1
Q
How can subjective data be used in relation to objective data?
A
used to clarify objective data
ex: asking “How did you get the scar?”
2
Q
How is objective data gathered?
A
- physical assessment
- laboratory results
- diagnostic tests
3
Q
How can objective data be used with subjective data?
A
validate or verify subjective data
ex: high pulse rate with description of pain
4
Q
What is primary data in healthcare?
A
subjective or objective
obtained directly from the client
* their words: “I’m in pain”
* your own observations: vitals, body cues…
5
Q
What is secondary data in healthcare?
A
- obtained secondhand
- the medical record: lab results
- or from another caregiver
6
Q
What are methods to obtain subjective data during a patient interview?
A
- interviewing
- open and closed questions
7
Q
What are methods to obtain objective data during a physical exam?
6 types of assessing
A
Objective data can be obtained through
* inspection: sight
* palpation: touch
* percussion: tapping
* olfaction: smell
* direct auscultation (just ears)
* indirect auscultation (with a stethoscope)
8
Q
What is the purpose of a comprehensive health assessment?
A
provides holistic information about the client’s overall health
- physiological
- psychological
- socio-cultural
- developmental
- spirituality
- chief complaint
- current medications
- health history: immunizations, conditions, surgeries
9
Q
What does a comprehensive exam include?
A
- observation
- physical exam
- interviewing
- extensive health history
10
Q
What and when is a focused assessment?
A
- targets a specific issue
- is performed when a particular problem is identified or suspected.
- PRN
- following up during treatment
11
Q
What is a special needs assessment?
A
A focused assessment
in-depth information about a particular area
- functional ability: PT, ST, RT
- withdrawal (CIWA)
- nutrition
- pain
- cultural/spiritual health
12
Q
What is the Lawton Instrumental Activities of Daily Living (IADL) scale?
A
a person’s ability to perform sophisticated everyday tasks independently
* shopping
* meal preparation
13
Q
What is the Katz Index of ADL scale used for?
A
patient’s independence in basic activities
* bathing
* dressing
* toileting
* transferring
* continence
* feeding
14
Q
How should nursing assessments be individualized based on lifespan considerations?
4 points
A
consider
* developmental stages
* physical abilities
* cognitive abilities
* sensory changes
15
Q
What are the five senses and their role in sensory perception across the lifespan?
A
- sight
- hearing
- taste
- smell
- touch
all of which can decline with age, impacting
* balance
* communication
* safety.
16
Q
How can sensory overload occur, and what are interventions for it?
A
- too much sensory input (e.g., noise, light)
Interventions include
* reducing stimuli
* providing rest
* organizing care to limit disturbance
17
Q
How can sensory deprivation occur, and what are interventions for it?
A
lack of stimulation (e.g., isolation)
Interventions include
* increasing stimuli
* engaging the patient
* providing meaningful interactions
18
Q
What are common manifestations of altered mental sensory function, and what are their causes?
A
Manifestations include
* confusion
* disorientation
* hallucinations
often caused by
* sensory deficits
* medications
* environmental factors
19
Q
What are the key components of cognition and communication?
A
- perception
- memory
- reasoning
- judgment
- problem-solving abilities
- clear thinking
- awareness
- effective communication skills
20
Q
What influences cognitive function across the lifespan?
A
- age
- health status
- education
- environment
- lifestyle factors: diet and exercise…
21
Q
What factors can affect cognitive processes?
A
- illness
- medication side effects
- age-related changes
- stress
- neurological disorders.
22
Q
What are the normal functions of the musculoskeletal system?
3 points
A
- supports movement
- posture
- protection of organs.
23
Q
What are the characteristics of normal movement?
3 points
A
- smooth, coordinated, voluntary movements
- full ROM
- muscle strength
24
Q
What factors can affect or alter mobility?
A
- age
- injury
- disease
- medications
- lifestyle habits: exercise and nutrition.
25
How does immobility impact **physio**logical functioning?
* muscle atrophy
* joint stiffness
* pressure ulcers
* constipation
* respiratory complications
* decreased circulation: causing blood clots.
26
How does immobility impact **psycho**logical functioning?
* depression
* anxiety
* social isolation
* decreased self-esteem due to loss of independence.
27
What is the purpose of logrolling in nursing interventions?
* Maintain **spinal alignment**
* **prevent injury**
* particularly for patients with **spinal or back injuries**.
28
How does ambulation support patient recovery?
- Ambulation **improves circulation, muscle strength**
- **prevents** complications such as **blood clots and pneumonia**.
29
Why is range of motion (ROM) important in patient care?
* maintain joint flexibility
* muscle strength
* circulation
* prevent contractures
30
What **subjective data** should be collected to **assess mobility status**?
includes the patient's
* pain level
* ability to move
* past injuries
* current limitations
31
What **objective data** should be collected to **assess mobility status**?
* range of motion
* muscle strength
* gait
* posture
* balance
32
What are the principles of correct body mechanics?
- **using legs** instead of the back for lifting
- keeping the **spine aligned**
- maintaining a **wide base of support**
33
How does the HIPAA Privacy Rule **protect** health information?
- regulating the **use and disclosure** of **protected health information (PHI)**
- ensuring individuals' **privacy rights**.
34
What are the methods for measuring body temperature?
| 6 points
- **oral**: 97.7-99.5 normal
- **rectal**: 98.7-100.5 can cause injuries/complications/discomfort
- **axillary**: lower than oral
- **tympanic**: 98.2-100 normal
- **temporal**: 98.7-100.5
- **dermal**
35
what technique is used for tympanic temperatures?
- **Adults**: pull top of ear **up and back**
- **Ped**: pull bottom of ear **down and back**
36
what is the dermal route for temperature?
- strip on forehead
- **used during surgery**
- not as accurate
37
When is oral temp **contraindicated**?
- not useful is patient is **eating/drinking**
- contraindicated in patients with **mouth injuries**
38
What can affect rectal temp?
