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. What would you like to do?
When would you need surgical asepsis?
•During procedures that require intentional perforation of the client’s skin
- •When the skin’s integrity is broken as a result
- of trauma, surgical incision or burns
-During procedures that involve insertion of catheters or surgical instruments into sterile body cavities
What are the common shapes of lesions?
- -Target, or Iris
What is the ABCDE rule of the self skin exam?
- –E—elevation and enlargement
What to do inspect when looking over someone's nails?
- -Shape and Contour
- -Profile Sign-clubbing?
- -Capillary Refill Time (CRT)
What are the functions of the skin?
- 1. Protection: physical, chemical, thermal and light
- 2. Prevents penetration & loss of fluids
- 3. Perception: touch, pain, temperature, pressure
- 4. Temperature regulation via sweat & adipose layer
- 5. Identification
- 6. Communication
- 7. Wound repair
- 8. Absorption and excretion
- 9. Production of Vitamin D
What are the symptoms of chronic pain?
- -Continues for 6 months or longer
- -Types are malignant (cancer related) and nonmalignant
- -Does not stop when injury heals
What are symptoms of acute pain?
- -Short term
- -Follows a predictable trajectory
- -Dissipates after injury heals
What are the sources of pain?
- -Visceral pain
- -Deep somatic pain
- -Cutaneous pain
- -Referred pain
What is Neuropathic Pain?
- -Abnormal processing of pain message
- -Most difficult type of pain to assess and treat
- -Damaged/dysfunctional/injured nerve fibers
What are the typical changes to aging adult's?
- -Temp:decrease fevers, increase risk hypo/hyperthermia, decrease sweating
- -Pulse: Normal range, but often irregular
- -Respirations: decrease Tidal Volume
- -BP: Systolic generally increases with age
What are the Korotkoff’s sounds?
- -I, the systolic pressure
- -IV, muffling of sounds
- -V, the diastolic pressure
What are physiologic factors controlling blood pressure?
- -Cardiac output
- -Peripheral vascular resistance
- -Volume of circulating blood
What does the pulse pressure equal?
Systolic BP - Diastolic BP
what does systolic pressure equal?
Left ventricular contaction
What are the routes of temperature measurement?
- -Electronic (via central line)
- -Tympanic membrane
What are the signs of developmental competence of an adolescent?
- -May examine alone without parent or sibling
- -Give feedback that they are developing normally
- -Do not treat like a child or adult
- -Focus on health teaching
- -Examine genitalia last and quickly
What are the responsibilities of an RN?
- -Clean the equipment
- -Set Clean vs. dirty area for handling equipment
- -Prevent Nosocomial infections
- -Wash hands
- -Wear gloves
- -Follow Standard precautions
- -ObserveTransmission-based precautions
What area of the body requires a different order of skills?
What is the order?
What are the order of skills?
What are the characteristics of percussion notes?
- •Resonant= clear, hollow
- •Tympany= musical & drum like
- •Dull= muffled thud
- •Flat= absolute dullness
What is the purpose of percussion?
-Purpose- to assess underlying structures
- •Map location and size of organs
- •Signal density of a structure by a characteristic note
- •Detecting superficial abnormal mass
- (penetrate ~5cm deep)
- •Elicit pain if underlying structure is inflamed
- •Elicit deep tendon reflex using percussion hammer
What is the purpose of palpation?
- -To assess-
- •Organ location/size
- •Swelling, vibration or pulsation
- •Rigidity or spasticity
- •Presence of lumps or masses
- •Presence of tenderness or pain
What is a part of the nursing process evaluation?
- -Refer to established outcomes
- -Evaluate individual’s condition and compare actual outcomes with expected outcomes
- -Summarize results of evaluation
- -Identify reasons for failure to achieve expected outcomes
- -Take corrective action to modify plan of care
- -Document evaluation in plan of care
What is a part of the nursing implementation phase?
- -Determine patient readiness
- -Review planned interventions
- -Collaborate with other team members
- -Supervise by delegating appropriate responsibilities
- -Counsel person and significant others
- -Involve person in health care
- -Refer for continuing care
- -Document care provided
What is a part of the nursing process planning stage?
- -Establish priorities
- -Develop outcomes
- -Set time frames for outcomes
- -Identify interventions
- -Document plan of care
What are the goals of the outcome identification?
- -Identify expected outcomes
- -Individualize to patient
- -Ensure outcomes are realistic and measurable
- -Include a time frame
What are the parts of the nursing diagnosis?
