Fund 50 week 2 day 3

Question 1

Nursing Roles in The
U.S. Healthcare System

Answer 1

Nursing Roles in The
U.S. Healthcare System• Institute of Medicine (IOM) Report: “To Err is
Human: Building a Safer Health Care System”
• 2003: “All health professionals should be educated to deliver pt-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality
improvement approaches and informatics” (IOM)

Question 2

QSEN Faculty
& National
Advisory
Board*

Answer 2

Proposed targets for the
knowledge skills and attitudes
(KSAs) to be developed in
prelicensure programs for each of
the competencies - this won’t change, but the language might a little bit

Question 3

Using the IOM (institute of medicine) competencies,
QSEN defined quality and safety
competencies for nursing (systems are the new way of thinking)

Answer 3

competencies for nursing - old way, focus on individual performance. Now, we need to think about systems. New train of thought is minimize risk of harm to patient through system effectiveness and individual performance.

Question 4

QSEN Faculty & National Advisory Board
Proposed targets (target the students)

Answer 4

for the knowledge skills and attitudes (KSAs) to be developed in
prelicensure programs for each of the competencies

Question 5

Quality and Safety Education for Nurses (QSEN)(Frances Pain Bolton School of Nursing. Case Western Reserve University) (Q says, be patient, be a team, use evidence, improve quality, safety, and information)

Answer 5

Competency:
Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics

Question 6

little example of system error is…

Answer 6

bags taped to rolling vital signs carts so you can dispense used probe on thermometer - some places take a bag so you can dispense it right there. The probes are dirty, don’t place in bag.

Question 7

2022 Hospital National Patient Safety Goals (ID me, communicate, meds, alarms, infection, risks, prevent mistakes)

Answer 7

• Identify patients correctly
• Improve staff communication
• Use medicines safely
• Use alarms safely
• Prevent infection
• Identify patient safety risks
• Prevent mistakes in surgery

Question 8

2022 Hospital
National Patient
Safety Goals

Answer 8

• Identify patients correctly
• Improve staff communication
• Use medicines safely
• Use alarms safely
• Prevent infection
• Identify patient safety risks
• Prevent mistakes in surgery

Question 9

Safety Hazards in the
Healthcare Facility (dont forget restraints)

Answer 9

BE aware of fall criteria - will need to do it every day.
1st question - what are you going to be alert for - behavior, fall risk, clutter, etc. Be alert for dangers at bedside, including fall risk.

Safety Hazards in the
Healthcare Facility
• Falls
– Falls is the most frequently
reported adverse occurrence in
adult inpatient setting
– Prevention: fall risk assessment;
environmental safety; clean, dry
floors; client education
• Restraints
• Equipment-related accidents
• Fires/electrical hazards

Question 10

Equipment Related Accidents (remember heating pads)

Answer 10

Equipment malfunction and
failures – What is the appropriate
action:
• Label clearly, send appropriate department to be repaired
• Wrong application, inappropriate use or unapproved use - example- heating pads! (remember this) they can burn someone. Ppl with pain don’t feel the burn.
• New equipment issues
(training, lack of supervision)
make sure you are oriented to all equipment

Question 11

Fires/Electrical
Hazards

Answer 11

Oxygen (know where the oxygen shut off valve is)
Malfunctioning electrical equipment (inspect cords and label, if not working take them out of service)
Smoking
Hospital Policies (to prevent any injury or hazards)

Question 12

Fire and how to use fire exstinguisher
(RACE AND PASS)
WHAT TO DO WHEN THERE IS FIRE: (YOU NEED TO MEMORIZE THIS)

Answer 12

Fire
(RACE AND PASS)
WHAT TO DO WHEN THERE IS FIRE:
• Rescue the patient
• Activate alarm
• Confine fire
• Extinguish fire/Evacuate
HOW TO OPERATE FIRE
EXTINGUISHER:
• Pull out safety pin
• Aim nozzle at base of fire
• Squeeze lever and handle
• Sweeping motion

you need to know where fire alarms are, exits, and extinguishers

Question 13

Types of Errors (NEPSN - never, ever put student nurse bc errors)