- presence of stool
- not as accurate as oral
39
How to take a rectal temperature?
- **Sims position**: left side, legs stacked
- **red probe**
- protective sheath and lube
- **adult: insert 1-1.5"**
- **ped: 1"**
40
how does axillary temp differ from oral reading?
axillary temp is **lower** than oral
41
What can affect a tympanic temp?
- presence of earwax
42
What is the least accurate temp location?
tympanic
43
What affects body temperature?
- exertion
* bathing
* location/route
* eating/drinking
- **wait 10-15 minutes** for body to settle
44
Define rigors
* **shaking**
* used to **create fever**
* could be **indication of sepsis**
* **fever will present within an hour of onset**.
45
febrile / afebrile
fever / no fever
46
hyperthermia / hypothermia
high body temp / low body temp
47
**What** is the **radial pulse** and **where** is it located?
* wrist, below the thumb
* routine pulse measurements
48
**Where** is the **apical pulse** and **how** is it measured?
* **fifth intercostal** space near the **left midclavicular** line
* measured **using a stethoscope**
* must count for **full minute**
49
What **characteristics** are assessed in **pulse** and **how long do you count**?
RRS
* **rate, rhythm, and strength**
* **even**: **15 sec** and **multiply by 4** for minute
* **irregular**: count **whole minute**
50
What is the difference between systolic and diastolic blood pressure?
- **Systolic** pressure is the force during **heart contraction**
- **diastolic** pressure is the force when the **heart is at rest**
51
How is **orthostatic hypotension** assessed?
Measure blood pressure in
* supine
* sitting
* standing positions
**check for a drop in BP upon standing**
52
What is the physiology and purpose of pulse oximetry?
* measures arterial oxygen saturation (**SaO2**)
* **detecting light absorption** differences
* **oxygenated vs. deoxygenated** hemoglobin
53
Tips for obtaining accurate pulse oximetry readings
- keep **arm straight**
- keep extremities **warm**: vasoconstriction May limit circulation
- can use the **earlobe or nose** for poor perfusion in extremities
- **dim lights** or cover the probe with covers or a towel
- May need to r**emove nail polish**
54
What are the characteristics of pain used for assessment?
* location
* intensity
* quality
* duration
* aggravating/relieving factors
55
What are the steps for **inspecting** the skin?
Inspect for
* color
* vascularity
* edema
* lesions
56
What are the steps for **palpating** the skin?
Palpate for
* temperature
* moisture
* texture
* thickness
* turgor
57
How are the eyes assessed during a physical exam?
* **pupil size**
* **PERRLA**
vision changes due to aging
* **cataracts**
* **presbyopia**: gradual loss of your eyes' ability to focus on nearby objects
58
What is PERRLA
**p**upils are
**e**qual
**r**ound and
**r**eactive to
**l**ight and
**a**ccommodation
59
What is SBAR communication, and why is it important in healthcare?
SBAR
**S**ituation
**B**ackground
**A**ssessment
**R**ecommendation
- a standardized method for **effective communication between healthcare professionals**.
60
What factors can influence pain perception in adults and geriatrics?
* **age**
* **cognitive function**
* **medication use**
* underlying **chronic illnesses**: that may **alter pain tolerance or expression**
61
When is a rectal temperature measurement contraindicated?
* **rectal surgery**
* **hemorrhoids**
* **low white blood cell count**: to avoid **risk of infection** or **injury**
62
What factors can influence vital signs?
* age
* activity level
* emotions
* medications
* illness
63
What are normal vital signs for adults?
**Temperature**: 97.7-99.5°F - Oral
**Pulse**: 60-100 bpm, athletes 40-60
**Respiration**: 12-20 breaths per minute
**BP**: <120/80 mmHg
**SpO2**: 95-100%.
64
What is the significance of pulse oximetry readings?
less than 94% can indicate **hypoxemia**
65
What is **orthostatic hypotension**?
* Orthostatic hypotension is a **drop in blood pressure** when moving from a **lying to standing** position
* must assess before first time getting a new pt out of bed
66
What interventions **prevent complications** of immobility?
* position changes
* ROM exercises
* compression devices
* proper hydration
67
What are the safety precautions when assisting patients to ambulate?
* proper **footwear**
* use **assistive devices**: (walker, cane, gait belt)
* **assess for dizziness or weakness** to prevent falls
68
What is the **purpose** of HIPAA?
HIPAA ensures
- **continuity of healthcare coverage** when changing jobs
- **simplifies health insurance** administration
- **manages health information**
- **protects** personal health information (**PHI**)
69
What rights does HIPAA give patients regarding their health information?
Patients have the right
- to **access** their health records
- to **control over** the **use and disclosure** of their **protected health information** (PHI)
- to **keep their information private**.
70
What is considered confidential information under HIPAA?
- Any **personally identifiable information (PII)**
- **protected health information (PHI)**
* name
* social security number
* date of birth
* medical records
71
What are the **permitted uses of PHI** under HIPAA?
can be used for
* healthcare treatment
* payment
* healthcare operations
* quality assessment
* legal cases
* compliance audits
72
What is the **difference** between **privacy and confidentiality**?
- **Privacy** refers to the **individual's right** to keep personal information private
- **confidentiality** is the **duty to protect that information** from being disclosed.
73
What are some **safeguards** to maintain HIPAA privacy?
Safeguards include
* speaking quietly
* not using names
* not sharing passwords
* disposing of PHI properly
* avoid photocopying or faxing PHI
74
What are the penalties for violating HIPAA?
**Civil penalties**
* range from **$100-$50,000 per violation**
* annual **maximum of $1.5 million**
**Criminal penalties**
* include **fines up to $250,000** and **imprisonment**.
75
What are the social media restrictions under HIPAA?
must not
* post patient information
* take pictures of patients
* establish social relationships with patients
* make offensive comments about coworkers or employers online.
76
What should you do if there is a breach of PHI?
