that should be noted when assessing the
nails?
What is synchronized movement of the eyes?
Transparent
Smooth
Rounded
Convex
Hygiene
Consensual Movement
The ability of the eyes to follow a moving object is known as...
Tracking
What is the 20 foot distant chart used to test both eyes together then
loosely covers one, reading smallest print testing visual acuity?
Snellen Chart
Six directions of gaze (Cardinal fields of gaze)
Extra-ocular movements
Alignment of the eye
Corneal light reflex
Checks peripheral vision
Visual Fields
Accomodation of the eyes reacting to change in light.
Pupillary Reflex
What does PERRLA stand for?
P= Pupils
E= Equal
R= Round
R= Reactive
L= light
A= Accommodation
This disorder is the farsightedness, or an inability of the eye to focus on
nearby objects.
Hyperopia
This is the condition of nearsightedness caused by the elongation of the
eyeball or by an error in refraction so that parallel ray are focused in front
of the retina.
Myopia
This is an abnormal condition of elevated pressure within an eye caused
by obstruction of the outflow of aqueous humor.
Glaucoma
This is a progressive deterioration of the maculae of the retina.
Macular degeneration
A hyperopic shif to farsightedness resulting from a loss of elasticity of
the lens of the eye.
Presbyopia
The abnormal progressive condition of the lens of the eye, characterized
by loss of transparency.
Cataract
An abnormal condition of the eye in which the light rays cannot be
focused clearly in a point on the retina because the spheric curve of the
cornea of lens is not equal in all meridians.
Astigmatism
An abnormal ocular condition in which the visual axes of the eyes are not
directed at the same point.
Strabismus
A group of noninflammatory eye disorders. Major contributing
conditions include diabetes, hypertension and atherosclerotic vascular
disease
Retinopathy
Involuntary rhythmic movements of the eyes; the oscillations may be
horizontal, vertical, rotary, or mixed.
Nystagmus
What are the parts of the ear consist of?
External: auricle, outer ear
canal, and TM
Internal: Bony ossicles
Inner: Cochlea vestibule, and
semicirclar canals
You notice a nurse in a patients room with a vibrating tuning fork
positioned at the center of the person's forehead. What test is this nurse
likely performing?
Weber's test
The sound heard the loudest in the unaffected ear, using Weber's Test is
_____.
Sensorineural
When performing the Weber's Test on a patient, what indicates
"conductive hearing loss?"
When assessing the nose and the area of the sinuses, what should a nurse
take note of?
The pharynx, palate, tongue, buccal mucosa, and teeth are all physical
components of what area of assessment?
What are some components should considered during a physical
assessment of the neck?
When inspecting and palpating the chest/thorax, what should one take
note of?
Sound is heard louder in
affected ear. (sounds heard by
bone conduction)
Nose: Patentcy, mucosa,
drainage
Sinuse: frontal and maxillary
Oral Cavity
Trachea: is it midline?
Thyroid glands: are nodules
swollen?
Muscle stregnth
Lymph nodes
Carotid arteries and jugular
veins
Inspection: symmetry and
shape of chest; spinal
alignment; skin condition
Palpation: expansion/chest
excursion, tactile/vocal
fremitus and chest wall.
What is a tremulous vibration of the chest wall caused by vocalization
that is primarily palpated during physical examination.
What are signs of a normal chest/thorax configuration?
Fremitus
Elliptical shape, ribs slope
downward.
A patient with chest configuration that appears rounded with their ribs
horizontal rather than at a downward loping angle has chronic asthma.
What type of configuration of the thorax does this patient have?
Barrel Chest
You notice, during your assessment of the patient, they have a sunken
sternum. They state they have had that since birth. What type of chest
configuration does this patient have?
Pectus excavatum
A sternum that protrudes somewhat resembling a "pigeon breast" is
known as _____.
Pectus Carinatum
A lateral S-shaped curve of the spine is called ____.
Scoliosis
The "humpback" appearance of the spine is called ____.
Kyphosis
The anterior concavity of lumbar spine is known as?
Lordosis
When testing this one uses the palms of the hands placed on the posterior
of the thorax and observes for normal expansion during inspiration. What
is this called?
Chest Excursion
Loud hollow high pitched sounds heard over the trachea is known
as____.
Bronchial Breathing sounds
Blowing, medium pitched sounds heard posteriorly between the scapulae
is what sound?
Bronchovesicular Breath
sounds
Soft breezy, low pitched sounds heard over the periphery smaller airways
is known as ____.
Vesicular Breath Sounds
Moving the stethoscope across in this equal fashion is known as _____.
Contralatteraly
The high pitched "rice krispie" sounds heard at the base of the lungs are...
Crackles
The rumbling coarse sounds heard over trachea and bronchi is _____.
