NURBN1006 exam revision PDF

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NURBN1006 MODULE 1 – PHYSICAL ASSESSMENT  Primary survey D – Danger: check environment for hazards R – Response: AVPU (Alert, Voice, Pain stimulus, Unresponsive) A – Airway: quality of their voice and their breath sounds B – Breathing: quality (depth and rhythm) or the rise and fall of chest C – Circulation: color of skin, any sweating D – Disability: level of mobility, extra cushioning or assistance required E – Exposure: examine for any other illnesses  Physical assessment techniques (HIPPA) H – History: patient profile – Name, sex, date of birth Chief complaint – P: provoking factors of the pain Q: quality of pain R: Radiates (pain origin) S: severity T: timing Bowel history – how often do you have bowel movements? Characteristics of your stool Medical history – did you have previous surgeries? Are you on any medications? Do you have a family history of an illness? Social history – tobacco? Alcohol? Work and home environment, stress, ethnic background and level of activity? I – Inspection: visual examination of a person o Look for any bruises, redness, scars, etc. P – Percussion: examination of the body by tapping it with the fingers P – Palpation: examination by touch; feeling for texture, size, consistency, and location of body part. A – Auscultation: hearing bowel sounds In abdominal assessment we use HIAPP because doing percussion before auscultation can affect bowel sounds o Integument – inspection o Head and neck – inspection, palpation o Thorax and lungs – inspection, palpation, percussion, auscultation

o Cardiovascular – inspection, palpation, percussion, auscultation o Peripheral vascular – inspection, palpation, percussion o Abdomen – inspection, auscultation, percussion, palpation o Male/female genitalia – inspection, palpation o Anus, rectum, prostate – inspection, palpation o Musculoskeletal – inspection, palpation  Importance of a physical assessment o Ascertain the person’s level of health and physiological function o Identify factors placing the person at risk for problems o Determine areas of preventative nursing o Detect alternations, disease or inability to perform the activities of daily living o Identify the need for additional testing for examination o Evaluate the outcomes of treatment and therapy  How to prepare a patient to undertake an assessment Environment o Determine any special requirements of the person o Adjust the environment to allow for placement of equipment on a surface that is clean and free from movement. o Clean the floor of any items that would place person in danger o Ensure privacy o Inform other personnel about the time of the examination to avoid interruption Equipment o Review the protocol relative to a physical examination and secure the forms required for documenting the assessment findings before beginning an examination o Perform 5 moments of hand hygiene and gather necessary equipment (stethoscope, sphygmomanometer, watch with second hand, pulse oximeter, penlight, gloves and lubricant) Positioning and draping o Sitting o Supine (lying down facing up) o Sims (lying face down with one knee bent align with hip) o Prone (lying down facing down) o Knee-chest (lying face down with knees up to the chest) o Lithology (lying facing up with knees bent in the air) MODULE 2 – VITAL SIGNS  Vital signs across lifespan

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Newborn o Temperature 36.8 degrees Celsius o Pulse rate 130 (80-180) o Respiration rate 40-90 o Blood pressure 80/40 1-3 years old o Temperature 37.7 degrees Celsius o Pulse rate 110 (80-150) o Respiration rate 20-40 o Blood pressure 98/64 6-8 years old o Temperature 37 degrees Celsius o Pulse rate 95 (75-115) o Respiration rate 20-25 o Blood pressure 102/56 10 years old o Temperature 37 degrees Celsius o Pulse rate 90 (70-100) o Respiration rate 17-22 o Blood pressure 110/58 Teen o Temperature 37 degrees Celsius o Pulse rate 80 (55-105) o Respiration rate 15-20 o Blood pressure 110/70 Adult o Temperature 36.7 degrees Celsius o Pulse rate 80 (60-100) o Respiration rate 12-20 o Blood pressure 120/80 Adult (70+ years) o Temperature 36-37 degrees Celsius o Pulse rate 80 (60-100) o Respiration rate 12-20 o Blood pressure 120/80 – 160/95  What affects vital signs i.e. age, gender, medication, lifestyle, etc. Factors that affect body temperature o Age, exercise, hormonal influence, daily variations, stress, environment, ingestion of food and hot/cold liquids, smoking