Answer 13

• “Near Miss” - reporting is just as significant as reporting errors. there are registries you can report to. seeing a med error on the 3rd check is near miss.
• Error - wrong med to patient
• Preventable Adverse Event
• Sentinel Event
• Never Event

Question 14

root cause analysis

Answer 14

if something happens in the OR - just what is the root cause

Question 15

systems to prevent error (prevent the vest and don’t forget checklist)

Answer 15

bar code, do not disturb vest, emr (health record) safety check lists, ***avoid workarounds

Question 16

Culture of Safety

Answer 16

Culture of Safety
• Goal is to lessen harm to patients and providers through both
system effectiveness and individual performance
• Safety culture requires strong, committed leadership together
with engagement and empowerment of all employees

why it’s importnat that we have just culture.

Question 17

Key Elements
of Culture of
Safety

Answer 17

Safety as organizational priority
Teamwork
Patient Involvement
Openness/Transparency
Accountability
Shared core values and goals, non-punitive responses to adverse
events and errors, promotion of safety through education/training

Question 18

just culture - why it’s important

Answer 18

Focus is on what went wrong, rather than who
caused the error. Balance between not blaming
individuals and not tolerating egregious
behavior emphasis on accountability, integrity,
honesty, excellence, teamwork, collaboration

Just culture is important so people won’t be afraid to report.

Question 19

• Culture of blame previous

Answer 19

prevailing attitude in healthcare
• Suggested as major source of the unacceptably high number of medical errors

Question 20

health assessment - objectives

Answer 20

• Review components of a Health Assessment
• How to perform a Physical and Safety Assessment
• Differentiate between comprehensive, focused and
ongoing assessments
• Identify normal and some abnormal findings
• Differentiate between subjective and objective data

Question 21

Purpose of Health Assessment (start w/ baseline, diagnose, monitor, screen)

Answer 21

Purpose of Health Assessment
● To establish a baseline
● To formulate a nursing diagnosis
● To monitor the status of an identified problem (had a stroke, and they’re not getting worse)
● To screen for health problems

Question 22

Health Assessment

Determining the person’s* (use both…)

Answer 22

overall present health by
collecting, validating (is this accurate, person coughing during bp, you want to wait), and analyzing data, both subjective and objective.

Question 23

4 Types of Assessments (I need COFE to be comprehensive, ongoing, focused and emergent) REMEMBER this

Answer 23

● Comprehensive
● Ongoing
● Focused
● Emergent

Question 24

Comprehensive (comprehensive head to toe)*

Answer 24

Includes a health hx and a head to toe assessment
• Annual physical exams•
Admission to inpatient settings (patient sent from ED)
Initial home health visits

Question 25

Ongoing (every 2 - 4)*

Answer 25

Brief ongoing assessment to monitor changes in patient status or to evaluate the effectiveness of an intervention• Physical: q4h neuro checks after a TBI or stroke• Labs: q6h Anti-factor XA to assess need to titrate heparin drip (PE) ex. 2-4 hour checks, changes in patient's status or meds. BP meds, or alcohol issues - looking for withdrawal bp.

