Unit 1- learning objectives

Question 1

Intent of health history

Answer 1

o provide a database of subjective information about the patient’s past and current health

Question 2

b. Summarize the components of a health history.

Answer 2

Identifying data, -(name address etc)

chief complaints,(purpose for visit )present illness,

past history, family history

,personal and social history,

review of systems

Question 3

c. Outline the techniques or effectively collect data during a health history.

Answer 3

Privacy

introduce interview

working phase-open ended and close ended questions

close interview

nonverbal

pqrstu

Question 4

d. Consider how age, ethnic, and cultural variations effect data collection during a health history.

Answer 4

all of these can affect how you talk to the patient and how you administer treatment. Certain ages or cultures cannot receive certain types of treaments. You may talk to patients differently depending on their culture or age, so adjusting to each patient is critical, no two are the same

you must modify your actions based upon the clients culture (ex: eye contact is thought of as rude in some cultures)

Question 5

e. Identify the source of data for the health history if the client is not able to participate.

Answer 5

If the cleint is unable to speak, then Charts and family members are considered secondary data sources. Primary data would be directly from the client. Subjective data are based on the signs and symptoms that the client reports; they may not be perceived by observers.

Question 6

f. Recognize when data from a health history should be communicated to other health care providers.

Answer 6

to arrive at the correct diagnosis, some clincainans may communicate and share data among different providers

Question 7

g. Consider how information from a health history can be used for patient teaching.

Answer 7

Using past information on health history, you can teach the patient how to do anything that might pertain to their well being. Making sure that the patient knows how to properly take care of themselves can lead to a betterment for their health

Question 8

h. Explain how obtaining a health history is modified across the lifespan.

Answer 8

as one gets older and older, their health history gets added onto. Each time should be adjusted so that questions are asked about past health problems to make sure they are all fixed.

Question 9

i. Differentiate between normal and abnormal findings.

Answer 9

normal findings is anything that is preveleant on the average human body

abnomral fidnings are most likely what the patient is in for, these are any findings that are differenet from the averag human. like different shape color temp etc

Question 10

j. Identify the purpose of the general survey.

Answer 10

provides initial information about the client’s overall demeanor, orientation, vital signs, appearance, gait, and behavior and can indicate the need for further targeted assessments.

Question 11

k. Indicate typical sequence for a general survey.

Answer 11

provides initial information about the client’s overall demeanor, orientation, vital signs, appearance, gait, and behavior and can indicate the need for further targeted assessments.

Question 12

l. Summarize the components of a general survey of the client.

Answer 12

-physical appearance
-body structure
-mobility
-behavior
mental status

Question 13

m. Contrast techniques of inspection, auscultation, palpation, and percussion.

Answer 13

inspection- sense of sight to identify specific chanracetidcs of individual

palpation- light 1-2cm, 3 fingers using finger pads (would use to assess swelling, crepitation, range of movement, injured joint)

Deep2.5cm depending on amount of abdominal fat, may be 5cm for obese. Usually performed as part of abdominal assessment.

Auscultation - Uses the sense of hearing to listen to body sounds

Percussion - Uses the sense of touch and hearing as examiner taps on an individual body to evaluate location and density of underlying structures.

Question 14

n. Identify techniques to promote the physical and emotional comfort of the patient during the assessment.

Answer 14

Facilitation-mhmm-go on

silence-allows to speak

reflection- repeat patient

empathy-emotion in sentances

clarification-

interpretation-give judgment

explanation-detail

summary

Question 15

o. Explain how to modify assessment techniques across the lifespan.

Answer 15

the way you speak changes to each individual as they get older. Addressing teenagers and up as Mr and Mrs promotes respect . not talking down and being respectful to each age

Question 16

p. Define pertinent terminology used in general survey/physical assessment.

Answer 16

talk in human terms. Dont use any medical jargon. Speak in all language that everyoje will understandf

dont reassure.use authority,dustance,talk too much ot use why questions

Question 17

q. Consider how age, ethnicity, and cultural variations may affect the general survey.

Question 17

r. Discuss how teaching opportunities can be used during a general survey/physical assessment.