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Factors that affect pulse rate o Age, exercise, hemorrhage, pulmonary conditions, fever/heat, acute pain/anxiety, postural change, severe/chronic pain, medication, metabolism Factors that affect respiration rate o Disease or illness, stress, fever, age, gender, body position, medication, exercise, acute pain, smoking, brainstem injury, hemoglobin function Factors that affect blood pressure o Anxiety, fear, pain, stress, medication, hormones, daily events, race, obesity, gender  Definitions i.e. hypertension, bradycardia, tachycardia, etc. Hyperthermia: dangerously overheated body Hypothermia: body loses heat faster than it can produce heat, causing dangerously low body temperature Tachycardia: abnormal rapid heart beat Bradycardia: heart beats less than 60 times a minute Tachypnea: abnormal fast breathing Bradypnea: abnormal slow breathing Hypertension: high blood pressure Hypotension: low blood pressure MODULE 6 – CARDIOVASCULAR ASSESSMENT  Steps involved in a focused cardiovascular assessment o Preparation of the patient: Explain the procedure to the patient. Gain consent from the patient. Analyse the patient's condition and make sure to choose an appropriate time to perform the assessment. Consider the patient's cultural and gender backgrounds. o Positioning of the patient: Position the patient in a supine position for cardiovascular assessment. Make sure the patient is comfortable in that position (Patients with back injuries find it hard to lie in a supine position or some patient develop shortness of breath when lying supine). o Preparation of the environment: Analyse and adjust the environment to allow for placement of the equipment. Clear any clutter in the environment. Make sure the room is at the right temperature as the patient is going to be exposed. o Privacy: Provide privacy to the patient by pulling curtains across or closing the door. Also be mindful that the patient is not exposed more than they should be. Expose one area at a time. Especially, when caring for female patients ensure the patient is exposed to the minimum. Patient information should be kept private and confidentiality should be maintained. Equipment o Stethoscope o Observation machine o Vital signs chart History: patient profile, chief complaint, past health history, family history, social history

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Inspection: visible pulsations on either side of the precordium are abnormal and need to be reported. Inspect extremities for clubbing or oedema Palpation: locate apical pulse, then pinpoint the pulse with finger pad. Palpate for thrills (vibrations) or heaves (lifts) of the cardiac area. Palpate the radial pulse and monitor the rate and the rhythm. Check for capillary refill in extremities (good indication of blood flow to extremities) Percussion: percuss the precordial area of the chest, listening for a resonant sound which indicates normal tissue beneath the fingers Auscultation: assess the apical pulse for 1 minute for both the rate and rhythm. If heart rate is irregular, determine if there is a pattern to the irregularity. Normal heart sounds consist of S1 & S2  Risk factors to cardiovascular disease Term

Definition

Causes

Symptoms

Nursing Management

Hypotension 

Hypotension refers to low BP, generally SBP 140mmHg or DBP> 90mmHg. Major risk factor for CVA (Cerebral Vascular Accident) & AMI (Anterior Myocardial Infarction)

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Genetic causes Hardening of arteries Endocrine disorders Renal diseases Smoking /Alcohol Obesity Stress Hereditary High salt intake

Can be nonsymptomatic Headaches Flushing Nose Bleeds Vision problem Fatigue

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Monitor BP Report to medical staff. Encourage Healthy diet Encourage exercise Administer prescribed medication

Postural hypotension refers to a sudden drop of 25mmHg in systolic and 10mmHg in diastolic pressure, when the person moves from a lying to sitting position or sitting to standing position.

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Dehydration Hypovolemia Ageing Medications

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Pallor Sweating Dizziness, resulting in falls.

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Monitor postural BP (lying and sitting BP). Encourage fluid intake prior to ambulation Instruct patient to slowly rise from the supine position. Review by a doctor. Administer prescribed medication, in cases of severe postural hypotension.

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Position patient with their legs elevated. Promotes venous return to the heart. Monitor vital signs. Report to medical staff. Encourage fluid intake. Advise patient to stay in bed until symptoms improve.

Hypertension 

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Postural / orthostatic hypotension

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Bradycardia 

Bradycardia is a heart rate of less than 60 beats per minute.