Question 26

Focused (focus on rash)*

Answer 26

Focused on a particular topic, specific part,or function of the body• Rash on leg.• (outline to make sure it's not getting bigger) Abd pain-Location, rebound, positional, last BM & void, last period, etc

Question 27

Emergent (immediate) (emergency chest pain)*

Answer 27

Rapid focused assessment ● Acute chest pain- EKG, Troponin and other labs, CXR, angiogram ● Sudden facial droop/weakness- Neuro assessment, CT, FSBG

Question 28

Health Assessment:Patient Interview (reason, history, family history)*

Answer 28

I. Reason for Seeking Care • Hx surrounding current concern • Good to record exact words from patient - “quote” II. Health History - everything • Chronic illness, Current medications, allergies, immunizations, Surgical hx, Obstetric hx (females) I. Family History • Relevant to know patient’s risks based on family history

Question 29

Patient Interview IV. Social / Biographical History (personal interview)

Answer 29

● Primary info: ○ Place of birth (TB is large in some countries), past & current residency, primary language ● Current lifestyles ○ Living situation, Relationship/Support systems, Daily activities, Hobbies, Cultural/spiritual beliefs, Alternative health care practices ● Risk factors ○ Health habits (nutrition, caffeine, exercise, sleep, safety, exposures), Tobacco, ETOH, recreational drugs, Sexual risks, Economic risks (health access), Stress, Violence, Advanced directives

Question 30

patient interview - reviews of systems (this is body systems)

Answer 30

GENERAL Present weight, any recent weight loss or gain, emotional state NEUROLOGIC Memory problems, disorientation (headaches) HEENT EYES: Glasses, vision, blindness, light sensitivity EARS: Deaf, hearing aids, hard of hearing (HOH) MOUTH Dentures, Difficulty chewing, Regular dentist visits, Recent dental work.

Question 31

patient interview cont

Answer 31

RESPIRATORY/ PULMONARY SOB, Dyspnea, waking up tired, frequent day naps, orthopnea CARDIOVASCULAR Chest pain on exertion or inspiration, palpitation (swelling in legs w/ heart failure) PERIPHERAL VASCULAR (diabetes - sores, swelling) Numbness, tingling of extremities, cool/hot skin, color GASTROINTESTINAL Diet, appetite, last BM and characteristic, normal frequency of BM, constipation, bloating/cramping URINARY Urinary retention, incomplete emptying, straining, change in force or stream; MEN – weaken stream; WOMEN: incontinence when laughing, sneezing SEXUAL HEALTH Changes in sexual relationship, erectile dysfunction, vaginal dryness, pain during intercourse MUSCULOSKELETAL Gait change – balance, weakness, difficulty with steps, fear of falling; Use of assistive device, joint pain, muscle pain (yoga helps) INTEGUMENTARY Wounds (healed/non-healing), changes in sensation to pain, heat or cold, discoloration, changes in moles

Question 32

Patient Interview VII. Functional Assessment/Psychosocial

Answer 32

How does the person manage activities of daily living (ADLs & IADLs) and the impact of disease on activities and quality of life (QOL) ❖Self concept, self esteem, depression ❖Suicidal Ideation ❖Occupation ❖Activities and Exercise ❖Sleep and Rest ❖Interpersonal Relationship / Resources – support system ❖Coping & Stress Management – recent change, death, loss of work ❖Environmental Hazard – home safety (stairs, rugs, getting into tub)

Question 33

Clinical Setting Assessment Requirements

Answer 33

A basic head-to-toe exam (hand squeeze, check eyes, do 4 areas of visual field - short check in ER), Vital Signs (frequency is usually per unit policy), and ongoing assessment are standards of care every shift (this is always done) ● Does not require a comprehensive physical assessment ● Additional assessments are specific to the unit and the patient, and will be in the patient’s orders) Here are some examples of additional assessments that might be ordered: • Full neuro exam • (frequency varies) • Neck circumference s/p thyroidectomy • Puncture site monitoring post cath lab • Monitoring for opiate and/or ETOH withdrawal (CIWA/COWS) (temp, heart rate, anxious, tremors) - maybe every 4 hrs, then 6, 8