Report the breach immediately to the appropriate authorities, as **required by the HITECH Act** for **breaches affecting more than 500 individuals**.
77
What are the consequences of academic HIPAA violations?
Consequences include
* academic suspension
* course failure
* dismissal from nursing school
* disciplinary action by the Board of Registered Nursing.
78
How can language barriers be addressed in communication?
Use
* interpreters
* visual aids
* simple language
**ensure patients understand their care**.
79
How can you promote understanding in patient interactions?
* clear language
* explain carefully
check for understanding
* asking the patient to clarify or repeat
80
How do you assess coping and stress tolerance?
Listen for cues about
* recent stressors
* coping mechanisms
* thoughts of harming self or others: must report
* using open-ended questions.
81
How does being under the influence of substances affect communication?
* impaired judgment
* confusion
* incoherence
requiring
* simple, direct, and nonjudgmental communication.
82
How does personal space affect communication?
* ensures **comfort**
* **reduces feelings of vulnerability or threat** during interactions
83
What are nonverbal cues in communication?
* facial expressions
* body language
* eye contact
* tone of voice
* gestures
convey emotions or attitudes.
84
What are the key components of a physical assessment?
* general appearance
* vital signs
* pain assessment
* gathering subjective and objective data from the patient
85
What are the key elements to ensure during patient interaction?
* privacy
* sit at eye level
* face the patient
* reduce distractions
* use therapeutic communication
* ensure the patient understands
86
What aspects are **assessed** under cognition and perception?
- **Awareness**
- **thought processes**
- **memory**
- **language**
- **judgment**
- **attention span**
- **sensory impairments**
- **trust**: assess if they will physically strike out. be on guard.
87
What communication strategies are used with hostile or anxious patients?
* **remain calm**
* use **non-confrontational language**
* provide reassurance to **defuse tension** and **build trust**.
88
What does it mean to facilitate communication?
ex: patient says they fell, **you facilitate specificity**.
what caused the fall? passing out? tripping? how often?
89
What effect does asking 'Why' questions have on communication?
Asking "Why" can
* **make patients feel defensive or blamed**, hindering open communication.
* **seem confrontational**
90
What is a physical assessment?
* comprehensive **head-to-toe** or **systems assessment**
* done **each shift** and **as needed** (PRN).
91
What is active listening in therapeutic communication?
* giving full attention to the speaker
* using verbal and nonverbal cues (e.g., nodding)
**show understanding** and **encourage further sharing**.
92
What is self-perception and self-concept?
**Self-perception** refers to **how a person views themselves**
**self-concept** includes their **self-esteem and body image**.
93
What is the difference between a physical assessment and a focused assessment?
- A **physical assessment** is **comprehensive** and done **head-to-toe or system-wide**
- a **focused assessment** is **abbreviated** and **targets a specific system or issue**.
94
What is the difference between closed and open-ended questions?
**Closed-ended** questions elicit **short answers** (e.g., yes/no)
**open-ended** questions encourage **more detailed responses** and discussion.
95
What is the difference between nursing history and medical history?
**Medical history** focuses on the **patient's diagnosis** and condition
**nursing history** focuses on the **patient's responses** to health problems.
96
What is the purpose of making observations during communication?
* helps you **note and reflect** on the **patient’s behavior or appearance**
* **encouraging them to share more** about their feelings or condition.
97
What is therapeutic communication?
| 8 points
* Silence
* Active empathetic listening
* Restatement
* Reflection
* Summarizing
* Clarifying
* Validating
* Touch
98
What role does silence play in therapeutic communication?
Silence allows patients **time to process thoughts, reflect, and feel comfortable sharing more information**.
99
What should you assess regarding a patient's roles and relationships?
| 4 points
- **family roles**
- **work status** (e.g., employed, retired)
- **financial concerns**
- **patient's support system**.
100
What should you avoid in patient communication?
- **using authority**
- **creating distance**
- **using medical jargon**
- **interrupting**
- **stereotyping**
- **appearing rushed**
- **asking "why" questions**.
101
What types of history are collected during an admission assessment?
- **Health history**
- **family health history**
- **medical conditions**
- **infectious diseases**
- **childhood illnesses**
- **immunization history**
102
Why is it important not to appear rushed during patient interactions?
Appearing rushed can
* make **patients feel unimportant or unheard**
* **affects trust and rapport**.
103
Why is it important to assess a patient's roles and relationships?
* help **guide care plans**
* address **potential social or financial stressors**
104
Why is it important to assess cognition and perception in healthcare?
Cognitive and perceptual functions affect a patient's ability to
* communicate
* follow instructions
* participate in their care.
105
Why is it important to assess self-perception and self-concept?
It gives insight into the patient’s
* **emotional health**
* **confidence**
* concerns about their **well-being** and **body image**.
106
Why is it important to assess spirituality in patients?
* Spirituality can affect the **mind, body, and spirit**
* **distress** in one area **can impact the patient's overall health**.
107
Why is it important to reduce distractions during patient interactions?
* helps the **patient feel heard**
* **ensures effective communication**.
108
Why should healthcare providers be aware of their own values and beliefs?
* **avoid letting personal biases affect patient care**
* **focus on the patient’s beliefs**
* **staying neutral on topics** like politics or other sensitive matters
109
Why should medical jargon be avoided in patient communication?
Medical jargon **can confuse patients**, leading to misunderstandings and **reduced comprehension of their condition**.
110
What vital signs are included in a physical assessment?
| 7 points
* **Temperature**
* **pulse**
* **BP**
* **respirations**
* **pain**
* pulse oximetry
* consciousness
| **"5 vitals"**
111
What is the most cost-effective way to prevent infection?
Hand hygiene
112
By how much can handwashing reduce deaths from diarrheal disease?
Up to 50%
113
What are the two main methods of hand hygiene?
**Soap and water** or **antiseptic hand rub**
114
When **should soap and water** be used instead of hand rub?
