Fundamentals for Nursing ATI

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for clients over age 65 and/or with permanent disabilities. premiums applied as insurance program reimburses providers based on DRGs. Premiums applied as Managed Care Organizations (MCOs) provide enrolled clients with comprehensive care overseen by a primary care provider. Is federally funded.


for clients with low income. is federally funded and individual states determine eligibility requirements.

Traditional Insurance

reimburses for services on fee-for-service basis.

Managed Care Organizations (MCOs)

comprehensive care is overseen by a primary care provider & focuses on prevention and health promotion

Preferred Provider Organizations (PPOs)

client chooses from a list of contracted providers. using non-contracted providers increases the client’s out of pocket costs

Exclusive Provider Organizations (EPOs)

the client chooses from a list of providers within a contracted organization

Long-Term Care Insurance

provides for long-term care expenses not covered by Medicare

Preventive health care

focuses on educating and equipping clients to reduce and control risk factors of disease. Examples include immunizations, stress management programs, and seat belt use

Primary health care

emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control. is based on a sustained partnership between client and provider. examples include office or clinic visits and scheduled school/work centered screenings (vision, hearing, obesity)

Secondary health care

includes the diagnosis and treatment of emergency, acute illness, or injury. examples include care given in hospital settings (inpatient and EDs), diagnostic centers, or emergent care centers

Tertiary health care

involves the provision of specialized highly technical care. examples include oncology centers and burn centers

Restorative health care

involves intermediate follow-up care for restoring health. examples include home health care, rehab centers, and skilled nursing facilities

Continuing health care

designed to address long-term or chronic health care needs. examples include hospice, adult day care, and in-home respite care

Health care regulatory agencies include:

-US Dept of Health and Human Srvcs -US FDA -State and local public health agencies -State licensing boards (to ensure providers & agencies comply with state regulations) -the Joint Commission/JCAHO (set quality standards for accreditation of health care facilities) -Professional Standards Review Organizations (PSROs) -Utilization review committees (monitor for appropriate diagnosis and treatment of hospitalized clients)


Job: provide spiritual care to client (pastors, rabbis, priests) Refer to when: the client requests communication or the family asks for prayer prior to client undergoing a procedure

Registered dietitian

Job: assess, plan for, and educate the client reg. nutritional needs; direct care of nutritional aids Refer to when: ex- the client has low nutrient levels and/or experienced a recent unexplained weight loss

Lab tech

Job: obtain specimens of the client’s body fluids and perform the necessary diagnostic tests Refer to when: ex- the provider orders a CBC to be performed immediately

Occupational therapist

Job: assess and plan for the client to regain ADLs, esp motor skills of the upper extremities; direct care of occupational therapy assistants Refer to when: ex- client has difficulties using an eating utensil with dominate hand following a stroke


Job: provide & monitor meds for the client as prescribed by the provider; supervises pharm techs in states in which the practice is allowed Refer to when: client concerns over meds; dosage concerns; etc

Physical Therapist

Job: assess and plan for client to increase musculoskeletal functions, esp of lower extremities, to maintain mobility; direct care of physical therapy assistants Refer to when: ex- following a hip replacement, a client requires assistance learning to ambulate and regain strength


Job: assess, diagnose, and treat cllient for disease and/or injury; includes MDs, DOs, APNs, and PAs Refer to when: ex- client experiences change in vital signs

Rad Tech

Job: position client and perform x-rays and other imaging procedures for providers to review for diagnosis of disorders of various body parts Refer to when: ex- provider orders x-ray of client’s hip after a fall

Respiratory therapist

Job: evaluate resp status and provide prescribed resp treatments including O2 therapy, chest physiotherapy, inhalation therapy, and artificial mechanical ventilation Refer to when: ex- client with resp disease experiences SOB and requests nebulizer treatment that is ordered PRN

Social Worker

Job: work with client and client’s family by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and/or discharge Refer to when: ex- client dying of cancer wishes to go home but is unable to perform ADLs; the spouse needs med equipment in the home to care for client

Speech therapist

Job: evaluate and make recommendations regarding the functions of speech, language, and swallowing impacted by various client disorders or injuries; teach client techniques and exercises to improve function when possible Refer to when: ex- a client is having difficulty swallowing a regular diet after trauma to the head and neck