Question 34

Findings Requiring Attention

Answer 34

Standard call parameters: (Notify provider if:) (if not in chart, call doc and ask for parameters and then put it in the chart) • BP: Systolic <90 or >160, Diastolic <60 or >100 • Temperature ≤ 36° C or ≥ 38° C (conversion to Farenheit,96.9/100.4° • Heart rate <60 or >100 BPM • Respirations ≤12 or ≥24/min • O2 saturation <92% • Urine output <30 or <240 mL/8 hours • Dark amber or bloody urine • Uncontrolled postoperative nausea or vomiting (PONV) • Surgical pain not controlled with medication and/or chest pain • Bleeding, new or unexpected increase/decrease. • Change in level of consciousness (LOC), confusion, difficulty arousing • Sudden restlessness and/or anxiety

Question 35

Head to Toe Approach

Answer 35

Start at the head and proceed down the body to the feet

Question 36

Body Systems Approach

Answer 36

Examine each body system in a predetermined order (Neuro, CV, MSK, etc.)

Question 37

➢ Pick an approach

Answer 37

➢ Modified based on pt need and time constraints ➢ Be systematic and consistent ➢ It takes practice

Question 38

Assessment Sequence

Answer 38

(look at the trend, if bp is high, then look at trend) • Starts before entering patient room • Handoff report from previous shift • Note orders and verify door signs such as isolation precaution, latex allergy, or fall precautions • Upon entry into patient room • Introduce yourself as patient’s nurse/nurse student for the next 8 hours or 12 hours • Set rapport • Make eye contact • Ask how patient is feeling; any pain or discomfort • How did patient spent the previous shift

Question 39

Step 1: General Appearance

Answer 39

Initial interaction will elicit such information as: • Neuro status: • (LOC), alert and oriented, attentive to your questions or lethargic, difficult to arouse • Follows direction, understands language/speech, hearing, sight • General appearance: • Facial expression and body language: relaxed or tense and fidgety; grimacing, withdrawn • Skin color: normal for ethnicity, flushed, diaphoretic • Nutritional status: weight appears in healthy range • Grooming ➢ Complete initial assessment by verifying correct name/DOB on ID band (Ask how pt prefers to be addressed)

Question 40

Step 2: Vital Signs Vital Signs

Answer 40

• Temperature • Pulse • Respiration • Blood Pressure • Oxygen Saturation • Pain

Question 41

Room and Patient Safety check: • IV (correct solution, rate, date)

Answer 41

any tube should be considered part of that person's body. • IV ■ Verify the correct IV solution is hanging ■ Verify it is running at the prescribed rate ■ Verify the date of tubing is current ■ Trace IV tubing to Pt’s IV (make sure the tubing is going somewhere) ■ Assess all IV sites • Note signs taped above head of bed • Check tubes: NGT, PEG, PEJ, chest, trachs, foley, rectal, JPs • Are Ambu bag and mask, suction canister, tubing, & yankauer (plastic hard tube) present? • Bed in locked & lowest position, call light within reach, tray table within reach • Bed alarm on if patient is a Fall risk

Question 42

Step 3: Physical Assessment: (ask yourself...)

Answer 42

• Comes with experience • Requires technical skill and clinical knowledge to gather data. Ask yourself: “Is this the finding I expect from this patient?”

Question 43

Preparing for a Patient Exam

Answer 43

• Establish a safe environment • Warm, comfortable, quiet • Maintain privacy • Expose only the area being examined • Tell the patient what you’ll be doing • Equipment – • Organized and within reach • Stethoscope, VS machine, pen light, etc. • Don appropriate personal protective equipment (maybe turn down the TV)

Question 44

Order of Physical Exam: (inspect, palp..etc BUT one is the other way) (I need an IPPA for the physical exam)

Answer 44

Order of assessment for most systems * 1. Inspection 2. Palpation 3. Percussion 4. Auscultation 5. (Olfaction if appropriate, e.g wounds, drainage, breath) *Exception: To avoid disturbing bowel sounds, the order of assessment of the abdomen is different: We go from least invasive to most invasive: • Inspect • Auscultate • Percuss • Palpate

Question 45

Order of Physical Exam

Answer 45

*Always inform the patient what you plan to do 1: Inspection – using your eyes to gather data (gait, physical marks, general survey, physical appearance) 2: Palpation– using tactile sense to check temp, moisture, mass, swelling, vibration, pulsation, presence of pain. Start with light then move to deeper palpation (within reason). Assess known tender areas last.