* hands are visibly soiled
* before eating
* after restroom use
* at the beginning of the shift
115
How long should you wash your hands with soap and water?
For at least 20 seconds
116
What is the procedure for washing hands with soap and water?
* Remove watch
* clean under jewelry
* keep **clothing away from water**
* **fingertips below wrists**
* use liquid soap
* rub in circular motion
* clean between fingers and under nails
117
When should **hand hygiene** be performed **before an activity**?
* Before eating
* before patient contact
* before putting on gloves
118
When should **hand hygiene** be performed **after an activity**?
* After using the restroom
* removing gloves
* contact with intact skin, body fluids
* contact with objects in the patient's room
119
Why should hand rub and soap not be used simultaneously?
It is ineffective to use both methods at the same time
120
What should be done if C. diff is confirmed or suspected?
* Use **soap and water**
* **alcohol-based hand rubs are ineffective against C. diff**
121
What is the recommended procedure for alcohol-based hand rubs?
* Apply **at least 3 mL**
* rub hands vigorously for **20 seconds**
* covering all surfaces **until dry**
122
What are some "Do Not" rules in hand hygiene?
* Do not wash gloved hands
* wear nail polish or artificial nails
* have nails longer than ¼ inch
* use hand rub and soap simultaneously
123
What should you do if a gown doesn't cover your back?
Wear a second gown in reverse
124
What are the key **differences in gloving** between **LTC** and **Acute Care**?
**LTC**: **One glove** holds dirty items
**Acute Care**: **Gloves** must be **removed in-room**
125
Where are linen and trash containers located in acute care settings?
In every patient room
126
What is the procedure for removing gloves in acute care?
* Strip off gloves **inside the room**
* perform **hand hygiene**
* **then exit** the room
127
What does PPE stand for? Why? What agencies?
* Personal Protective Equipment
* **worn for protection against infectious materials** (OSHA)
**OSHA** regulates
**CDC** Recommends rules
128
What types of PPE are used in healthcare?
* Gloves
* gowns
* masks/respirators
* goggles
* face shields
129
What are gloves used for in healthcare?
* Protect hands from **contact with infectious materials**
* can be **sterile or non-sterile**
* Always **change gloves after use**
* or if they are **torn or heavily soiled**
130
What is the purpose of wearing a gown?
* Protect skin and/or clothing
* gowns can be reusable or disposable.
131
How do masks and respirators differ?
* **Masks** protect the **mouth and nose** from droplets
* **respirators** protect the **respiratory tract** from **airborne** infectious agents
* (Respirators are not used in nursing school)
132
Why should goggles be used?
* To protect the eyes
* should fit snugly
* regular glasses are not a substitute.
133
What does a face shield protect?
Face, mouth, nose, and eyes
134
What are standard precautions based on?
* The **assumption that any blood or bodily fluid could be infectious**.
* **Hand hygiene** and **appropriate PPE** are used to **prevent infection**.
135
When should gloves be worn according to standard precautions?
When touching **blood, bodily fluids, secretions, excretions, or non-intact skin**.
136
What should be worn during patient care activities that may generate splashes?
* **Mask and goggles or face shield** to protect against splashes or sprays of blood, bodily fluids, secretions, or excretions.
137
What PPE is required for contact precautions?
**Gloves and gown** for contact with patient or patient environment.
138
What PPE is required for droplet precautions?
A **surgical mask within 3 feet** of the patient.
139
What PPE is required for airborne infection isolation?
A particulate **respirator and a negative pressure isolation room** for the patient.
140
What is the sequence for donning PPE?
1. Gown
2. Mask or respirator
3. Goggles or face shield
4. Gloves.
141
What is the sequence for doffing PPE?
1. Gown and gloves
2. Goggles or face shield
3. Mask or respirator
4. Wash hands.
142
What should you check before feeding a patient?
Ensure the patient is receiving the **correct diet** (e.g., regular, mechanical soft, clear liquid, diabetic, etc.).
143
What is the recommended ratio of staff to patients in the dining room in LTC?
* **One staff** for every **2-3 patients**.
144
How long should a meal take when feeding a patient?
* 20-30 minutes
145
What should be avoided during a patient's meal?
* Interrupting with medications
146
What should you do before assisting a patient with their meal?
* Assist to the **bathroom** and **help with hand washing** before and after the meal.
147
What are important steps when feeding a patient with dementia?
* Assess feeding ability
* minimize distractions
* remove inedible items
* cue verbally ("take a bite, chew, swallow")
* avoid feeding too fast.
148
What should be documented after a patient’s meal?
* The **amount of food and fluid** consumed
* any **unusual feeding behaviors**.
149
what is dysphagia
difficulty swallowing
150
What position should a patient be in for oral hygiene?
* Semi-Fowler's position
* 15-45 degrees
151
How should dentures be cleaned?
* Remove from mouth
* clean in the sink **over a towel** with **cool water**: hot can warp them
* do not use hot water
* store in a labeled denture cup.
152
What is the most commonly lost article in hospitals?
(1) hearing aids, dentures
153
How should you check the function of a hearing aid?
* Listen for feedback after turning it on.
154
What are clues that a patient might have hearing loss?
* Inappropriate answers to questions or **confabulation** (making up answers).
155
How should you communicate with a patient who has hearing loss?
* Make eye contact
* speak directly and clearly
* check for understanding
* write it down if necessary.
156
How do you brush a patient's teeth?
* Use a **45-degree angle**
* gently brush **all surfaces and the tongue**
* rinse and spit.
157
What should be done before removing hearing aids?
* Turn off the hearing aid before removing.
158
How do you clean hearing aids?
* Wipe with a damp cloth
* check for cracks or loose tubing
* clean the outer ear for wax buildup.
159
What is the first step in washing a patient during a bed bath?
* Wash the eyes with a wet, soap-free washcloth, one eye at a time.
160
How should the perineum of a female patient be cleaned?
* Wash from front to back
* avoiding contact with the anus to prevent infection
* Rinse and dry well, without using powder.
