More on the physical health assessment, etc

More on the Physical Health Assessment, Etc. How long should you listen to an apical pulse? 1 minute. What are the landmarks to find the apical pulse? My way: Apex area – It is the PMI “Point of Maximum Impulse,” at the bottom of the sternum on the L side. It is to the left and slightly below the tricuspid area, which is still @ the 5th intercostal space. Actual Way: Start at the top of the sternum, move fingers ↓ L side of sternum to 5th intercostal space, right below the breast.

How will a blood pressure cuff that is too large for your patient affect your results? Using a cuff that is too wide can give a false low B/P reading. What if it is too small? Using a cuff that is too narrow can give a false high B/P..

Do you expect the heart rate to be increased or decreased when a patient is dehydrated?

Increased What about BP? Decreased Discuss Kubler-Ross' stages of grief.

1. Denial – "I feel fine."; "This can't be happening, not to me." Denial is usually only a temporary defense for the individual. This feeling is generally replaced with heightened awareness of situations and individuals that will be left behind after death.

Nurse Should: Listen, get a sense of what he/she is worried about, be honest, don’t give false hope, don’t argue 2. Anger – "Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?"

Once in the second stage, the individual recognizes that denial cannot continue. Because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Any individual that symbolizes life or energy is subject to projected resentment and jealousy.

Nurse Should: Not take personally, help family to not take personally, visit the patient often and answer call lights promptly, assist family w/much-needed breaks 3. Bargaining – "Just let me live to see my children graduate."; "I'll do anything for a few more years."; "I will give my life savings if..." The third stage involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle.

Psychologically, the individual is saying, "I understand I will die, but if I could just have more time..."

Nurse Should: Offer frequent chances for patient or family to talk, offer visits from clergy or other supports 4. Depression – "I'm so sad, why bother with anything?"; "I'm going to die... What's the point?"; "I miss my loved one, why go on?" During the fourth stage, the dying person begins to understand the certainty of death. Because of this, the individual may become Page 1 of 4

More on the Physical Health Assessment, Etc. silent, refuse visitors and spend much of the time crying and grieving. This process allows the dying person to disconnect oneself from things of love and affection. It is not recommended to attempt to cheer up an individual who is in this stage. It is an important time for grieving that must be processed.

Nurse Should: Not force cheerful or important conversation, allow the patient or family to voice concerns, offer visits from clergy, offer cultural or religious supports 5. Acceptance – "It's going to be okay."; "I can't fight it, I may as well prepare for it." In this last stage, the individual begins to come to terms with their mortality or that of their loved one.

Nurse Should: Encourage family to come often but for brief visits, offer visits from clergy, offer cultural or religious supports Discuss how you deal with stress. Say no, know my limitations, enjoy a hot bath, pamper myself for a day, eat more nutritiously and exercise, get adequate sleep (ha, ha – not possible in nursing school) What rate is considered tachycardia? Rate ≥ 100. What rate is considered bradycardia?

Rate ≤ 60.

Discuss one common barrier in communication. Low health literacy, which also includes cultural and/or language barriers. How to overcome it? Provide better, more thorough patient education in a manner that the patient can understand.

What is the correct method for charting when you have made an error in documentation?

Draw one single line through the error, write error above it, and initial it. Then proceed to write the correct documentation.

Discuss types of isolation and what illnesses they are used for.

Standard Precautions       

Used to help prevent nosocomial infections Used when working w/all patients Replaces the universal precautions and the blood and body precautions Applies to blood, all body fluids, secretions, excretions (except sweat) To be used even if blood is not visible Also applies to nonintact skin and mucous membranes Designed to reduce the risk of transmission of microorganisms

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More on the Physical Health Assessment, Etc. Transmission-Based Precautions    

Used for patients known or suspected to be infected w/specific pathogens There are three subgroups of transmission-based precautions (airborne, droplet, and contact) Subgroups can be combined for diseases w/multiple transmissions routes Subgroups are to be used in addition to standard precautions

Airborne Precautions  

Used for airborne infectious agents of 5 micrometers or smaller TB, Pertussis, Pneumonia

Droplet Precautions     

Used for infectious agents larger than 5 micrometers Droplets from the mucous membranes of the nose or mouth Droplets from coughing, sneezing, or talking Droplet contracted within 3 feet or less Rubella, Mumps

Contact Precautions (Direct or Indirect)   

Direct is skin-to-skin contact through touch, turning, or bathing Indirect contact is made by touching contaminated items, items within the patient’s room VRE, MRSA

Discuss types of fire extinguishers. Fire extinguishers are labeled A, B, C, or D according to the types of fires they extinguish. Some are used for more than one type of fire and are labeled w/more than one letter. The types of fires the letters correspond to are A: Paper or Wood, B: Liquid or Gas, C: Electrical, D: Combustible Metal.

Discuss the physiological hazards of immobility. Bowel changes, Cardiac changes, Integumentary Changes, Metabolic changes, Musculoskeletal changes, Respiratory changes, Neurosensory changes, and Urinary changes.

List nursing interventions to prevent pressure ulcers. Regular repositioning (at least q 2 hrs, but may be necessary to do more often), use pillows or wedges to decrease pressure over bony areas, maintain position and distribute weight evenly, use special mattresses like the circulating air mattresses, utilize friction prevention measures, refer patient to PT and/or provide passive and active ROM exercises, manage incontinence, manage nutrition, monitor healing process.

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More on the Physical Health Assessment, Etc. References Ignatavicius, D., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th ed.). St. Louis, Mo.: Saunders/Elsevier.

"K端bler-Ross Model." Huntington's Disease Society of America. Web. Retrieved from https://www.hdsa.org/.

Peterson, V., & Potter, P. (2013). Clinical companion for Fundamentals of nursing: Just the facts (8th ed.). St. Louis, Mo.: Elsevier Mosby.

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