Question 46

Percussion

Answer 46

Using fingers to tap skin with short sharp stroke to assess underlying structures (location, size, and density of underlying structures– air, fluid, mass) • Stationary hand – middle finger of non-dominant hand • Striking hand – middle finger of dominant hand • Compare left and right sides

Question 47

Auscultation

Answer 47

Step 4: Auscultation Using a stethoscope to hear sounds produced by the body There are 2 parts of the Stethoscope: • A Diaphragm for high pitched sounds (normal heart, lung, and bowel sounds) • A Bell for low pitched sounds (extra heart sounds, murmurs)

Question 48

Systems Approach Exam NEUROLOGICAL (lethargy makes me obtuse, stupid, and coma)

Answer 48

● LOC – awake, alert, oriented, responds to stimuli Level of Sedation: ● Alert & Oriented? Person, Place, Time, Situation AOx0? AOx4? ● Lethargic ● Obtunded ● Stuporous ● Coma STEP 1: INSPECTION: ● Eyes open spontaneously to name ● Spontaneous motor and verbal response ● Moves all extremities

Question 49

Systems Approach - NEUROLOGICAL - how to assess if the patient is oriented (neuro isn't a person, place, or time)

Answer 49

Assess if they are oriented to: • Person - Do they know who they are? • Place - Do they know where they are? • Time - Do they know the date? situation - do they know what's going on?

Question 50

motor strength grading (0 - 5 Ethan - the motor flicks, defies gravity, then resists)

Answer 50

Sensation intact: light touch, pain, vibration ( perform on face and each extremity) Motor Strength grading • 0/5: no contraction • 1/5: muscle flicker, but no movement • 2/5: movement possible, but not against gravity • 3/5: movement against gravity, but not against resistance • 4/5: movement against some resistance • 5/5: normal strength

Question 51

Integumentary Assessment

Answer 51

Examined when each area of the body system is being assessed Step 1: Inspection • Skin color: Consistent with person’s baseline/heritage • Abnormal findings: jaundice, cyanosis, mottling, erythema, petechiae (dots), pallor (pale) • For people with darker skin tones pallor can be assessed by inspecting the mucus membrane of the mouth or the conjunctiva ( inside the lower eyelid). • Skin integrity: clean, intact or rash, pressure injury present, wounds, ecchymosis, etc.

Question 52

Nails

Answer 52

Nails Contour, shape and color (nychia means nail)

Question 53

nails Step 2: Palpate

Answer 53

• Warm and dry or cool, hot, diaphoretic (use back of hands) • Skin turgor: Pinch up a fold of skin under clavicle to note any tenting (dehydration), skin returns to original shape (normal) • Assess for pitting edema, crepitus (oxygen gets into subcutaneous area of body - ie lung injury and if tube isn't put right, air can get under the skin) Capillary refill • Press down firmly on nail bed for 3 secs and release • Normal when blood refills ≤ 3 secs • Blanch fat pad of finger if nails are thickened and opaque

Question 54

Palpate Pulses: (gotta be equal w/ pulses)

Answer 54

• Compare all for equality • Sites: radial, ulnar, brachial, femoral, popliteal, dorsalis pedis (DP) posterior tibialis (PT) • Carotid and femoral pulses not routinely palpated unless indicated

Question 55

HEAD: (head - Am I drooping?)

