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Thursday, January 8, 2015

Nursing Review: Vital Signs



Vital Signs

 Ã˜  Temperature (NV 36 – 37.5 C)
ü  Elderly people are at risk of hypothermia
ü  Hard work or strenuous exercise can increase body temperature
ü  Oral: most accessible 2-3 mins. * 15 minutes interval after ingestion of hot or cold drinks
ü  Rectal: most accurate 2-3 mins.
ü  Axillary: most safest 6-9 mins.

Ø  Pulse (NV 60-100 bpm)
   Ã¼  Wave of blood created by contraction of the left ventricle of the heart
   Ã¼  Radial: best site for adult
   Ã¼  Brachial: best site for children
   Ã¼  Apical: best site for 3 years old below

Ø  Respiration (NV 12/16-20)

Normal Breath Sound

Vesicular
Soft, low pitch
Lung periphery
Broncho-vesicular
Medium pitch
Larger airway blowing
Bronchial
Loud, high pitch
Trachea

Abnormal Breath Sound
Crackles
Dependent lobes
Random, sudden reinflation of alveoli fluids
Rhonchi
Trachea, bronchi
Fluids, mucus
Wheezes
All lung fields
Severely narrowed bronchus
Pleural Friction Rub
Lateral lung field
Inflamed Pleura


Ø  Blood Pressure (NV 120/80 mm/hg)
  ü  This is the force exerted by the blood against a vessel wall
  ü  The pressure rises with age.
  ü  A rest of 30 minutes is indicated before the blood pressure can be readily assessed 
             after stressful activity.
  ü  Interval of 30 minutes is needed after smoking or drinking caffeine.
  ü  After menopause, women generally have higher blood pressures than before.
  ü  Pressure is usually lowest early in the morning, when the metabolic rate is lowest, 
             then rises throughout the day and peaks in the late afternoon or early evening


Common Errors in Blood Pressure Assessment

Errors
Effect
Bladder cuff too narrow
Erroneously high
Bladder cuff too wide
Erroneously low
Arm unsupported 
Erroneously high
Insufficient rest before the assessment
Erroneously high
Repeating assessment too quickly
Erroneously high
Cuff wrapped too loosely or unevenly   
Erroneously low
Deflating cuff too quickly
Erroneously low systolic and high diastolic reading
Deflating cuff too slowly
Erroneously high diastolic reading
Failure to use the same arm consistently
Inconsistent measurements

Arm above level of the heart
Erroneously low
Assessing immediately after a meal or while client smokes
Erroneously high

Failure to identify auscultatory gap pressure
Erroneously low systolic pressure and erroneously low diastolic

Wednesday, January 7, 2015

Nursing Review: Nursing Process



ASSESSMENT PHASE

Data Collection
Organize Data
Validate Data
Document Data
Subjective Data  also referred to as symptoms or covert data
Objective Data also referred to as signs or overt data, are detectable by an observer
Primary source is the client
Secondary source is family or anyone else that is not the client

Methods of Data Collection
Observing To observe is to gather data by using the sense.
Interviewing Is a planned communication or a conversation with purpose
Examining Is a systematic data-collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems.

DIAGNOSIS PHASE
Analyze Data
Identify Health Problem
Formulate Diagnostic Statements

Diagnostic Statements
Problem (P): statement of the client’s response.
Etiology (E): factors contributing
Signs and Symptoms (S): defining characteristics manifested by the client
Types of Nursing Diagnosis

Actual diagnosis is a client problem that is present at the time of the nursing assessment.
Risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors
Wellness diagnosis
Possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear.
Syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses
.
PLANNING PHASE

Prioritize problems
Formulate goals
Select actions
Write nursing orders
Types of Planning

Initial planning, admission assessment.
Ongoing planning
Discharge planning:
M edications
E xercise
T reatment/therapy
H ygiene
O ut-patient follow up
D iet/nutrition
S exual activity/spirituality

INTERVENTION /
IMPLEMENTATION

Determining needs for assistance
Putting into action the plan
Supervising delegated care
Documenting nursing activities
Types of Intervention
  1.   Independent
  2.   Dependent
  3.   Collaborative

Cognitive or Intellectual Skills Such as analyzing the problem, problem solving, critical thinking and making judgments regarding the patient's needs.
Interpersonal Skills
Which includes therapeutic communication, active listening, conveying knowledge and information, developing trust or rapport-building with the patient
Technical Skills Which includes knowledge and skills needed to properly and safely done the procedure

EVALUATION PHASE
Collecting data related to outcome
Comparing data
Drawing conclusion
Continuing, modifying or  terminating the nursing care plan

Monday, January 5, 2015

Fundamentals of Nursing Review Bullets

Fundamentals of Nursing Review Bullets
View more documents from Mark Fredderick Abejo




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