161
How should the perineum of a male patient be cleaned?
* Gently retract the foreskin (if applicable)
* wash the penis and scrotum with a soapy washcloth
* rinse, and dry.
162
How should the anus be washed during a bed bath?
* Turn the patient onto their side
* raise the top leg
* wash, rinse, and dry the anal area.
163
When should the RN be notified during a bed bath?
* If redness or skin breakdown is observed.
164
What additional care can be offered after a bed bath?
* Oral care
* shaving
* air care.
165
What are CHG baths?
**Chlorhexidine gluconate** (CHG) baths are **used to reduce the risk of infection in patients**
* especially before surgery
166
What should you monitor before assisting a patient with toileting?
* check for intake/output **(I/O) orders**
* be aware of any **stool or urine sample needed**
167
What should be considered before assisting with toileting?
* **Activity level**
* **mobility restrictions**
* **personal, cultural, and religious concerns**: patient may prefer a **same-sex caregiver**.
168
What supplies should be gathered before toileting?
* Wipes
* toilet paper
* gloves
* barrier cream
169
Why is perineal care important?
* The **perineum** is dark, warm, and moist, which **supports bacterial growth**.
Peri care prevents
* **infection**
* **maceration**
* **excoriation**
and **promotes comfort**.
170
what is maceration
* A **softening and breaking down** of skin resulting from **prolonged exposure to moisture**
171
What is excoriation?
* **redness and removal** of the **topmost surface of the skin**
172
What is the PureWick system used for?
* It is used for **female urinary incontinence** and **immobility**.
* **do not** use in **combo with a brief**
173
What are the contraindications for using PureWick?
* **Confused patients**: can't vocalize discomfort
* **bowel incontinence**: causes UTI
* **skin irritation or breakdown**: will worsen with suction
174
When should a bedpan be used?
* When the patient has **no bed mobility restrictions** and **can sit upright** in bed.
175
When should a fractured bedpan be used?
* When the patient **has mobility restrictions** (e.g., joint or back surgeries) and **must lie flat** in bed.
176
How often should incontinent patients be checked?
* Hourly to prevent skin breakdown.
177
What to do every time you leave a patient?
* bed locked and lowered
* call light in reach
* belongings are within reach
178
What is the proper technique for lifting?
* Lift with your legs/arms
* keep the curve in your back
* avoid twisting while lifting.
179
Why is it important to obtain vital signs on patients?
* To establish a baseline
* monitor effects of surgery/disease
* recognize changes
* watch trends.
180
What is the normal temperature range for adults and geriatrics?
**Adults**: 97.7-99.5°F
**Geriatrics**: 95-96.8°F
181
What is the normal pulse rate for adults?
* 60-100 beats per minute
* Average: 80 bpm
* athletes 40-60
182
What affects pulse rate?
* Age
* sympathetic/autonomic nervous system
* and medications.
183
What are the main sites for pulse assessment?
* **Radial artery**: thumb side of wrist
* **apical (PMI)**: point of **maximum impulse**
* **brachial**: elbow. site for BP
Emergency sites include
* **femoral**: in groin
* **carotid**: caution. can dislodge plaques in older pts.
184
How is pulse quality rated in EHR?
* 0 = Absent
* 1+ = Thready
* 2+ = Normal
* 3+ = Bounding
too strong = hypertension, extra hydration
185
What is the normal respiratory rate for adults?
* 12-20 breaths per minute
* geriatric may be faster
186
What factors **increase** respiratory rate?
* age = less efficient lungs = higher resp rate
* Activity
* pain
* fever
* anxiety
* anemia: low O2
* chronic disease.
187
What factors **decrease** respiratory rate?
* sleep
* some medications (opiates)
* dying process
188
what are respiratory characteristics
* rate
* depth
* rhythm
* effort
189
What are the terms for abnormal respiratory patterns?
| 4 terms
* **Tachypnea** (fast)
* **dyspnea** (difficulty)
* **exertional dyspnea** (with activity)
* **apnea** (no breathing)
190
What is the normal blood pressure range for adults and elderly?
* **Adults**: 120/80 mmHg
* **Geriatrics**: up to 160/95 mmHg
191
What can cause inaccurate blood pressure readings?
* Wrong cuff size
* incorrect placement
* auscultatory gap
* irregular heart rate
* using an electronic BP machine.
192
what is auscultatory gap?
* interval of **absolute or relative silence** occasionally found on listening over an artery during deflation of the blood pressure cuff
* may **underestimate systolic** (didn't pump high enough)
* may **overestimate diastolic** (sound may disappear and come back)
193
What are orthostatic abnormal findings?
HR and BP taken lying down, sitting, then standing.
* **pulse increases** by 20+ BPM
* **systolic decreases** 20+ mmHg
* **diastolic decreases** 10+ mmHg
* pt **becomes dizzy**
* allow **1-3 min between readings**
194
Significance of orthostatic hypotension
* dehydration
* blood loss
* risk for loss of consciousness/falls
195
What is pulse oximetry used for?
* A non-invasive procedure to **measure the amount of hemoglobin bound with oxygen**
* normal value is **95% or greater**.
* in healthy patient **less than 94% is clinically significant**
196
How is pain intensity assessed and treated?
* Using the **0-10 scale**
* goal is to **get pt to a 2 or less**
* **don't risk respiratory depression**
* **vitals should support claim**: high bp, hr, rr
197
What does PAIN stand for?
* **p**attern: how it changes with circumstance
* **a**rea: location
* **i**ntensity: 1-10
* **n**ature: throbbing, stabbing, etc...
198
Non-numeric pain scale
- Wong-Baker **Faces** scale
199
Duration pain terms
* **acute**: short term
* **chronic**: long term. 3+ mo.
* **intracatable**: constant
* **intermittent**: comes and goes
200
What nursing tools can **cool a febrile patient**?
* **Radiation** (uncover patient)
* **convection** (fan)
* **evaporation** (cool cloth)
* **conduction** (ice pack to reduce inflammation).