Answer 55

always looking for symmentry Step 1: Inspection • Position midline • Facial features – symmetry, moon face, edema, facial droop • Any involuntary movements, hair pattern, lice present

Question 56

head Step 2: Palpation (eyebrow, cheek bone, tears, temple)

Answer 56

• Skull and face for tenderness Lymph nodes: Frontal (below eyebrow) and Maxillary sinuses (below cheekbone), Ethmoid (tear canal) Sphenoid (temple area)

Question 57

EYES:

Answer 57

Step 1: InspectionPupils • Pupils-Pupils Equal Round Reactive to Light and Accommodation (PERRLA) ● Visual acuity/field ● Eyebrows, eyelids, sclera, conjunctiva ● Extra-occular movements –nystagmus● Ptosis (droopy eyelid) Pupils: ● Size measured in mm ● Use a pupillometer if uncertain of size or reaction to light

Question 58

EARS:

Answer 58

EARS: Step 1: Inspection ❖Gross and fine hearing, drainage (if clear, drainage can be a CNS problem) Step 2: Palpation ❖ External ears for deformity, lesions

Question 59

NOSE:

Answer 59

Step 1: Inspection ❖External, discharge, sinus tenderness Step 2: Palpation – patency

Question 60

MOUTH/THROAT:

Answer 60

STEP 1: Inspection: ❖Appearance of lips, tongue. ❖Condition of teeth and gums ❖Appearance of pharynx, tonsils, uvula, floor of mouth ❖Movement of tongue and palate

Question 61

NECK:

Answer 61

if they have a trach, make sure it's midline and the ties are tied. STEP 1: Inspect – symmetry of muscles, ROM, JVD STEP 2: Palpate - muscle strength, trachea, carotid pulse (one at a time), thyroid for goiter

Question 62

Objectives:

Answer 62

Objectives: • Review components of a Health Assessment • How to perform a Physical and Safety Assessment • Differentiate between comprehensive, focused and ongoing assessments • Identify normal and some abnormal findings • Differentiate between subjective and objective data

Question 63

Thorax and Lungs

Answer 63

Best to assess in high fowler’s position (make sure even, breathing, regular pattern) Anterior Chest: Step 1: Inspect Color, shape, breathing pattern Normal • Color consistent with overall skin color • Transverse diameter > anterioposterior diameter of chest • Normal breathing pattern and effort Abnormal • Rash, ecchymosis, suspicious moles, etc. • Barrel chest (transverse diameter ≦ anterioposterior diameter) - usually w/ ppl who have COPD • Use of accessory muscles, grunting, heaving

Question 64

Barrel Chest

Answer 64

Barrel Chest Assess the anterior posterior (AP) diameter to the lateral diameter • Normal ratio is 1:2 • Barrel Chest is 1:1

Question 65

Thorax and Lungs

Answer 65

don't palpate on rib, do the intercostal Anterior Chest: Step 2: Palpation • Apical pulse (also known as: apex beat, point of maximal impulse, and apical impulse) located at the 5th intercostal midclavicular area • If displaced laterally, may indicate cardiomegaly

Question 66

Thorax and Lungs - what is the acronym

Answer 66

(All patients take meds - acronym) Step 4: Auscultate with bell & diaphragm • High Fowler’s position (if possible) • Apical pulse : Can best heard at 5th ICS left midclavicular • Listent to Aortic, Pulmonic, Erbs Point, Tricuspid, Mitral

Question 67

Systole – contraction of ventricles to push blood

Answer 67

through the aorta and the pulmonary artery Diastole – the ventricular is relaxed and filling ● S1-– the first heart sound. Systole “Lub sound” - The AV valves close (tricuspid, mitral) ● S2 - the second heart sound. Diastole (“Dub sound”) Semilunar valves close (aortic, pulmonic) At Erbs Point - both S1 and S2 are heard well

Question 68

Lungs step 1 - Best to assess in high fowler’s position

Answer 68

Step 1: Inspect • Oxygen therapy-if any check for proper fit, liters of O2/FiO2, humidify) • Work of breathing, breathing pattern; presence of accessory muscle use, dyspnea, or orthopnea

