Assessment:

Inspection:  Things you can see, general appearance
Palpate:  Consistency, tenderness, heat
Percuss:  Sound of underlying structure
Auscultation:  Pattern, pitch, volume, timing, duration, intensity

Bell:  Low-pitched sound hearing
Diaphragm:  High-pitched sound hearing

Levels of consciousness:  Alert, drowsy, lethargic, stuporous, comatose, obtunded, resting quietly, resting with eyes opened/shut


Transient flora:  Random and not normally there
Resident flora:  Normally found on or in the body

Must be able to list 2-3 factors that interfere with good hand hygiene (Institutional factors) 
Don't use, "Nurses are stupid and lazy." 
You may however use: 
Nurses are overworked
Nurses aren't eduated
Nurses weren't playing Halo; and when the aliens did invade, they were left totally unprepared and were taken away before they could wash their hands. 

Must treat all bodily fluids, (including sweat,) as infectious

Where to find out about islation requirements on a patient:
Facility policy and procedures manual
Preceptor
CDC web site

Everything is now non-latex



Braden Scale of Pressure Sore Risk
Flat or raised? 
    Macule:  0 mm raised
    Papule:  1-5 mm raised
    Plaque >5 mm raised

Fluid or pus filled?
    Serous or purulent exudate?
    Pustules or vesicles?

Color?
Tenderness
Ecchymosis?
Sunken?
Irregular?
Temperature?
Moist or dry?
Flaky?
Erythematous


Acuity?
    Snellen chart
    Color blindness tests
Activities
Pupil size in mm, equalness, roundness


When looking in the eye, follow blood vessels to/from the optic disk

Optic Disc Diameters are your frame of reference

Decibels of hearing loss (dbHL)
Rinne Test:  Air conduction > bone conduction
    On jaw, move to ear
Weber test:  Doesn't rely on conduction, but the auditory nerve
    Internalized on the bad side. 

Symmetry
Contour
A:P diameter:  (Anterior:Posterior) (2X Width = Depth)
Apical pulse
Jugular vein distention:  Should be 0

Arterial pulses
Bounding:  4+
Full/Increased:  3+
Brisk/Expected:  2+
Diminished:  1+
Absent:  0+


32 mm/Hg is the blood pressure in a capillary bed

Best blood pressure measure is a catheter

It is possible to palpate a systolic pressure with a cuff

2% of health care workers do blood pressure correctly

Hypertension costs $23.7 B a year


41% of patients are elderly
12% of the population are elderly
Cataracts
Light sensitivity
Light non-sensitivity
Presbyopia
Loss of high pitch
Blanket of sound
Tinnitis
Deafness

After 50 years, there is a slowness to the speed of reasoning
Gerontology:  Study of the biologic, physiologic, psychosocial and spiritual needs of the elderly

Many disease states occur more commonly with age

There is an increase in the elderly population mostly because of clean water and sanitation, (moreso than because of healthcare advances.)

77% of women older than 65 years are widowed
50% of men older than 65 years are married
73% of people over 65 years live with a spouse
17% of people over 65 years are por or near poor
90% of income of people over 65 is from Social Security

A:  Inpatient care
B:  Outpatient care
C:  Medigap coverage (private supplemental coverage) 


P Wave:  Atrial depolarization
QRS Complex:  Ventricular depolarization

Sudden onset of sore throat
Fever > 104 degrees
Mouth:  Tonsil erythema, tonsil exudate
Higher cardiac output
Englarged lymph nodes
Jugular venous distention
Prominent carotid pulsation

Percussion: 
On chest; note dullness of percussion
Dullness is normal over the heart. 
Measure in cm

The heart sound is from two sets of valves closing

Sound 1 (S1):  Mitral valve and tricuspid valve closing ("Lub)
Sound 2 (S2):  Aortic and pulmonic vavles closing ("Dub")

S2 > S1:  At base of heart
S1 > S2:  at the apex of the heart
(The base is superior to the apex) 

Listen for high- and low-pitched sound over each region


See The Cheap Students Guide to Medical Terminology and Medical Shorthand for new definitions


It's good if the diagnosis covers as may symptoms clusters as possible
Point of nursing care plan:  Plan and organize nursing care

Diagnostic priviledge:  Diagnosis and treatment of the human response to illness

Nursing care happens at a place where skilled observation occurs.  Medical care can happen anywhere. 

Patient outcome:  Should be about patient, not nursing care.  Use, "The patient will..."

Good words:  Demonstrate, state, attend, report

Specificity is good

Time oriented is good

e.g., "The patient will be able to state three food to avoid in a cardiac diet before discharge." 