Answer 17

During general survey inform patient about normal range of vital signs for age and physical condition and normal weight for height and body frame

.
* If patient is on a therapeutic diet, discuss any problems that he or she has preparing a diet or selecting food. The best form of weight reduction is to achieve gradual weight loss by increasing exercise and decreasing caloric intake. Refer to clinical dietitian for specific information.

• Explain to patient any findings that need further examination.

Question 18

s. Indicate processes of referral for clients with abnormal findings of general survey/physical assessment.

Answer 18

the registered nurse should then seek out resources, as well as utilize and employ different internal or external resources such as a physical therapist, a clergy member or a home health care agency in the community and external to the nurse’s healthcare agency.

These resources are tapped into and, when considered appropriate for the client and their needs.

Question 19

t. Describe the concept of bloodborne pathogens.

Answer 19

cause disease and are present in blood. HIV,hep ABC HCV. Using all ppe to prevent infection spread. these are present in blood

Question 20

u. Describe the principles of standard precautions.

Answer 20

everything is treated as if it is infectious. all body fluids are contaminated and are treated as if they are worst case scenario

Question 21

v. Define medical and surgical asepsis.

Answer 21

Medical asepsis: practices that kill some microorganisms to prevent them from spreading.

Surgical asepsis (a.k.a. “sterile technique”): practices that completely kill and eliminate microorganisms.

Question 21

w. Identify situations in which you would use clean versus sterile gloves/technique.

Answer 21

clean goes to clean–when the rest of procedures

sterile to sterile– when the integrity of the skin is accessed, impaired, or broken

Question 22

x. Indicate techniques to maintain medical and surgical asepsis.

Answer 22

hand washing

cleaning clothes

sterilization

sterile gloves

sterile field

ppe

Question 23

y. Compare and contrast different forms of transmission-based precautions.

Answer 23

droplet-mask

airborne-gloves, gown, masks,eye west

contact-gown and gloves

Question 24

z. Describe characteristics of a sterile field.

Answer 24

A sterile field is a designated area which is free of microbes and other pathogens that can infect someone.

Question 25

aa. Describe the procedure you would follow if sterile technique has been broken.

Answer 25

If sterile procedure is disrupted in any way, the nurse must discard all items (including the field) and begin preparing a new sterile field. Reaching over a sterile field would disrupt the sterility of the area.

Question 26

bb. Using a designated format, distinguish between normal and abnormal data during assessment of skin, hair, and nails.

Answer 26

normal: skin color,tempature, turgor and mobility, normal hair and skin colors

abnormal: different colored skin, skin may be weird temps,decresed turgor and mobility,consistacnty of hairs and skin are different

Question 27

cc. Consider how age, ethnicity, and cultural variations may affect the integumentary assessment.

Answer 27

depending on how you age and where you come from, you may have different skin types. Some ages/cultures may be thicker skin, and some may be thinner. Also using specific products may not be of use when you are with a certain culture

Question 28

dd. Define pertinent terminology used in integumentary assessment.

Answer 28

inspect color, scalp, lesions and breakdown

palpate skin

capillary refill, skin turgor, edema

Question 29

ee. Discuss how teaching opportunities can be used during an integumentary assessment.

Answer 29

• Help patient and family caregiver understand multiple factors involved in preventing and treating pressure injuries
  .
• Explain and demonstrate positioning options to achieve pressure redistribution.
• Explain the purpose and maintenance of pressure-redistribution devices
• When teaching patients to change position for pressure redistribution, suggest using television programming and commercial intervals or a watch with an alarm as reminders.

basically teach patient how to prevent and treat skin injuries

Question 30

ff. Discuss the theory and practice of moist wound healing.–

Answer 30

-full thickness wound is kept moist until re-epithelialization occurs (12-15 days)-is faster w/decresed pain and is more effective. Patient uses hydrogel, wet gauze and hydrocolloiods

Question 31

gg. Describe the phases of wound healing.

Answer 31

—Hemostasis- blood vessels constrict resulting in less blod flow to injured area. Ends with leaking exudate from injury site. Inlafmattory – wbc(leokocytes and macrophages) move to wound to ingest bacteria.. Proliferation- tissues are built with fibrolblasts. Maturation phase—scar tissue is formed, this is where the bone starts to settle

Question 32

hh. Define wound debridement and its place in wound care management.