- -Interpret data
- -Identify clusters of cues
- -Make inferences
- -Validate inferences
- -Compare clusters of cues with definitions and defining characteristics
- -Identify related factors
- -Document the diagnosis
What is involved in the assessment in the nursing process?
- -Collect data
- -Review of clinical record
- -Health history
- -Physical examination
- -Functional assessment
- -Cultural and spiritual assessment
- -Review of the literature
What is the nursing process?
- Outcome identification
What is objective data?
- Observed when inspecting, percussing, palpating, and auscultating patient during
- physical examination
What is dementia?
- –Gradual onset
- –More common in elderly
- –Causes: Alzheimer’s,Parkinson’s, CVA, HIV, head trauma
What is Delirium?
- –Acute onset
- –Young or old
- –Causes: infection, intoxication, withdrawal, hypoxia, F&E imbalance, post head trauma, postop
What are important developmental signs for children?
- Differentiated crying by 4 weeks
- Cooing at 6 weeks
- One word sentences at 1 year
- Multi-word sentences by 2 years
What are subjective?
Statements from the patient that are not verifiable.
Mental Status exam?
What are the orentation times 4?
Person, place, time and purpose
What are the 4 main headings of mental status assessment?
What is a mental disorder?
- •a significant behavioral or psychological pattern associated with: distress or
- disability and has a significant risk of pain, disability, or death, or a loss
- of freedom.
–Organic disorder: brain disease of known specific organic cause
–Psychiatric mental illness: no organic etiology established
What is mental status?
•a person’s emotional and cognitive functioning.
- –Optimal functioning aims toward
- simultaneous life satisfaction in work, caring relationships, and within the self
- –Usually, mental status strikes a balance between good and bad days, allowing person to function socially and occupationally
What does R.E.S.P.E.C.T stand for?
- R= Realize that you must know the heritage of yourself and your patient.
- E= Examine the patient within the cultural context.
- S= Select questions that are simple and speak them slowly.
- P = Pace questioning throughout the exam.
- E = Encourage patient to discuss meaning of health and illness with you.
- C = Check patient’s understanding and acceptance of recommendations.
- T = Touch the patient within the
- boundaries of his or her heritage.
What are some Health-Related Behaviors Affected by Religion?
- Exercising/physical fitness
- Sleep habits
- Willingness to undergo physical examination
- Truthfulness about how patient feels
- Maintenance of family viability
- Hoping for recovery
- Coping with stress
- Genetic screening and counseling
- Living with a disability
- Caring for children
What is culturally competent?
- •Understanding and attending to
- total context of patient’s
- situation including:
- -Immigration status, Stress factors, Social factors, & Cultural similarities and
What is culturally appropriate?
- •Applying underlying background
- knowledge necessary to provide the best possible health care
What is culturally sensitive?
- •Possessing basic knowledge of and
- constructive attitudes toward diverse cultural populations
What is Illness?
- The loss of the person’s balance, within one’s
- being—physical, mental and/or spiritual—and
- in the outside world—natural, communal, and/or metaphysical
What is Health?
- The balance of the person, both within one’s
- being—physical, mental and/or spiritual—and
- in the outside world—natural,communal, and/or metaphysical, is a complex, interrelated phenomenon
What are factors that effect wound healing?
- Chronic health condition
When doing pain assessment what do you want to know?
- Pain Scale
- Alleviating factors
- Stop, look, and listen
- Before, during, and after
- Medication and results
When cleaning and irrigating a wound how should you move?
- -Least to most contaminated
- -Clean to dirty
- -Top to bottom
What is the goal of cleaning a wound?
Remove dead tissue and debris, which impedes healing
Nursing Diagnosis for wounds
- Impaired Tissue Integrity
- Risk for Infection
- Disturbed Body Image
- Deficient Knowledge (wound care)
What types of drainage come from a wound?
What is important with a Jewish patient who has died?
Typically need to be buried before sundown
What do you do to asses a wound bed?
- Wound dimensions (size and depth)
- Tunneling and undermining
- Bed texture
- Bed moisture
- Wound odor
- Margins and surrounding skin
What is required with escar tissue?
Risk Factors for Alteration in Skin Integrity
- -Limited activity levels
- -Impaired nutritional status
- -Diminished sensations
- -Altered level of consciousness
- -Friction and shear injury
- -Aging skin
- -Medications that delay healing
- -Decreased blood flow to lower extremities
Numeric value for 6 risk factors related to impaired skin integrity
Total score <18 = risk
- 6 risk factors:
- Sensory Perception, Moisture, Activity, Mobility, Nutrition and Friction & Sheer
Skin self-examination, using the ABCDE rule?
- and enlargement
What would you like to do?
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