Registered Nurse (RN)

-Functions under state nurse practice laws -Perform assessments; establish nursing diagnoses, goals, and interventions; conducts ongoing client evaluations -Participate in developing interdisciplinary plans for client care -Share best practices; continuing education

Licensed Practical Nurse (LPN)

-Works under supervision of the RN -Collaborate with other team members -Possess technical knowledge and skills -Participate in the delivery of nursing care, using the nursing process as a framework

Unlicensed Assistive Personnel (UAP)

-Includes CNAs, CMAs, and non-nursing personnel -Work under direct supervision of an RN or LPN -Specific tasks usually outlined in position description -Tasks may including feeding clients, preparing meals, lifting, basic care, measuring & recording vital signs, and ambulating clients

The foundation of ethics is based on:

an expected behavior of a certain group in relation to what is considered right and wrong; it is the study of conduct and character

Morals are:

the values and beliefs held by people that guide their behaviors and decision making

Ethical theory examines:

the different principles, ideas, systems, and philosophies used to make judgments about what is right/wrong and good/bad

Ethical principles

standards of what is right/wrong with regard to important social values and norms


ability of client to make personal decisions, even when those decisions may not be in the client’s best interest


agreement that the care given is in the best interest of the client; taking positive actions to help others


agreement to keep one’s promise to the client about care that was offered


fair treatment in matters related to physical and psychosocial care and use of resources


avoidance of harm or pain as much as possible when giving treatments

Hospital’s ethics committee

may meet to discuss/resolve unusual or complex ethical issues; not a legal entity

Ethical dilemmas are:

problems about which more than one choice can be made and the choice made is influenced by the values and beliefs of the decision makers

A problem is an ethical dilemma if:

-it cannot be solved solely by a review of scientific data -it involves a conflict between two moral imperatives -the answer will have a profound effect on the situation/client

Steps in ethical decision making

-identify whether or not the issue is indeed an ethical dilemma -state the ethical dilemma including all surrounding issues and individuals involved -list and analyze all possible options for resolving the dilemma and review implications of each option -select option that is in concert with the ethical principle applicable to this situation, the decision maker’s values and beliefs, and the profession’s values set forth for client care; justify why chosen over other options -apply this decision to the dilemma and evaluate the outcomes


support of the cause of the client regarding health, safety, and personal rights


willingness to respect obligations and follow through on promises


ability to answer for one’s own actions


protection of privacy without diminishing access to quality care

According to the UDDA, death is determined by one of two criteria:

-an irreversible cessation of circulatory and respiratory functions -irreversible cessation of all functions of the entire brain, including the brain stem

A determination of death must be made:

in accordance with accordance with accepted medical standards

Nurse’s roles in ethical decision making include:

-agent for client facing an ethical decision: adolescent child debating on abortion; parent contemplating blood transfusion even when against religious beliefs -decision maker in regard to nursing practice: increasing staff load due to shift cuts; witnessing a surgeon discussion only surgical options without informing client of more conservative options

Entities with codes of ethics that may be used to guide nursing practice include:

-the American Nurses Association (ANA) -the International Council of Nurses (ICN) -the National Association for Practical Nurse Education and Services, Inc.

By practicing nursing within the confines of the law, nurses are able to:

-shield oneself from liability -advocate for client’s rights -provide care that is within the nurse’s scope of practice -discern the responsibilities of nursing in relationship to the responsibilities of other members of the health care team -provide safe, competent care that is consistent with standards of care

Federal laws impacting nursing practice include:

-HIPAA -ADA -the Mental Health Parity Act (MHPA) -the Patient Self-Determination Act (PSDA)

Criminal law:

-is a subsection of public law -relates to the relationship of an individual with the government -ex: a nurse falsifies a record to cover up a serious mistake may be found guilty of breaking a criminal law

Civil law:

-protect the individual rights of people -one type that relates to the provision of nursing care is tort law

Types of unintentional torts

-Negligence -Malpractice (professional negligence)

Types of quasi-intentional torts

-Breach of confidentiality -Defamation of character

Types of intentional torts

-Assault -Battery -False imprisonment


example: a nurse who fails to implement safety measures for a client who has been identified as at risk for falls