Specific
Measurable
Attainable
Realistic
Timely

Nursing
Outcome
Classification
Diagnosis
Therapeutic
Educational
Consulting/Follow-Up

Nursing
Intervention
Classification

Outcomes:  Short and Long Term  (short term can be in three hours or a few weeks)
Name
Uses
Normal Dose}Mechanism
Side Effects}Mechanism
Nursing Implications

Absorption
Distribution
Metabolism
Excretion
Drugs scheduled by FDA based on potentials for addiction or diversion
A:  No risk
B:  No evidence of human risk
C:  No human studies
D:  ? benefits > risk
X:  Risk > benefit
Onset of action
Duration of action
Prevent medication errors
"Accidents"  (crashes too)
Falls
Asphyxiation/Choking
Poisoning
FPP (Falls prevention protocol) 
Restraints
Fire prevention
10-15% of elderly falls are associated with fracture
Fear
    Fallen people have decreased self efficacy 
    Activity resrtictions
Estimated cost $12.6 B

Need to be aware of organic causes to falls

Beer's list:  Meds to avoid in the elderly.  Different from Beer list or DeBeer's list. 

Two rails:  An aid to mobility
Four rails:  A restraint
Definition:  Anything for stopping self injury or injury to others
Mechanical:  Limits movement
Passive:  Makes people aware of movement
Chemical:  Any medication that alters ability to move (If that is the purpose of it.) 

Anyone oriented X3 is allowed to refuse care.  (Because they're competent.  However, they will probably become incontinent of stool when they find out they left AMA and their insurance company won't cover their bill now.) 
Minimum data set (MDS):  List of a resident in a long term care facility's functional capabilities.  It's required for Medicare and Medicaid. 

Be aware of food allergies and absorption problems
Albumin
Pre-albumin
Lymphocyte
Dx:  Diagnostic
Tx:  Therapeutic
Ed.:  Educational
Ref./ F/U:  Referral/Follow up

November 15, 2007
"General Nursing Knowledge" = Fancy term for common sense
Open or closed
Size
Color
Discharge
Injury
Migratory Phase (inflammation) (about 48 hours)  Framework for repair put into place
Fibroplasia:  Collagen networks form (few days to 5-6 weeks)
Maturation:  Wound stabilized, scab formation, skin tensile strength
Approximated:  Skin adhered, stapled, sutured
Secondary intention:  Wound bottom -> top healing, open
Tertiary intention:  Bottom -> top healing, closed
Intermittent:
Continuous
Blanket continuous
Retention 
Infection:  Microorganisms
Hemorrhaging:  Loss of blood
Fistula:  A hole opens where a hole shouldn't. 
Dehiscence:  Why post-abdominal surgeries shouldn't smoke
Skilled assessment
Hygiene
Patient Education
Care plan
Referrals
Consults
Consult medical orders

Nursing, (not doctoring) regulates nursing practice
Nursing is the human response to health problems
Title protection will probably have a question on the final.  (I.e., only certain people can call themselves RN.  I can freely refer to myself as, "Imperial Princess."  There's no governing body to stop that.) 
Assessment
Analysis
Planning
Implementation
Evaluation
1.  Non-blanchable erythema of intact skin
2.  Partial-thickness skin loss involving the epidermis, dermis or both
3.  Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying fascia
4.  Full-thickness skin loss with extensive destruction, tissue necrsis, or damage to muscle, bone, or supporting structures
1.  Red
2.  Through skin
3.  To fat
4.  To bone and muscle
*Michael's tips*  Smoking may be okay, but don't rub active hyperemia
1.  Review Kozier, (i.e., you should've been reading all quarter.) 
2.  Reread the interventions from Ackley
3.  Reread the lecture notes
Unpleasant sensory and emotional experience
Acute pain is protective
Chronic Pain (4-6 weeks) or (>6 months)
Pain can also be whatever patient says it is
Persists or occurs intermittently for six months or longer
Rarely resolves on its own
ay be associated with cancer or chronic non-malignant illness
Patient typically does not demonstrate clinical or physical signs

Addiction:  Continue to use despite harm
Pain Threshold:  How much pain can you stand, (Mr. Bond)
Resiliency:  See the above
Onset
Location
Duration
Character
Aggravating factors
Relieving factors
Temporal
Symptoms
November 26, 2007
Primary prevention:  Stopping an event, (that's never happened,) from happening
Secondary:  To prevent complications
Tertiary:  Rehabilitate to restore previous function

Need to give a population for an intervention

The board of medicine can't control nursing practice.  Can regulate collaborative care
Medication administartion is an, "all or nothing," concept
Patient
Care
Aanalgesia
Lockout interval:  Time between button presses
Cognitive:  "Patient will know..."
Psychomotor:  "Patient will demonstrate..."
Affective:  "Patient will feel..." 
November 29, 2007
Check out Kozier pp. 1366 and the graph of lung volumes
Know the nursing process
Documentation:  Vitals, assessments, changes, ADLs, evaluate nursing plan
Medicare is a federal program
Medicaid is a state program
OBRA is medicare
Know minimum data set
Check out the Ohio Revised Code on Carmen
Know about insulin
The nurse must have a duty to be there, (i.e., clocked in)
The nurse must do harm
There must be a causal relationship

Expert witnesses must be experts to the situation
Respondent Superior  "Let the master answer"  (i.e., hospitals are liable for their employees)
Title Protection:  Only RNs may call themselves RN.  -Ohio B.o.N.