EXAM 1 Study Guide health care 2021/2022 100% approved

THE PROCEDURE o Pt doesn’t need a complete head to toe physical every 24 hr stay o Initial Assessment 1 – note anything that needs continuous monitoring o Initial Assessment 2 – basic reassess for adults in med, surg, cardiac stepdown care areas  Then specialized to each adult o Health Hist Sequence 1  Verify markers/flags on way to room – isolations, allergies, fall precaution  Once inside room  introduce, wash hands, make eye contact & ask how theyre feeling/any pain or discomfort/how they spent previous shif o Health Hist Seq 2  Refer to what u heard from previous shif  Offer water as courtesy (if pt is not NPO) – indicates pt is able to hear, follow directions, ability to swallow, etc  General appearance, verify name band o Vitals: Temperature, Pulse, Respiration, BP, pulse oximetry, pain level (1-10), if pain med given then note response in 15 mins for IV admin to 1 hr for oral admin o THINGS TO DO (activity)  If pt is on bed rest  HOB should greater than 15 degs as pt at risk for skin breakdown  If SCD(Sequential compression device)s ordered then note that & follow protocol  If ambulatory  assist to sitting level and move to chair  Not any resistance needed & ability to transfer  Assess need for aid or equipment  Complete standardized scales per protocol to quantify fall risk  Complete documentation  SKILLS performed one at a time o Inspection o Palpation (sense of touch) – assessing texture, temp, moisture, organ location/size, swelling/vibration/pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, presence of tenderness or pain o Percussion – mapping location/size of organs, density, superficial abnormal mass (vibrations penetrate about 5cm deep & deeper mass would give no change), eliciting pain/deep tendon reflex o Auscultation (listening to sounds produced by body) – heart, bowel, lung, abnormal vascular sounds  General Survey This study source was downloaded by from CourseH on :38:02 GMT -06:00 o Physical Appearance – Age, Sex, LOC, Skin color, facial features, overall appearance o Signs of Acute distress o Body Structure & Mobility o Behavior – facial expressions, mood/affect, speech pattern, dress, personal hygiene o Initial Measurements – ht, wt, BMI o Vital signs – temp, pulse, BP, respirations, pain o Ethical & Legal Implications  Vital signs- know the ranges, causes of abnormalities and variations, when to report the findings and when to reassess o Vitals: Temperature, Pulse, Respiration, BP, pulse oximetry, pain level (1-10), if pain med given then note response in 15 mins for IV admin to 1 hr for oral admin o THESE REQUIRE IMMEDIATE ASSISTANCE  Systolic BP 160 or 90  Normal 120/80 (syst/diast)  Systolic  maximum pressure felt on artery during lef ventricular contraction  Diastolic  resting; pressure that blood exerts constantly bw each contraction  Temperature = 97 or =100 F  Normal 98.6F  Fever can cause rise in temp  Rectal temp – not for those who have bleeding disorders  Heart rate = 60 or = 90 beats/min  Lower heart rate can imply more efficient heart function & better cardiovascular fitness aka athlete who has 40bts/min  Bradycardia  low HR  Tachycardia - high HR  Radial abnormal  check apical  Pulse defecit = apical – radial  Respirations =12 or =28 /min  Normal is 12-20  Aging affects respiratory rates o Newborns – 30-40 o Adolescents – 12-20 o Adults – 10-20  Abnormal blood cell function (sickle cell) reduces ability of hemoglobin to carry O2  inc resp rate & depth  O2 saturation =92%  Normal 95-100  Urine output 30 or 240ml/8hrs  Normal for 24 hr urine 800-2000ml  Dark amber or bloody urine (*urology pts)  Postop nausea or vomiting  Surgical pain not controlled w/ medication and/or chest pain  Bleeding This study source was downloaded by from CourseH on :38:02 GMT -06:00  Altered level of consciousness (LOC), confusion, or difficulty arousing  Sudden restlessness and/or anxiety o If vitals are abnormal, have another nurse or health care provider repeat measurement to verify readings. – report immediately & document in record o Report to provider immediately during these:  BP not responding to HR changes  hypotension associated w/ pallor, skin mottling, clamminess, confusion, inc HR, or dec urine output is life threatening  Pressure difference greater than 10mmHg in arms  Any abnormal findings TBH o Reassess if ur unsure of BP or others