Malpractice (professional negligence)

example: a nurse administers a large dose of medication due to a calculation error; the client has a cardiac arrest and dies

Breach of confidentiality

example: a nurse releases the medical diagnosis of a client to a member of the press

Defamation of character

example: a nurse tells a coworker that she believes the client has been unfaithful to her spouse


example: the conduct of one person makes another person fearful and apprehensive (threatening to place a nasogastric tube in a client who is refusing to eat).


example: intentional and wrongful physical contact with a person that involves and injury or offensive contact (restraining a client and administering an injection against her wishes)

False imprisonment

example: a person is confined or restrained against his will (using restraints on a competent client to prevent his leaving the health care facility)

State laws

-regulate the core of nursing practice -each state has enacted statutes defining parameters of practice and gives authority to regulate to the state board of nursing

Board of nursing

-has authority to adopt rules and regs for nursing practice in that state -has authority to both issue and revoke a nursing license -set standards for nursing programs -delineate scope of practice among RNs, LPNs, and APNs

Nurse licensure compact

allows licensed nurses who reside in a compact state to practice in other compact states under a multi-state license; must provide care in accordance to statutes and rules in state care is being provided

Professional negligence

-failure of person with professional training to act in a reasonable and prudent manner -issues that prompt malpractice suits include failure to: follow standards of care, use of equipment in responsible & knowledgeable manner, effectively & thoroughly communicate with the client, document care was provided

5 elements necessary to prove negligence

1) duty to provide care as defined by a standard 2) breach of duty by failure to meet standard 3) foreseeability of harm 4) breach of duty has potential to cause harm (combines 2&3) 5) harm occurs

Nurses can avoid being liable for negligence by:

-following standards of care -giving competent care -communicating with other health team members -developing a caring rapport with clients -fully documenting assessments, interventions, and evaluations

Client’s rights

-legal guarantees that clients have with regard to their health care -situations where nurses have opportunity to protect client’s rights include: informed consent, refusal of treatment, advanced directives, confidentiality, and information security

Resident rights

further protection of rights for residents in nursing facilities that participate in Medicare programs; govern the operation of such facilities

Nurse’s role in client rights includes:

-client understands their rights -protecting rights of clients under their care

The client has the right to:

-be informed about the aspects of care in order to be active in the decision making process -accept, refuse, or request modification to the plan of care -receive care that is delivered by competent individuals who treat the client with respect

Informed consent

legal process by which the client has given written permission for a procedure or treatment to be performed

Consent considered informed when the client has been provided and understands:

-the reason the treatment or procedure is needed -how the treatment or procedure will benefit the client -risk involved if treatment or procedure is chosen -other options to treat the problem (including no action)

Nurse’s role in the informed consent process is:

to witness the client’s signature on the informed consent form and to ensure the informed consent has been appropriately obtained

Implied consent

client adheres to instructions provided by the nurse; ex: the nurse is preparing to administer a TB test and the client holds out his arm for the nurse

For an invasive procedure or surgery, the client is required to provide ____ consent.


Individuals who are authorized to grant consent for another person include:

-parent of a minor -legal guardian -court-specified representative -individual who has durable power of attorney for health care -emancipated minors (for themselves)

The provider’s responsibility for informed consent:

-obtain informed consent -must give complete description of treatment/procedure, description of who will be involved in treatment, description of risks, options for other treatments, and the right to refuse -provide clarification if requested

The client’s responsibility for informed consent:

-giving informed consent -must give consent voluntarily (no coercion), be competent and of legal age (or authorized individual), and receive enough information to make a decision

The nurse’s responsibility for informed consent:

-witness informed consent -must ensure provider provided necessary information, ensure the client understood and is competent to give consent, have the client sign informed consent document, notify provider if more information or clarification needed/requested by client, and document client questions and that the provider was notified (also if interpreter was used)

Refusal of treatment

-PSDA stipulates all clients have the right to accept and refuse care and must be advised of this right upon admission -if client refuses treatment, will be asked to sign an "Against Medical Advice" form and nurse must document information was provided and provider notified -if client refuses to sign form, nurse must document -if a client decided to leave the facility w/o discharge order, nurse must notify provider and discuss risks of leaving prior to discharge