Question 69

lungs step 2

Answer 69

• Tactile fremitus (vibration) – compare vibration while pt says 99 • Indirect measure of density of lung tissue • Denser the tissue, stronger the vibration • Solid mass> PNA w/consolidation > emphysema-air filled • Thoracic excursion (expandability) ● symmetrical; normal 2-5in ● Limited excursion d/t shallow breaking ● Asymmetry d/t air obstruction, pleural effusion, pneumothorax

Question 70

lungs step 3 - resonance

Answer 70

Percuss • Resonance (hollow sound)- normal over lung fields

Question 71

Normal lung sounds STEP 4: Auscultate

Answer 71

Auscultate breath sounds comparing side to side • (minimum 10-12 sites) • Normal Breath sounds: • Bronchial – Heard over larynx and trachea • loud high pitched blowing hollow, tubular sound • I > E (inhale and exhale probably)

Question 72

Adventitious Lung Sounds (fine, of course, rhonda strides)

Answer 72

Crackles indicate inflammation or fluid filled lungs Fine Crackles (rales) (better) • popping, crackling sound • high pitched Coarse crackles (rales) (worse) • Bubbling sound • lower pitched than fine crackles Rhonchi (even worse) • Air passing through mucous and secretions in large airways • May be cleared by coughing • low pitched continuous, coarse snoring quality Stridor (very dangerous) • Narrowing of upper airway; Foreign body obstruction • Harsh loud high pitched

Question 73

ABDOMEN (Note the difference in order of exam, why?) STEP 1: Inspection

Answer 73

(Special thing about abdomen is the order of how you listen or palpate) • Position of umbilicus, visible hernia or pulsation, symmetry, lesions, color of skin, presence of ecchymosis (this just means bruise), scarring • Presence of tubes/drains/wounds • Contour: Is it flat, rounded, distended, bulging, is there ascites?

Question 74

Abdomen STEP 2: Auscultation (what is inactive?)

Answer 74

Listen to all 4 quadrants. NORMAL • Presence of sound (every 5-34 sec is normal) • Use bell side to listen for bruit – may indicate narrowing of vessels Hyperactive • BS frequent in quantity, loud in quality • ↑ gastric mobility with inflammation, anxiety, diarrhea, early bowel obstruction • Borborygmi: rumbling or gurgling sound made by the movement of fluid and gas in the intestines Hypoactive • Infrequent < 5 sounds per minute • Absent: can indicate obstruction or ileus Absent • Listen for >2min each quadrant before documenting absence of bowel sound • May indicate obstruction or ileus • Common immediate post-op

Question 75

abdomen STEP 3: Percussion

Answer 75

(Advance practice)• Normal: Tympany (drum like) indicates air in intestine • Dullness suggests fluid or underlying organs like the liver & spleen • Extremely high-pitched tympanic sounds = distention • Extensive dullness=organ enlargement or mass

Question 76

abdomen STEP 4: Palpation

Answer 76

STEP 4: Palpation• Start with light touch then deeper • Palpate known tender area last • Normal: Soft, relaxed, nontender • Abnormal: mass, tenderness, pain, spasm (may indicate peritonitis, infection, tumors)

Question 77

Genitourinary

Answer 77

• Foley present? Recently removed ? • Check urine for color, clarity, sediments • Pain with urination? • If urine output is less than expected, perform a bladder scan • Check genitals for edema, lesions, discharge

Question 78

Musculoskeletal

Answer 78

Musculoskeletal Back/Spine STEP 1: Inspection • ROM of spine • Normal Curvatures of spine • Normal forward curve of cervical spine and lumbar spine • Normal backward curve of thoracic spine and sacral spine

Question 79

Objective Data

Answer 79

Objective • Information you can gather using your senses. It is either a measurement or an observation. • Information gathered during your head to toe exam is objective data • VS, lab results, diagnostic imaging

Question 80

Subjective data

Answer 80

Information from the patient’s perspective including feelings, perceptions, concerns, Pmhx, family hx Subjective data: • My chest hurts • I have been having diarrhea for 3 days • I have a family hx of ovarian CA • I feel bloated • My pain is 10 out of 10

Question 81

pupils

Answer 81

size measured in mm, use a pulillometer if uncertain

Question 82

• Preventable Adverse Event (preventing the turn)

Answer 82

reasonable and prudent person would not carry out that error. failing to turn patient every 2 hours.