201
What nursing tools can **warm a patient**?
* **Radiation** (cover patient)
* **convection** (close doors)
* **evaporation** (keep patient dry)
* **conduction** (warm packs to help healing. increase blood flow 2-3 days after injury).
202
What are some signs to assess for violence?
* #1 history of violence
* Altered LOC
* psychiatric history
* substance abuse
* verbal/non-verbal signs of aggression
* awareness of surroundings (pt and nurse safety): leave yourself an exit
* potential weapons: no steth on neck
203
What are the abnormal skin color changes?
* **Pallor**: paleness
* **erythema**: redness
* **cyanosis**: blueness of lips, mucous membranes
* **jaundice**: yellow
* **ecchymosis**: abnormal bruising
204
What causes ecchymosis?
* anticoagulant or antiplatelet meds
205
what does cyanosis indicate?
* **hypoxia**
206
What is skin **turgor**, and what is abnormal?
* Pinching the skin **should result in it snapping back**
* if it **"tents" or stays up, it is abnormal**.
* best to pinch **near collar bone on geriatric**
207
What is clubbing in nails a sign of?
* Chronic hypoxia
* lung disease
208
What are common skin variations in the elderly?
* Dry skin
* skin tags
* **lentigines**: sun spots
* thinning hair
* **senile purpura**: like ecchymosis (easy brusing)
209
Why perform neurological assessments?
* To **determine baseline**: iteracting/talking...
* **recognize changes** in neuro status throughout the day
* **identify the need** for tests or interventions
* **safety**: impulsivity/lowered awareness
* see if they **can retain info** from morning to afternoon
210
What are the main points to document in a neurological assessment?
* Level of consciousness (**LOC**): aware, alert, awake
* **orientation/mental status**: ask specific questions. pt's may try to hide/play off if they are disoriented.
* **pupillary response**: should constrict with light
* **motor response and strength**
* **sensory function**: can they feel you
* **reflexes**
211
What should you ask to determine if a pt is oriented?
* full name
* time of day
* what city
* what season
* note changes from baseline
212
What is pronator drift?
* A test where a patient **holds arms out with eyes closed**, and **if one arm drifts downward**.
* can indicate **opposite hemisphere issue**
213
What are common terms used in heart rate assessment?
| 4 points
* **Bradycardia**: less than **60** bpm
* **tachycardia**: greater than **100** bpm
* **pulse deficit**: diff between apical and peripheral pulse
* **dysrhythmia**: irregular rhythm
214
How do you assess sensation?
Test for response to stimulus
* normal
* numbness/tingling
* lack of sensation, or pain
215
What are the main components of a musculoskeletal assessment?
* Symmetry
* strength
* range of motion (ROM)
* pain
used to prep to ambulate
216
How do you assess musculoskeletal system?
Arms
* **hand grips**: give on finger in each hand to squeeze
* **push pull**: palm to palm, have them push you away and pull against you
Legs
* **push/pull**: they bend knee to meet your hand
Feet
* **flex/point**: against hand pressure
217
What factors should be included in a
neurological health history (**subjective**)?
Ask open ended questions
* Headache
* Head injury
* Dizziness/Vertigo: inner ear
* Seizures
* Tremors
* Weakness
* Deficits
* Lack of coordination
* Numbness or tingling
* Difficulty swallowing (**dysphagia**)
* Difficulty speaking (**aphasia**)
* Significant history: stroke, brain injury
* Environmental/occupational hazards
218
What is **expressive** aphasia?
* **Difficulty speaking** after a stroke (CVA)
* patient **can understand** others.
219
What is **receptive** aphasia?
* individuals have **difficulty understanding written and spoken language**
220
What are the abnormal changes in pupil function for geriatric patients?
* **Cataracts**: pupils develop irregular shape.
* changes due to **eye surgery**
221
How can illness affect a person's ability to perform self-care?
Illness can **limit mobility, cause pain, and affect sensory perception, cognitive abilities, or mental health**, making it difficult to perform daily hygiene tasks.
222
How does pain affect the ability to perform self-care?
Pain can **reduce mobility and motivation, while pain medications may cause drowsiness**, limiting a person's ability to perform self-care.
223
What is the impact of sensory deficits on patient safety and hygiene?
Patients with sensory deficits **may not be aware of hazards** and are at **increased risk of injuries or infections** due to **impaired vision, hearing, or touch**.
224
How can cognitive impairment affect hygiene?
Cognitive impairment may **prevent patients from recognizing the need for hygiene or knowing how to perform related tasks**, compromising their overall health.
225
What are the types of baths?
Types include
- **prepackaged**
- **towel bath**
- **bag bath**
- **basin and water bath**
- **shower**
- **tub bath**
- **therapeutic bath**
226
What are prepackaged bathing products used for?
* ensure **consistent technique**
* **prevent skin damage**
* **reduce the risk of infections** from **rough washcloths or basins**.
227
When is a towel bath recommended?
for patients with
* mild to moderate **skin integrity impairment**
* **activity intolerance**
* **dementia**.
228
What are guidelines for assisting patients with meals and feeding?
* checking for **diet restrictions**
* ensuring **safe swallowing**
* positioning the **patient upright**
* offering **assistance without rushing**.
229
What does the term accomodation mean?
* Healthy **pupils dilate** when looking at **something far away**
* **constrict** when looking at **something close**.
230
Which patients are at high risk for falls?
* Patients with mobility impairments
* sensory deficits
* cognitive impairments
* those on medications affecting balance
231
What are safety measures to prevent falls?
* uncluttered environment
* tab alarms
* grippy footwear
* call lights in reach
* pads on floor
* lowering bed
* 2 bed rails (4=restraint)
232
What is a bag bath?
A bath using **8 to 10 washcloths** instead of a towel and bath blanket, where **each section of the body is cleansed with a fresh cloth**.
233
When is a basin and water bath used?