Advanced directives

-communicate client’s end-of-life care wishes for them if they become unable to -PSDA requires all clients be asked if they have advanced directives upon admission -clients with out advanced directives must be provided with written information about their health care rights and how to formulate advanced directives -a health care rep should be available to help with the process

Living will

legal document that expresses client’s wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues

Durable power of attorney for health care

document that designates a health care proxy, who is authorized make health care decisions for a client who is unable

Provider’s orders

"do not resuscitate" (DNR) or "allow natural death" (AND) are orders written by a provider and must be placed in the client’s medical record; the provider consults the client and family prior to administering a DNR or AND

Nursing role in advanced directives

-provide written information regarding advanced directives -document the client’s advanced directives status -ensure that the advanced directives reflect the client’s current decisions -inform all members of the health care team of the client’s advance directives

Mandatory reporting

-abuse: child or elder abuse, domestic violence -communicable diseases (according to CDC) such as hepatitis and TB

Documentation must be: F___, A___ & C___, C___ & C___, and O___.

-Factual -Accurate & Concise -Complete & Current -Organized

The client’s chart or medical record is the ____ record of care


Subjective data can be documented as:

direct quote, within quotation marks, or summarized and identified as the client’s statement

Objective data should be documented:

-descriptive and should include what the nurse sees, hears, feels, and smells -w/o derogatory words, judgments, or opinions -accurately

Legal guidelines of documentation

-begin each entry with date & time -legible and in black, non-erasable ink -no white out or blackened out errors -info inadvertently omitted may be added as a "late entry" -signed with signature of person making entry and dated -should reflect assessments, interventions, and evaluations

Flow charts are used to record and show trends in:

vital signs, blood glucose levels, pain level, and other frequently performed assessments

Narrative documentation records information as

a sequence of events

Problem-orientated medical records consist of:

a database, problem list, care plan, and progress notes; examples include SOAPIE, PIE, and DAR


S-ubjective O-bjective A-ssessment (inc nursing diagnosis) P-lan I-ntervention E-valuation


P-roblem I-ntervention E-valuation

DAR (focus charting)

D-ata A-ction R-esponse

Change of shift report

-given at the conclusion of each shift by the nurse leaving to the nurse assuming responsibility for the client -can be given face-to-face, audiotaped, or presented during rounds -should include significant objective info, given in logical order, free of gossip and personal opinions, and relate recent changes in meds, treatments/procedures, or discharge plan

Telephone report

-useful when contacting provider or other members of the interdisciplinary team -important to have all data prepared before calling; use professional demeanor; use exact, relevant, and accurate info; document name of person called, time, content of message, and instructions or information received

Telephone orders (TO) or verbal orders (VO)

should be avoided but may be necessary during emergencies and at unusual times

When accepting an order from a provider over the phone or verbally, the nurse should:

-have a second RN/LPN listen to the phone order -repeat back the order given including med name, dosage, time and route -document reading back the order and presence of the second nurse on the telephone -question any order that may seem contraindicated due to a previous order or to the client’s condition

Transfer reports should include

-client’s demographic information -client’s medical diagnosis and providers -and overview of the client’s health status (physical and psychosocial), plan of care, and recent progress -any alterations that might become urgent or emergent situations -directives for assessments or client care essential w/in next few hours -most recent vital signs -meds prescribed and last doses administered (inc PRN) -allergies -diet & activity orders -presence of or need for special equipment or adaptive devices -advance directives and resuscitation status -family involvements in care & health care proxy, if applicable

Incident reports (unusual occurrences)

-important part of a facility’s quality improvement plan -examples of incidence include med errors, falls, and needle sticks -facts documented without judgment or opinion -should not be referred to in client’s medical record


Process of transferring authority and responsibility to another member of the health care team to complete a task, while retaining accountability


Process of directing, monitoring, and evaluating the performance of tasks by another member of the health care team

RNs may delegate to

Other RNs, LPNs, and AP

LPNs may delegate to

Other LPNs and AP

RNs CANNOT delegate

-nursing process -client education -tasks that require nursing judgment to LPNs or AP

Prior to delegating client care, the nurse should consider:

-predictability of outcome -potential for harm -complexity of care -need for problem solving and innovation -level of interaction with the client

Examples of questions to use to determine predictability of care:

-will the completion of the task have a predictable outcome? -is it a routine treatment? -is it a new treatment?