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Ageing Medications Cardiac conditions Hypothyroidism Athlete Hypertension

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Monitor vital signs. Closely monitor patient.

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Fatigue Shortness of breath Dizziness

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Heart disease Exercise Hypotension Stress Smoking Fever Recreational drugs Caffeinated drinks Medications

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Palpitations Syncope

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Monitor vital signs Encourage fluid intake, if cause hypotension

Tachycardia 

Tachycardia is a heart rate in excess of 100 beats per minute in an adult.

 Heart sounds/valves Number of pulse waves / minute = pulse CO (cardiac output) = SV (stroke volume) X HR (Heart rate) 'Normal’ cardiac output 60 - 70 ml X 70 – 80 bpm = ~ 5L o Rate is assessed by counting the number of pulsations in one minute. Rate can be modified by the autonomic nervous system (Parasympathetic stimulation slows the heart rate and sympathetic stimulation accelerates the heart rate). Rhythm is assessed by noting the pattern between the beats. The normal rhythm of the heart beat is regular. Irregular pulses are abnormal and need to be reported for further management. Dysrythymia is the term that describes irregular rhythm caused by an early, late or missed heartbeat.

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 S1 sounds are caused by the closure of the mitral and tricuspid valves. S1 sounds are heard at all sites and louder at the apical sites.  S2 sounds are caused by the closure of semilunar valves. S2 sounds are heard at all sites and louder at the base of the heart.  S3 sounds are normal in children and young adults. S4 sound are present in many older adults MODULE 7 – WORKING WITH DEATH, DYING & GRIEF  Physiological changes to the body associated with death and dying 

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Loss is any situation (either actual, potential or perceived) in which a valued object is changed or no longer accessible to the individual. Because change is a major part of every individual’s life experience every individual experiences loss. Loss can be actual e.g. a spouse or loved one dies. Loss can be anticipated e.g. a person is diagnosed with a terminal illness and has only a short time to live. It is important to realise that each individual will perceive and experience loss in their own manner. Grief is a series of intense physical and psychological responses that occur following a loss. Loss leads to the adaptive process of mourning, the period of time during which the grief is expressed and resolution of the loss is achieved. Bereavement is the period of grief following the death of a loved one. STAGE

DESCRIPTION

Somatic distress

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Episodic waves of discomfort lasting 10-60 minutes Multiple somatic complaints Emotional pain

Preoccupation with the image of the deceased

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A sense of unreality Emotional detachment from others Overwhelming preoccupation with visualising the deceased

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Bereaved consider the death to be a result of their own negligence or lack of attentiveness Look for evidence of how they could have contributed to the death

Guilt 

Hostile reactions

Loss of patterns of conduct

Mourning

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Relationships with others become impaired owing to the bereaved's desire to be left alone, irritability, anger

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Inability to sit still (generalised restlessness) Continually searching for something to do

STAGE

CHARACTERISTICS

Stage I: Shock and disbelief Can last from minutes to days

Stage II: Developing awareness

marks the beginning of the healing process and may take up to several years

EMOTIONS

PHYSICAL SETTINGS

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Increased sensitivity to noise Constricted feeling in throat and chest Shortness of breath Hollow feeling in stomach Dry mouth Muscular weakness Lethargy

PHYSICAL REACTIONS

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Loss of appetite Weight loss Insomnia Fatigue

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Emotional pain occurs with increased reality of loss Recognition that one is powerless to change the situation Feelings of helplessness Anger and holtility may be directed at others Guilt Sadness Isolation Loneliness

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Stage III: Restitution and resolution

Sadness Anxiety Guilt Relief Emancipation Self-blame Fatigue Numbness Shock Helplessness yearning Loneliness

Disorientation Perceived helplessness Denial gives protection until person is able to face realityn

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May last from 6 to 12 months

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Emergence of bodily symptoms May idealise the deceased Mourner starts to come to terms with the loss Establishment of new social patterns and relationships

BEHAVIOURS

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Disrupted sleep patterns Dreaming about the deceased Forgetfulness Crying Avoiding reminders of the deceased Treasuring objects belonging to the deceased Social withdrawal