* When a patient **refuses a prepackaged bath**
* or if the **patient is grossly soiled**.
234
What is a risk of using reusable basins for bathing?
Reusable basins can **become a reservoir for microorganisms** and may lead to **healthcare-associated infections**.
235
what kind of water should be used for bathing?
Use **distilled, sterile, or filtered water** to **prevent skin contamination from bacteria biofilm**.
236
What is recommended if tap water is used for bathing?
Bathe the patient with a solution of **chlorhexidine (CHD) and water to combat bacteria** that may be present.
237
When is a shower appropriate for patients?
Showers are suitable for **ambulatory patients who can safely stand and move**.
238
What are the benefits of a tub/therapeutic bath?
Soaks **crusty or scaly areas**, and relaxes stiff, **sore muscles and joints**.
239
What are examples of therapeutic baths?
**Oatmeal or coal tar baths** for skin conditions like **psoriasis**, or a warm sitz bath for **cleansing and soothing inflammation**.
240
slow heart rate < 60 bpm
**bradycardia**
241
fast heart rate, > 100 BPM
**tachycardia**
242
pulse deficit
* **variance** between **apical/Peripheral pulses**
* contractions **not making it to extremities**
* premature ventricular contractions
243
abnormal rhythm, irregular
**dysrhythmia**
atrial fibrilations
244
What is external respiration?
* Oxygen enters the lungs, and carbon dioxide exits **during ventilation**.
245
What is internal respiration?
* The **exchange of gases** between blood and cells **through diffusion (O2 and CO2)**.
246
What is perfusion?
* The **distribution of RBCs/oxyhemoglobin** to cells **in the body**.
247
What muscles are involved in the mechanics of breathing?
* The **thoracic muscles** and the **diaphragm**.
248
What is normal blood pressure?
Less than 120/80 mmHg.
249
What is considered **Stage 2 hypertension**?
140+ systolic
90+ diastolic.
250
What is a hypertensive crisis?
Blood pressure **higher than 180/120** mmHg; consult a doctor immediately.
251
What is the direct method of measuring blood pressure?
A catheter is inserted into an artery.
252
What is the indirect method of measuring blood pressure?
* A **blood pressure cuff** is used; also known as blood pressure by auscultation.
* **stethescope and sphygmomanometer**
253
What factors affect blood pressure?
* Sympathetic & parasympathetic nervous systems
* blood volume
* medications
* peripheral vascular resistance.
* sleep, activity, stress, exercise
254
How does the size of the blood pressure cuff affect readings?
* A cuff that is **too small** may give **high readings**
* a cuff that is **too large** may give **low readings**.
| inverse relationship
255
How is systolic blood pressure detected?
* The **first sound heard** during auscultation.
* inflate to **30 points above expected systolic**, and begin to deflate
* ask pt what their **norm** is and **use as guideling for inflation**
256
How is diastolic blood pressure detected?
The absence of sound after the final beat heard.
257
What are reasons to avoid using certain limbs for blood pressure measurement?
* **Mastectomy or lymph issues**: could trap lymph fluid = **lymphedema**
* **hemodialysis grafts or fistulas**: **could clot device**: can make them unusable
* **PICC lines**
* **IVs in the arms**: if IV in both arms, use the lower flow rate option
* Do not use the arm that is **paralyzed or on the same side of previous breast or shoulder surgery**
258
What are blood pressure locations?
| 4 points
* **Radial artery** (at wrist)
* **posterior tibial artery** (inner ankle)
* **brachial artery** (at elbow)
* **popliteal artery** (behind inner knee)
**systolic pressure may be 20 to 30 mm Hg higher in the lower extremities**
259
What are normal findings in a skin assessment?
* Warm, mostly dry
* moist with activity
* smooth and firm texture
* absence of injury (intact skin).
260
What are abnormal skin changes?
* Cool, cold, hot
* localized changes: **cellulitis**
* **diaphoretic**: sweating heavily
* **clammy**: damp and sticky
* dry, and flaky skin
temp changes can indicate low blood sugar
261
What are normal skin variations in adults?
* **Cherry angiomas**: raised vessel bumps
* **seborrheic keratoses**: bumpy, scaly moles
262
What should be assessed during a hair examination?
* Hygiene
* condition: well groomed?
* infestation: lice, scabies...
263
What should be assessed during a nail examination?
* Hygiene
* color
* shape
* capillary refill: hands and feet
abnormal
* clubbing or spoon-shaped nails **koilonychia**
264
What cultural considerations should be made for dark-skinned patients during a skin exam?
* **Check lighter pigmented areas or mucus membranes** for color changes
* **jaundice** in the **sclera of the eyes**
* **cyanosis** in **nail beds or lips**.
* **paleness** = yellow/brown to ashen
* **erythema** = dark purple
265
What is the continuum of consciousness from alert to coma?
* **Alert**
* **lethargic**: sleepy
* **obtunded**: can be roused with verbal stimuli
* **stuporous**: responds to painful stimuli (sternal rub, pen on nail bed)
* **comatose**: unresponsive to stimuli
266
What should be inspected during an eye assessment?
* Check for **asymmetry: lazy eye**
* pupil size before light (**3 mm normal**)
* **ability to track**
* **incomplete closure**
* **ptosis**: dropping lid after stroke
* response to light reflex (**PERRL**)
267
Types of PERRL findings
Light reflex
* **Brisk** (Normal)
* **Sluggish** (Slow)
* **Unresponsive** (Fixed)
Unilateral or Bilateral
268
What are common causes of abnormal pupil response?
* **Drug use** or **brain injury**
* lead to **sluggish, unresponsive, or pinprick pupils**.
269
What should be assessed during an ear exam?
* Check for tenderness
* pain
* hearing loss: general hearing acuity
* hearing aids
* document any abnormal findings: lacerations, etc...
270
What are common speech abnormalities?
* **Slurred**: slow, strained, alcohol...