Examples of questions to use to determine potential for harm:

-is there a chance something negative may happen to the client (risk for bleeding, risk for aspiration)? -is the client unstable?

Examples of questions to use to determine complexity of care:

-are complex tasks required as part of the client’s care? -is the delegatee legally able to perform the task and do they have the skills necessary?

Examples of questions to use to determine need for problem solving and innovation:

-will a judgment need to be made while performing the task? -does it require nursing assessment skills?

Examples of questions to use to determine level of interaction with the client:

-is there a need to provide psychosocial support or education during the performance of the task?

Factors to consider when selecting a delegated

-education, training, and experience -knowledge and skill required to perform the task -level of critical thinking required to complete the task -ability to communicate with others as it pertains to the task -demonstrated competence -agency policies and procedures -licensing legislation (state nurse practice acts)

Examples of tasks that can be delegated to LPNs

-monitoring client findings -reinforcing client teaching from a standard care plan -trach care -suctioning -checking NG tube patency -admin enteral feedings -inserting urinary cath -admin meds (exc IV in most states)

Examples of tasks that can be delegated to AP

-ADLS -bathing, grooming, dressing, toileting -ambulating -feeding (w/o swallowing precautions) -positioning -bedmaking -specimen collection and I&Os -VS for stable clients

5 rights of delegation help decide:

-what task should be delegated (right task) -under what circumstances (right circumstance) -to whom (right person) -what info should be communicated (right direction/communication) -how to supervise/evaluate (right supervision /evaluation)

Right task

Is repetitive, requires little supervision, and is relatively noninvasive for a certain client

Right circumstance

-Assess the health status and complexity of care required by the client -match complexity of care demands to skill level if team member -consider the workload of the team member

Right person

-assess and verify the competency of the team member -continually review the performance of the team member & determine competency of care -assess team member performance based on standards & remediate if needed

right direction/communication

communicate verbally or in writing: -data to collect -method and timeline for reporting -specific tasks to be completed; client specific instructions -expected results, timelines, and expectations for follow-up communication

right supervision/evaluation

the delegating nurse must: -provide supervision (direct or indirect) -provide clear instructions and understandable expectations of the task(s) to be performed -monitor performance -provide feedback -intervene if necessary (unsafe clinical practice) -evaluate the client and determine if client outcomes were met -evaluate client care tasks and identify needs for performance improvement activities and/or additional resources


-occurs after delegation -oversees a staff’s performance of delegated activities -determines if: completion of task is on schedule; performance was satisfactory; abnormal/unexpected findings documented & reported; assistance is needed to complete assigned tasks in a timely manner; assignment should be re-evaluated & possibly changed

Critical thinking incorporates: R___, L___, and I___.

R-eflection L-anguage I-ntuition


purposefully thinking back or recalling a situation to discover its meaning and gain insight into the event. -"Why did I say this or do that?" -"Did the original plan of care achieve optimal client outcomes?"


precise, clear language demonstrating focused thinking and communicating unambiguous messages and expectations to both the client and other health care team members. The nurse should consider the following: -"Did I use language appropriate for the client?" -"Did I communicate the message clearly to the provider?"


an inner sensing that something is not currently supported with fact. Intuition should spark the nurse to search the data to confirm or disprove the "feeling." The nurse should ponder the following: -"Did the vital signs reflect any changes that would account for the client’s present status?" -"When the client’s status changed in this way last month, there was a specific reason for it. Is that what is happening here?"