PSYCHSOCIAL REACTIONS

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Profound sadness Helplessness Hopelessness Denial

THOUGHT PROCESSES

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Disbelief preoccupation Confusion Sense of presence of the deceased Hallucinations (e.g. seeing or hearing the deceased)

COGNITIVE REACTIONS

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Inability to concentrate Forgetfulness Impaired

COGNITIVE REACTIONS

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Impulsivity Indecisiveness Social withdrawal

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Decreased libido Decreased immune functioning (increased susceptibility to illness) Multiple somatic complaints (e.g. headache, backache) Restlessness

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Anger Hostility Guilt Nightmares Ennui (overwhelming sense of emptiness) Preoccupation with lost object Loneliness

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judgement Decreased problem solving ability Impaired decision-making ability

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Distancing Crying

 Palliative care, loss and grief and associated terms When speaking to a person who is dying or their relatives, understand the impact of the terms used. o Where possible, try to explain things in plain English, rather than automatically using potentially unfamiliar terms like 'palliative' and 'end of life' care'. o Regardless of the terms used, always check what the person has understood from the conversation. o Always speak in a kind and caring way to the person who is dying as well as to their relatives and friends. o Nurses need to communicate how much they care about the person who is dying, as well as being clear about what they're doing to help and support the person and their friends and relatives. Nurses need to ask themselves whether the words they are using convey this compassion, and also check with those they are caring for, that the information they are providing is clear as well as compassionate. Again it needs to be stressed how important it is to use clear straight forward language and avoid using "medical jargon". MODULE 8 – CARING FOR THE OLDER ADULTS  Common physiological changes by the adult o Mental problems, pre-existing mental health concerns. o Dementia and mental health concerns and these are frequently complicated with physical health concerns. o Older adults who develop schizophrenia early in life and have no ‘graduated’ into old age o Social isolation and anhedonia tend to plateau or diminish slightly during middle age, positive symptoms (auditory hallucinations, though disorder, paranoid ideation and delusions) persist. o Causes of relapse in older adults with schizophrenia include not taking medication, loss of a caregiver, medical illness, dementia or depression  Differentiate between delirium, dementia and depression Delirium: a transient disorder characterised by impaired cognitive function and reduced ability to focus, sustain or shift attention. It may occur in any setting - the home or comminity,

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hospital or residential care. Onset is usually sudden and there are rapid fluctuations in symptoms and severity. The presence of delirium requires prompt assessment and intervention. o Pain o Medication - side effects, drug-drug interactions (prescribed, over-the-counter, complementary medicines) o Alcohol use o Infection e.g. pneumonia, urinary tract infection o Malnourishment o Dehydration o Urinary retention o Hypoxia, hypotension, cardiopulmonary disorders leading to anoxia or transient ischaemia o Electrolyte imbalance o Constipation and faecal impaction Dementia: describes a collection of symptoms that are caused by disorders affecting the brain. It is not one specific disease. Dementia affects thinking, behaviour and the ability to perform everyday tasks. Brain function is affected enough to interfere with the person’s normal social or working life. Depression: Delirium and depression are both reversible disorders, but are often mistaken for irreversible dementia in the older adult. This is because cerebral dysfunction and cognitive impairment occur with delirium and depression, as well as with dementia. When depression and dementia occur together, the distress of the older adult and the family is markedly increased. Depression reduces happiness and wellbeing, contributes to physical and social limitations and can complicate treatment of medical conditions. There is a chronic underreporting of depression across the lifespan, but older people are particularly vulnerable as they may experience loss of health, vitality, independence and possibly relationships. Risk factors for depression in older adults include: o being female o recent bereavement o living in residential aged care home o multiple physical comorbidities o dementia o medication regimen which includes antihypertensives, analgesics or hypoglycemic agents o social isolation o prior history of depression  Issues associated with psychological changes in ageing

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o Complex and multi-factorial in causation o Gradual in onset with variation in symptoms experienced, from acute or sudden onset of symptoms through to symptom-free periods o Persistent and long-term in nature, leading to gradual deterioration of health more prevalent with older age; but, like asthma and renal disease, can occur throughout the life span o Compromising to an individual's quality of life thr...