Answer 32

— debridement is the removal of necrotic (dead) tissue from the wound bed or the removal of a foreign object from the tissue. plays a vital role in wound bed preparation.

Question 33

ii. Describe techniques for removal, application of a wound dressing (surgical asepsis, “no touch”), and wound culture.

Answer 33

Perform hand hygiene and apply clean gloves

Gently remove tape, bandages, or ties: use nondominant hand to support dressing and, with your dominant hand, pull tape parallel to skin and toward dressing

With gloved hand or forceps, remove dressing one layer at a time, observing appearance of drainage on dressing. Carefully remove outer secondary dressing first, and then remove inner primary dressing in contact with wound bed

inspect wound and periwound for appearance, color, size (length, width, and depth), drainage, edema

Fold dressings with drainage contained inside and remove gloves inside out

create sterile field

clean around wound from least to most infected-remove gloves

put on clean gloves, apply dressing

secure dressing with tape

remove of all infected stuff

Question 34

jj. Describe characteristics of a wound and any drainage to be included in documentation.

Answer 34

location

type of wound

measurment

wound edges

drainage

odor

infection

pain

Question 35

Contrast types of products and dressings indicated for use in wound management, including application and maintenance.

Answer 35

hydrogel-Composed of water based product to provide moisture to wound.used for partial to full thickness

alienate-Highly absorptive products that are retentive gel or fiber-gelling dressings.used to moderate or heavy wound

foam-absortion/protection.absortpion of exudate

guaze-Available in woven or nonwoven, cotton or synthetic, sterile and nonsterile.Protection of surgical wounds
Moist-to-dry dressings

hydrocolloids-Adhesive dressings that contain a gel-forming agent, mold to body contours.used to absorb exudate

Question 36

ll. Discuss the necessity of pain management prior to and during a dressing change.

Answer 36

pain is the #1 thing to avoid with the patient. Discussing pain with the patient can help to formulate a care plan to further progress healing.

Question 37

mm. Differentiate among types of drains and management devices indicated for use in wound healing.

Answer 37

Penrose drain-rubber drain tube connected to an open wound to retain fluid. This is not connected to a bulb that harbors the drainage. uses gravity/negative pressure to pull drainage out

Jackson pratt- this is a drain that contains a tube and bulb that takes on the fluid. This is a closed system that will self-suction blood into the drain.

Hemovac-circular drain system that removes fluids from a wound. This is a closed system. The container will expand as it retains more fluid.

Question 38

nn. Indicate techniques and precautions to be implemented during wound irrigation

Answer 38

.— Perform hand hygiene and apply clean gloves–

Gently remove tape, bandages, or ties: use nondominant hand to support dressing and, with your dominant hand, pull tape parallel to skin and toward dressing-

–With gloved hand or forceps, remove dressing one layer at a time, observing appearance of drainage on dressing.

Carefully remove outer secondary dressing first, and then remove inner primary dressing in contact with wound bed-

–inspect wound and periwound for appearance, color, size (length, width, and depth), drainage, edema-

–Fold dressings with drainage contained inside and remove gloves inside out–

-create sterile field–

Fill the irrigation syringe with solution.

Using your nondominant hand, gently apply pressure to the basin against the skin below the wound to form a seal with the skin.

8.Gently direct a stream of solution into the wound. Keep the tip of the syringe at least 1 inch above the upper tip of the wound. When using a catheter tip, insert it gently into the wound until it meets resistance.

Gently flush all wound areas-remove glovesput on clean gloves, apply dressing-

• secure dressing with tape

remove of all infected stuff

Question 39

oo. Identify criteria and procedure for removal of sutures, staples, and/or drains.

Answer 39

clean with sterile saline

-tips under center of staple, tip press over top, freeing the staple from skin

Start 2nd to the last on either side, go every other staple/suture
- Snip suture opposite of the knot close to the skin surface

Never pull the visible part of a suture through the underlying tissue

-clip suture materials as close to the skin edge on one side as possible and pull the suture through from the other side.