Question 83

• Sentinel Event (sentinelly severe)

Answer 83

so severe that it can cause death or severe harm, permanent severe harm or temporary severe harm

Question 84

• Never Event

Answer 84

events that should never happen, several ppl failing to turn patient and getting pressure ulcer, surgery on wrong limb. not monitoring patient who is at fall risk

Question 85

vital signs - pain (PQRST D)

Answer 85

Frequency depends on unit policy and pt status P Provoking Factors What factors precipitating the pain Q Quality Description of pain R Region and Radiation S Severity on a pain scale T Time How long

Question 86

neurological - levels of sedation (sedation is LO in SC)

Answer 86

● Lethargic ● Obtunded ● Stuporous ● Coma

Question 87

pulse grades

Answer 87

Pulse Grading: • 0 absent (check with doppler) • 1+ diminished/ weak • 2+ normal • 3+ increased • 4+ bounding

Question 88

• Clubbing

Answer 88

chronic hypoxia. Ex: pt with COPD: angle >160 degrees

Question 89

• Koilonychia (nail) (Tu is koil)

Answer 89

spoon nail/ concave- iron deficient anemia, syphilis

Question 90

• Paronychia

Answer 90

inflammation at side or base of nail

Question 91

• Onychomycosis (0ynchi has fungus)

Answer 91

fungal infection

Question 92

when does urine output require attention? (the numbers)

Answer 92

Urine output <30 or <240 mL/8 hours

Question 93

• Borborygmi (rumble in bora bora)

Answer 93

rumbling or gurgling sound made by the movement of fluid and gas in the intestines

Question 94

abdomen ausclatation - normal Presence of sound is every...

Answer 94

5-34 sec is normal

Question 95

pain assessment - PQRST

Answer 95

P = provoking factors - what factors precipitate pain Q=Quality - description of pain R=region or radiation S=severity on a pain scale T = how long has it been present? what makes it better or worse?

Question 96

3 parts of glasgow coma scale (glasgow is an emv - start w/ eyes)

Answer 96

eye, motor, and verbal

Question 97

pulse grades 0 - 4

Answer 97

0 - absent (use doppler) 1 +- weak/diminished 2 + - normal 3 + - increases 4 + - bounding

Question 98

when checking pulse, where should the arm be?

Answer 98

heart level

Question 99

Accommodation - eyes (your glasses will accommodate your eyes)

Answer 99

how the eye looks at something far away, pupil wider when looking at something far away

Question 100

Tactile fremitus (lungs) (your fremitus is vibrating)

Answer 100

means vibration

Question 101

kyphosis (ky has kyphosis)

Answer 101

hunchback

Question 102

• If measuring abdominal girth, do so at the

Answer 102

umbilicus

Question 103

• Peristaltic waves indicates (during stomach exam)

Answer 103

intestinal obstruction

Question 104

• Pulsation may indicate (during stomach exam)

Answer 104

aortic aneurysm

Question 105

● Lethargic

Answer 105

drowsy, sleeps most of the time, woken by gentle shaking

Question 106

● Obtunded (obtuse shake)

Answer 106

difficult to wake; woken by vigorous shake

Question 107

● Stuporous (stupor)

Answer 107

cannot be aroused; responds to pain only

Question 108

● Coma

Answer 108

no response at all, complete unconscious

Question 109

when to use a doppler for pulse?

Answer 109

edema or vascular disease