* **garbled**: word soup
* **dysarthria** (difficulty speaking). stroke, **broca area** of brain
271
What are **abnormal** gait patterns?
* Slow
* unsteady
* leaning to one side
* shuffling
* wide gait (duck walk) - geriatric
272
What movements are involved in range of motion (ROM) assessments?
| 4 points
* Flexion
* extension
* abduction
* adduction
273
What is flexion?
Movement that **decreases the angle** between two body parts (e.g., **bending the elbow**).
274
What is extension?
Movement that **increases the angle** between two body parts (e.g., **straightening the elbow**).
275
What is abduction?
Movement of a limb **away from the midline** of the body (e.g., **raising the arm sideways**).
276
What is adduction?
Movement of a limb **toward the midline** of the body (e.g., **lowering the arm to the side**).
277
What is included in neurosensory (CMS) checks?
**CMS** = **circulation/motion/sensation**
check 3 diff areas of body
* **cap refill**
* **ROM**
* **response to stimulus**
- normal, numb/tingling, lack of sensation, pain
**establish baseline and assess for changes**
278
What is the **CIWA protocol** used for?
| Clinical Institute Withdrawal Assessment
Assessing **alcohol withdrawal symptoms**
* Nausea and vomiting
* Tremors
* **Paroxysmal sweats**: sudden recurrence or intensification
* Anxiety
* Agitation
* **Tactile disturbances**: false feeling of something touching you, either on the surface of your skin or inside your body
* **Auditory disturbances**: hear voices or noises that aren't there
* **Visual disturbances**: short spell of flashing or shimmering of light in your sight
* Headache
* Disorientation
* **clouded sensorium**: the inability to think clearly or concentrate
Scored with points system to assess risk
279
What is included in the "**Situation**" section of SBAR?
* Identify yourself
* patient details
* admitting diagnosis
* **current problem or situation**
280
What is included in the "**Background**" section of SBAR?
* **Pertinent medical history**: pertinent comorbidities
* code status
* allergies
* vital signs/trends
* pain status
* recent meds
* labs/diagnostics
* **what circumstances led to this event**?
281
What is the purpose of the "**Assessment**" section in SBAR?
**your assessment of the situation**
* **the problem**
* condition change
* interventions taken
282
What should be addressed in the "**Recommendation**" section of SBAR?
* State **what action you recommend** to correct the problem
* ex: meds, O2, activity changes, or consults.
283
What are the key factors assessed in the **Morse Fall Scale**?
* History of falling
* secondary diagnosis: HT, DM...
* ambulatory aids
* IV/heparin lock: cords are trip hazard
* gait
* mental status
284
What is considered a **high fall risk** on the Morse Fall Scale?
A score of 45 or higher.
285
What score range indicates a **moderate fall risk**?
25-44 points.
286
What score indicates a **low fall risk**?
0-24 points.
287
What tones come from stethoscope **diaphragm**?
high frequency
most used
288
What tones come from stethoscope **bell**?
low frequency sounds
289
How is capillary refill tested?
* **Press on the nail** bed or skin **for a few seconds** until it blanches (turns white), **then release and observe**.
290
What is a normal capillary refill time?
Less than 2 seconds.
291
What does prolonged capillary refill (more than 2 seconds) indicate?
* poor circulation
* shock
* dehydration
292
Abnormal findings in capillaries?
- darkness
- blackness
- cyanosis
293
What is the Glasgow Coma Scale (GCS) used for?
* To assess a patient’s **LOC following a head injury or neurological impairment**.
294
What are the three components of the Glasgow Coma Scale GCS?
* Eye-opening response
* verbal response
* motor response.
295
How is eye-opening scored in the GCS?
Spontaneous = 4
to sound = 3
to pressure = 2
no response = 1.
296
How is the verbal response scored in the GCS?
Oriented = 5
confused = 4
inappropriate words = 3
incomprehensible sounds = 2
no response = 1
297
How is the motor response scored in the GCS?
Obeys commands = 6
localizes pain = 5
withdraws from pain = 4
abnormal flexion (**decorticate**) = 3
abnormal extension (**decerebrate**) = 2
no response = 1
298
GCS Score breakdowns
**15**: indicating **full consciousness**.
**13-15**: **mild** brain injury
**9-12**: **moderate** brain injury
**8 or less**: **severe** brain injury
**3**: indicating **deep coma or unresponsiveness**.
299
What is decorticate posturing?
* patient’s **arms** are **flexed towards the body**
* **legs extended**
* indicating **severe brain damage**
300
What is decerebrate posturing?
patient’s **arms and legs** are **extended and rotated outward**, with the **head arched back**.
301
Which posturing is considered more severe, decorticate or decerebrate?
**Decerebrate** posturing is considered more severe, as it **indicates deeper brain damage**
302
If you plan is to **recheck vitals**, how long is normally a **reasonable amount of time to see a significant change** with most patients?
10 minutes
303
Abnormal BP findings
3 broad terms and values
**hypotension**: below 90/60
**hypertension**: above 140/90
**systolic hypertension**: 130**+**/80**-** (common in elderly)
304
What is vasodilation?
* The **increase in the diameter** of blood vessels, which diverts core-warmed **blood to the body surface** for heat transfer.
* **cools the body**
305
What is vasoconstriction?
The **narrowing of blood vessels** that **conserves heat** by shunting blood from the periphery to the body's core.
306
What is the correct size for a blood pressure cuff for adults?
* The **bladder** width should cover **two-thirds of the upper arm** length
* **40% of arm circumference** with the bladder encircling 80% of the arm.
307
What should you do if using an improperly sized cuff?
If necessary, **use a cuff that is too large** rather than too small, and **document the cuff size with the BP reading**.
308
What should always be documented when taking blood pressure?
Always document **the site used** for the measurement.
309
farenheit to celsius
* subtract 32
* multiply by 5
* divide by 9
310
celsius to farenheit
* multiply by 9
* divde by 5
* add 32
NRAD 201B
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