Rhonchi
The high pitched musical sound heard over all lung fields are known as
____.
Wheezes
The rubbing/grating sound heard over the thoracic cavity is known as
____
Pleural Friction Rub
The Ventricles contacting, blood moving from left vent jnto the aorta and
from the right vent into pulmonary arteries is known as the...
Systole
The ventricles relaxing and atria contracts, blood moves from atria into
ventricles and coronary arteries is known as _____.
Diastole
A fine vibration, felt by an examiner's hand on a patient's body over the
site of an aneurysm or on the precordium, the result of turmoil in the flow
of blood, indicating the presence of an organic murmur of grade 4 or
greater intensity.
Thrill
This is the "Lub" sound of the mitral/tricuspid valve closing.
S1
This is the "Dub" sound of the aortic/pulmonic valves closing.
S2
This sound is located at the right base, second intercostal space to the
right of the sternum.
Aortic
This sound is located at the left base, second intercostal to the left of the
sternum.
Pulmonic
This sound is located left lateral sternal border, fifth intercostal space to
the left of the sternum.
Tricuspid
This sound is located at the apex: midclavicular line at 5th intercostal
spaces.
Mitral
The blowing swooshing sounds that are graded from i-vi with grade i
being barely audible and grade vi being the loudest (heard without
stethoscope)
Murmurs
This test checks for proper circulation in the distal parts of the upper
extremities by completely cutting off circulation from the distal upper
extremity and releasing.
Allen test
This is the ultrasound device that detects pulse.
Doppler
What are the 3 "P's" of physical assessment of venous/arterial
insufficiency?
Pain
Pallor
Pulselessness
Capillary refill should be less then ____
2 seconds
This type of edema is typically around the feet and ankles. Prominently in
older adults and those who stand a lot.
Dependent Edema
This type of edema is caused by venous insufficiency of R heart failure
resulting in fluid accumulation in tissue.
Pitting Edema
You are doing a physical assessment on a client. Prior to palpations over
the abdomen what should you make sure is done first?
Empty bladder
When assessing normal bowel sounds what should you hear?
5-35 sounds per minute
This is an audible abdominal sound produced by hyperactive intestinal
peristalsis.
Borborygmi
What is the release of palpation that is followed by a feeling of pain
called?
Rebound tenderness
What are some things to assess for on an IV site?
Patency, Integrity of Site,
and what is being infused
pertaining to the nose and stomach, as in aspiration of the stomach's
contents.
Nasogastric
This law consists of civil and criminal.
Statutory Law
This prevents harm to society and provide punishment for crimes such as
felonies and misdemeanors.
Criminal Law
This protects the rights of individual persons within out society and
encourage fair and equitable treatment among people.
Civil Law
This reflects decisions made by administrative bodies such as State
Boards of Nursing when they pass rules and regulations
Administrative Law
This is the results from judicial decisions made in courts when individual
legal cases are decided.
Common Law
The willful acts that violate another’s rights, such as assault, battery, and
false imprisonment.
Intentional Torts
These are acts where intent is lacking but volitional action and direct
causation occur, such as found with invasion of privacy and defamation
of character.
Quasi-Intentional Torts
This includes negligence or malpractice.
Unintentional Torts
This is required for all routine treatment, hazardous procedures such as
surgery, some treatment programs such as chemotherapy, and research
involving clients.
Consent
This is conduct that falls below the standard of care. The law established
the standard of care for the protection of others against an unreasonably
great risk of harm.
Negligence
This is one type of negligence and often referred to as professional
negligence
Malpractice
Nurses can call this when the assignment given to them is unsafe and can
cause potential harm to patient safety
Safe Harbor
This is a photograph of the interaction between the health care providers
and a patient at a particular moment in time. The quality of the
photograph is dependent on the skill of the picture taker.
Medical Record
The purpose of this organization is to protect and promote the welfare of
the people of Texas. This purpose supersedes the interest of any
individual, the nursing profession, or any special interest group. The
board fulfills its mission through two principle areas of responsibility:
(1) regulation of the practice of professional and vocational nursing, and
(2) accreditation of schools of nursing.
Texas Board of Nursing
This organization represents the interests of the nation's 2.9 million
registered nurses through its constituent member nurses associations
and its organizational affiliates.
ANA
This organization advances the nursing profession by fostering high
standards of nursing practice, promoting the economic and general
welfare of nurses in the workplace, projecting a positive and realistic
view of nursing, and by lobbying the Congress and regulatory agencies
on health care issues affecting nurses and the general public.
ANA
Mission: Moving the nursing profession forward through leadership,
advocacy and innovation.
Vision: The trailblazer for nursing!
TNA
“State of complete physical, mental, and social well-being, not merely the
absence of disease or infirmity”
Health (WHO, 1947)
Health is an acute state of being perfect health then severely ill. T/F
False: Health is viewed on a
continuum that goes between
"perfect" health to severe
illness and death.