Levels of critical thinking

-basic critical thinking -complex critical thinking -commitment

basic critical thinking

-the nurse trusts the experts and thinks concretely based on the "rules." -results from limited nursing knowledge and experience, as well as inadequate critical thinking experience

complex critical thinking

-the nurse begins to express autonomy by analyzing and examining data to determine the best alternative -results from increased nursing knowledge, experience, intuition, and more flexible attitudes


-the nurse expects to have to make more choices without help from others and fully assumes the responsibility for those choices -results from an expert level of knowledge, experience, developed intuition, and reflective, flexible attitudes

components of critical thinking

-knowledge -experience -competence -attitudes -standards


information specific to nursing and acquired through: basic nursing ed; continuing ed courses; advanced degrees and certifications


decision-making ability derived from opportunities to observe, sense, and interact with clients followed by active reflection. The nurse: demonstrates an understanding of clinical situations; recognizes and analyzes cues for relevance; incorporates experience into intuition.


cognitive processes a nurse uses to make nursing judgments, such as: -general critical thinking: scientific method; problem-solving; decision-making; diagnostic reasoning and inference; clinical decision-making – collaboration -specific critical thinking in nursing: the nursing process


mindsets that affect how a nurse approaches a problem. Attitudes of critical thinkers include: confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility


model to which care is compared to determine acceptability, excellence, and appropriateness -intellectual standards ensure the through application of critical thinking. -professional standards include: nursing judgment based on ethical criteria; evaluation that relies on evidence-based practice; demonstration of professional responsibility

baseline data

-provided by the admissions assessment -compared with future assessments to monitor client status and response to treatment

discharge planning

– an interdisciplinary process started by nurse at time of admission -conducted with both client and client’s family for optimal results

upon admission (but prior to client arrival to room) take necessary equipment into the room including:

-appropriate documentation forms -equipment to obtain vital signs -pulse oximeter -hospital attire for client

When client arrives to room the nurse should:

-intro yourself, explain your role and role of other nursing staff, provide hospital attire, position comfortably, apply ID/allergy bracelets, provide written info and info on advanced directives, document advanced directives in medical record -assess/collect: baselines, reason for seeking care, health history, family history, psychosocial history, nutrition, review of systems, spiritual info, safety assessment, discharge info -inventory personal items brought by client

Upon admission, orient client and family to room/facility including:

-call light -bed operation -telephone/tv -overhead lighting -smoking policy -restroom locations -waiting areas -meal times -usual times for physician visits -dining/vending services -visiting policies

indications for transfer and discharge

-client’s level of care has changed -another setting is required to provide necessary client care -facility does not offer type of care now required -client no longer needs inpatient care and is ready to return home

discharge planning

-should begin when client is admitted (with the exception of LTC) -assess if the client will be able to return home and/or if they will need assistance at home -assess residence to see if adaptations or specific equipment will be necessary -make referral to social worker if needed -communicate client health status and needs to community service providers -if client chooses to leave before discharged, notify provider and have pt sign off

discharge education should:

-be clear and concise and also print ed for client to take home -identify safety concerns at home -review s/s of potential complications and when to contact provider -include provider phone number -provide names and numbers of community resources -instructions for continuing treatments -dietary restrictions and guidelines -amount and frequency of therapies -directions and information on medications

Items to be transferred/discharged with the client include:

-personal belongings at the bedside -valuables from the safe -medications -assistive devices -medical records or transfer form

responsibilities of the nurse when transferring/discharging the client:

-on day/time of transfer, confirm they are expecting and have a bed -communicate time client will be arriving -complete documentations -give verbal transfer report in person or over the phone -confirm mode of transportation to complete transfer/discharge -ensure client is dressed appropriately -account for all of client’s valuables

responsibilities of the nurse when receiving the transferred client

-have any specialized equipment ready -inform roommate of client’s arrival (if applicable) -inform other team members of arrival -meet with client and family to complete admissions/orientation process -assess how client tolerates the transfer -review transfer docs -implement appropriate nursing interventions in a timely manner

transfer documentation should include:

-med diagnosis and care providers -client demographic info -overview of health status, plan of care, and recent progress -any alterations that may be of immediate concern -notification of any assessments/client care needed within the next few hrs -most recent vital signs and meds (inc PRNs) -allergies -diet and activity orders -presence of/need for special equipment or adaptive devices -advanced directives & emergency code status -family involvement and health care proxy (if applicable)

discharge documentation should include

-type of discharge -date/time of discharge, how the client was transported out and with who -where discharged to -summary of condition upon discharge -description of any unresolved difficulties and procedures for follow up -deposition of valuables and meds -copy of discharge instructions

discharge instructions should include:

-step-by-step for procedures done at home -precautions to take when performing home procedures and with meds -s/s of complications that should be reported -names and numbers of providers and community services contacts -plans for follow-up care and therapies


-the absence of illness-producing micro-organisms -maintained through the use of aseptic technique with hand hygiene as the primary associated behavior

medical asepsis

-aka "clean technique" -the use of precise practices to reduce the number, growth, and spread of micro-organisms from an object, person, or area -used for administering oral meds, managing NG tubes, providing personal hygiene, and many other common nursing tasks

surgical asepsis

-aka "sterile technique" -the use of precise practices to eliminate all micro-organisms from an object or area -used for parenteral med administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, and many other common nursing procedures

before beginning any task or procedure that requires aseptic technique, health care team members must check for:

-latex allergies (client and team members) -if there is a known allergy, latex-free gloves, equipment, and supplies must be used

the number one measure to reduce the growth and transmission of infectious agents is:

-hand hygiene -hand hygiene refers to both handwashing with an antimicrobial or plain soap and water as well as the use of alcohol-based gels, foams, and rinses

the three essential components of hand washing include:

-soap -water -friction

time requirements for handwashing

-at least 15 seconds to remove transient flora from the hands -up to 2 minutes when hands are more soiled

do not place items on the floor in the client’s environment (even soiled laundry) because

the floor is considered "grossly" contaminated

do not ___ linens because do can spread micro-organisms in the air


all health care staff should:

-follow facility protocols for isolation and protection -wash hair frequently and keep it short or pulled back to prevent contamination of care area or client -not wear artificial nails while providing care and keep natural nails short and clean -remove jewelry from hands and wrists to facilitate hand disinfection

prolonged exposure to airborne micro-organisms can make sterile items nonsterile. Avoid:

-coughing, sneezing, and talking directly over a sterile field -air movement should be controlled by special ventilation

only sterile items may be in a sterile field

-the outer wrapping and 1 inch edges are non-sterile -touch sterile materials only with sterile gloves -any object held below the waist or above the chest is considered contaminated -sterile materials may only tough other sterile materials/surfaces; contact with nonsterile materials at any time renders a sterile area contaminated, no matter how short the contact

microbes can move by gravity from a nonsterile item to a sterile item:

-do not reach across or above a sterile field -do not turn your back on a sterile field -hold items to be added to a sterile field at a min of 6 inches above the field

sterile fields and moisture

-keep all areas dry -discard any sterile packages that become wet

equipment and sterile fields

-select a clean area in the client’s environment to set up the sterile field -check that all sterile packages are dry and have a future expiration date -make sure an appropriate waste receptacle is nearby

sterile procedure steps

-perform hand hygiene -open packaging, slipping package onto center of workspace with top flap opening away from the body -reach around to open top flap -open side flaps, using left hand for left flap and right hand for right flap -grasp last flap and turn it down toward the body -open additional sterile packages and add contents directly to sterile field by dropping contents into place -pour sterile solutions -don sterile gloves

steps to donning sterile gloves:

-with cuff side pointing toward the body, use non-dominate had to pick up dominate glove -while picking up edge of the cuff, pull the dominate glove onto the hand -with sterile dominate hand gloved, place fingers of dominate hand inside cuff of left hand, lifting it off the wrapper and put non-dominate hand into it -when both hands are gloved, adjust fingers as needed -during this time, only sterile gloved hand can touch the other sterile gloved hand

risks of infection

-inadequate hand hygiene (client and caregivers) -compromised health or defenses against infection -use of poor medical/surgical asepsis by caregivers -clients who have poor personal hygiene, poor nutrition, and those who are stressed -clients who live in a very crowded environment -older adult clients -clients who used IV drugs and share needles -clients who engage in unprotected sex -clients who have recently been exposed to poor sanitation, mosquito-born/parasitic diseases, or diseases endemic to area visited but not in client’s home country

individuals with compromised health or defenses against infection include:

-those who are immunocompromised -those who have had surgery -those with indwelling devices -a break in the skin -those with poor oxygenation -those with impaired circulation -those who have chronic or acute disease

health-care associated infections (HAIs)

