"For every day you spend in bed..."
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"... it takes you two days to recover."
Lung assessment components
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, Auscultate:
Vesicular sounds (fancy word for wind sounds when breathing in and out)
(heard over most lung fields)
Bronchial (Over trachea, Abnormal over lung tissue)
Bronchovesicular sounds (Between scapulae and lateral to sternum)
Why is it important for a nurse to be aware of their body balance, alignment and
posture?
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•To reduce the risk of injury
•To facilitate body movements
•To allow for physical mobility without muscle strain
•To avoid excessive use of muscle energy (muscle fatigue/strain)
De-escalation techniques
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First, keep your own safety in mind!
Realize how or why they are upset
AVOID "I'm sorry" (if you didn't do anything wrong, can make patient feel as
if they need to comfort the nurse)
AVOID "Don't be angry" or "everything will be okay"
Don't negate their anger
Calm words
Non-confrontational verbiage or body language
Setting clear limits/boundaries
Therapeutic communication
, Acknowledge the anger and ask what is going on
"You seem like"
"Let's discuss how you're feeling about"
"What can we do to help you?"
Use their own words - if they said "angry", say "angry"
Avoid commands, insults, anger towards patient
Avoid closed-ended (one word response) questions
*Non-invasive to invasive*
Define "body alignment"
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Body alignment refers to the relationship of one body part aligning to
another body part along a horizontal or vertical line
What is a collaborative problem?
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Potential problems that nurses manage using both independent and
physican-prescribed interventions. These are problems or conditions that
require both medical and nursing interventions with the nursing aspect
focused on monitoring the client's condition and preventing development
of the potential complication.
Older patient vascular assessment considerations
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, Efficiency of blood vessels decreased overall
More likely to have sign of arterial/venous insufficiency in lower extremities
Peripheral edema is common in those with venous insufficiency
Higher BP
Varicosities more frequent
A nursing diagnosis is NOT
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1. Statement of equipment used in medical regimen (e.g. "Large blood
pressure cuff needed for...")
2. Statement of medical regimen (e.g. "Give antibiotic as ordered by
doctor")
3. Statement of a diagnostic procedure
4. A statement of a nursing activity.
5. A statement that includes the care required by the patient/client
6. Astatement of an interpersonal problem the nurse has with the
patient/client (e.g "Pt uses call light too much")
7. A statement of a nursing need (e.g. "Give meds after break")
8. The same as a medical diagnosis ("Pneumonia related to respiratory
congestion")
9. A statement that no problems exist that require nursing intervention.
10. A statement of a nursing problem ("Difficult to transfer to wheel chair...")
Assist vs Complete vs Partial bath
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Assist Bath - nurse helps patient with areas that may be difficult to reach
(back, feet, legs, etc)
Complete bath - nurse washes patient's entire body without assistance
from the patient
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"... it takes you two days to recover."
Lung assessment components
Give this one a try later!
, Auscultate:
Vesicular sounds (fancy word for wind sounds when breathing in and out)
(heard over most lung fields)
Bronchial (Over trachea, Abnormal over lung tissue)
Bronchovesicular sounds (Between scapulae and lateral to sternum)
Why is it important for a nurse to be aware of their body balance, alignment and
posture?
Give this one a try later!
•To reduce the risk of injury
•To facilitate body movements
•To allow for physical mobility without muscle strain
•To avoid excessive use of muscle energy (muscle fatigue/strain)
De-escalation techniques
Give this one a try later!
First, keep your own safety in mind!
Realize how or why they are upset
AVOID "I'm sorry" (if you didn't do anything wrong, can make patient feel as
if they need to comfort the nurse)
AVOID "Don't be angry" or "everything will be okay"
Don't negate their anger
Calm words
Non-confrontational verbiage or body language
Setting clear limits/boundaries
Therapeutic communication
, Acknowledge the anger and ask what is going on
"You seem like"
"Let's discuss how you're feeling about"
"What can we do to help you?"
Use their own words - if they said "angry", say "angry"
Avoid commands, insults, anger towards patient
Avoid closed-ended (one word response) questions
*Non-invasive to invasive*
Define "body alignment"
Give this one a try later!
Body alignment refers to the relationship of one body part aligning to
another body part along a horizontal or vertical line
What is a collaborative problem?
Give this one a try later!
Potential problems that nurses manage using both independent and
physican-prescribed interventions. These are problems or conditions that
require both medical and nursing interventions with the nursing aspect
focused on monitoring the client's condition and preventing development
of the potential complication.
Older patient vascular assessment considerations
Give this one a try later!
, Efficiency of blood vessels decreased overall
More likely to have sign of arterial/venous insufficiency in lower extremities
Peripheral edema is common in those with venous insufficiency
Higher BP
Varicosities more frequent
A nursing diagnosis is NOT
Give this one a try later!
1. Statement of equipment used in medical regimen (e.g. "Large blood
pressure cuff needed for...")
2. Statement of medical regimen (e.g. "Give antibiotic as ordered by
doctor")
3. Statement of a diagnostic procedure
4. A statement of a nursing activity.
5. A statement that includes the care required by the patient/client
6. Astatement of an interpersonal problem the nurse has with the
patient/client (e.g "Pt uses call light too much")
7. A statement of a nursing need (e.g. "Give meds after break")
8. The same as a medical diagnosis ("Pneumonia related to respiratory
congestion")
9. A statement that no problems exist that require nursing intervention.
10. A statement of a nursing problem ("Difficult to transfer to wheel chair...")
Assist vs Complete vs Partial bath
Give this one a try later!
Assist Bath - nurse helps patient with areas that may be difficult to reach
(back, feet, legs, etc)
Complete bath - nurse washes patient's entire body without assistance
from the patient