This model is the relationship between a person's belief and behavior.
Health Belief Model
This health model looks at the relationship between multidimensional
persons and their environment.
Health Promotion Model
This health model looks at the relationship of needs and survival.
Basic Human Needs Model
This programs goal is to achieve a high level of wellness to avoid
preventable illness by active and passive processes such as working out,
stop smoking, clinics, schools, etc.
Health Promotion Program
This level of preventative care is health promotion & protection. Simply a
preventative action before any signs and symptoms arise.
Primary
This level of preventative care is early treatment & interventions, limiting
"harm." (You find an aching wrist so you go to the doctor for a check up.
No hospitalization required most of time)
Secondary
This level of preventative care is treatment when condition is permanent
or irreversible: restoration and rehabilitation. (ex: ISRD)
Tertiary
This is an alteration in body functions which causes reduced capacity or
shortened life span
Disease
This is a state in which the person perceives physical, emotional,
intellectual, social, developmental, or spiritual functioning is diminished
or impaired.
Illness
This is a sudden onset and severe illness
Acute
The duration of these type of illness appears in a six month span and has
varying limitations.
Chronic Illness
This is an illness that ultimately results in death.
Terminal Illness
How people monitor their bodies, define and interpret their symptoms,
take remedial actions, and use the health care system.
Illness Behavior
What are some internal influences of Behavior on illness?
Pre-contemplation--> Contemplation--> Preparation--> Action-->
Maintenance Stage--> Poss ??relapse??
These are the stages of ____.
What are some components of Self Concept?
Any real or perceived change that threatens identity, body image, or role
are stresses toward ____.
If stress is not successfully managed by client what could be the result?
The client's perception of the
illness.
The nature of the illness
(acute, chronic, etc)
The client's coping skills.
Spiritual belief
Health Behavior Change
Identity
Body Image
Role performance
Self Esteem
Self Concept
May lead to negative self
Concept
This stage of Development consists of early adulthood (18-40) with the
task of establishing intimate bonds of love and friendship.
Intimacy vs Isolation
This stage of Development (middle adulthood 40-65) has the task of
fulfilling life goals that involve family, career, and society.
Generativity vs Stagnation
This stage of Development takes place in later adulthood (65-Death) with
the task of looking back over one's life and accepting its meaning.
Integrity vs Despair
The imparting or interchange of thoughts, opinions, or information by
speech, writing, or signs.
Communication
What are some result of poor communication?
Threatens Professional
credibility
Increases Risk of Liability
Worst Outcome---- May result
in harm to client.
This type of communication is within ones self, either positive or
negative.
Intrapersonal
This form of communication is face to face.
Interpersonal
This form of communication is within a spiritual aspect/domain.
Transpersonal
This form of communication is the interaction with an audience and is the
most formal form of communication!!!
Public
This zone of personal space usually is between 0-18inches with great
sensitivity needed before approaching. (Genitalia, rectum)
Intimate Zone
This zone of personal space is between 18in-4ft usually between close
friends.
Personal Zone
This zone of personal space is between 4-12ft that does not require
permission.
Social Zone
This zone of personal space is 12ft and greater.
Public Zone
Pre-interaction Phase--> Orientation Phase--> Working Phase-->
Termination Phase. All part of the phases of___.
Helping Relationships
This is one of the fundamental impediments of critical thinking.
Egocentric thinking
This is to understand, comprehend, decipher & explain the meaning of
written materials, verbal & nonverbal communication, empirical data &
graphics.
Interpret (Interpretation)
To examine, organize, categorize, or prioritize variables such as signs &
symptoms, evidence, facts, research findings, concepts, ideas, beliefs &
points of view.
Analysis
To assess the credibility of sources of information, to assess the strength
of evidence, to assess the relevance, significance, value or applicability of
information in relation to a specific situation, & to assess information for
biases, stereotypes, & clichés.
Evaluation
To continuously monitor, reflect on, & question one’s own thinking, to
reconsider interpretations or judgments as appropriate based on further
analysis of facts or added information, & to examine one’s own views
with sensitivity to the possible influence of personal biases or selfinterest.
Self-Regulation
What is the ABC's of the nursing process?
Oxygen, Circulation,
Neurosensory, Nutrition,
Elimination, Mobility, and
Aging
What are some good attributes and characteristics of Critical Thinking?
Open-minded, flexible,
inquisitive, reflective,
creative, self-directed
This implies that a person is conscientious in actions, knowledgeable in
the subject, and responsible to self and others
Professionalism
the diagnosis and treatment of
human responses to actual or potential
health problems (ANA, 1980)
Professional Nursing
What is the nursing process?
Assessment
Analysis
Planning
Implementation
Evaluation
What are the levels of Health Care?
Preventive
Primary
Secondary
Tertiary
Restorative
Continuing