-an infection acquired while the client is receiving care in a health-care setting -formally called nosocomial infections -can come from exogenous source or endogenous source -most common setting for HAIs is the ICU -best way to prevent HAIs is through frequent and effective hand hygiene -most common site of HAIs is the urinary tract -most common causative agents are Escherichia coli, Staphylococcus aureus, and enterococci -an iatrogenic infection results from a diagnostic or therapeutic procedure -HAIs are not always preventable and not always iatrogenic

s/s of generalized or systemic infection

-fever -increased pulse and resp rate (in response to high fever) -malaise -anorexia, nausea, and/or vomiting -enlarged lymph nodes

s/s during 1st stage of the inflammatory response (local infection):

-redness (from dilation of arterioles bringing blood to the area) -warmth of the area on palpation -edema -pain or tenderness -loss of use of the affected part

the types of exudate appearing at the site of infection during the 2nd stage:

-serous (clear) -sanguineous (contains RBCs) -purulent (contains leukocytes and bacteria)

during the 3rd stage of infection, ___ ___ is replaced by ___ ___.

damaged tissue is replaced by scar tissue

lab results indicating infection include:

-leukocytosis (WBCs > 10,000/uL -increases in the specific types of WBCs on differential (left shift = increase in neutrophils) -elevated erythrocyte sedimentation rate (ESR) -presence of micro-organisms on culture of the specific fluid/area

components of the chain of infection include:

-an infectious agent (bacteria, virus, fungi, protozoa) -a reservoir where the infectious agent grows (wound drainage, food, oxygen tubing) -an exit portal of the infectious agent (skin, resp or GI tracts) -a means of transmission (droplet, person-to-person contact, touching contaminated items) -an entry portal to a susceptible host (same as exit) -a host that must be susceptible to the infectious agent

adequate fluid intake/hydration prevents:

-the stasis of urine by flushing the urinary tract and decreasing the growth of micro-organisms -the skin from breaking down which will help prevent micro-organisms from entering the body

pulmonary hygiene for immobile clients

-includes turning, coughing, deep breathing, incentive spirometry -done every 2 hrs or as prescribed -decreases growth of micro-organisms and development of pneumonia by preventing stasis of pulmonary excretions, stimulating ciliary movement and clearance which expands the lungs

components of hygiene/cough etiquette that applies to anyone entering a health care setting includes:

-covering the mouth and nose when coughing and sneezing -using facial tissues to contain respiratory secretions, and disposing of them promptly into a hands-free receptacle -wear surgical mask when coughing to minimize contamination of the surrounding environment -turning head when coughing and staying a min of 3′ away from others, especially in common waiting areas -performing hand hygiene after contact with respiratory secretions

isolation guidelines

-group of actions that include hand hygiene and use of barrier precautions, which are intended to reduce the transmission of infectious organisms -apply to everyone regardless of diagnosis, and must be implemented whenever contact with a potentially infectious material is anticipated -PPE is changed after contact with each client and between procedures with the same client if in contact with large amounts of blood and body fluids

standard precautions (tier 1)

-applies to all body fluids (excluding sweat), non-intact skin, and mucous membranes -hand hygiene recommended after all contact and alcohol-based waterless product is preferred unless hands are visibly dirty; also required after removal of gown -clean gloves are worn when touching all body fluids, non-intact skin, mucous membranes, and contaminated equipment/articles -gloves removed and hand hygiene completed between each client -masks, eye protection, and shields required when splashing or spraying of body fluid may occur -gloves worn whenever touching anything that has potential to contaminate hands of the nurse -sturdy, moisture resistant bag used for soiled items; contaminated laundry to be bagged and handled to prevent leaking; equipment for client care properly cleaned and one time use items disposed of -safety devices on all equipment/supplies enabled after use and sharps disposed of properly -private room not needed unless client is unable to maintain appropriate hygienic practices

transmission precautions (tier 2) include:

-airborne precautions -droplet precautions -contact precautions

airborne precautions

-used to protect against droplet infections smaller than 5mcg (measles, varicella, pulmonary or laryngeal TB) -require a private room, masks/respiratory devices for caregivers and visitors (N95 or HEPA respirator for known/suspected TB), and negative pressure airflow exchange room of at least 6 exchanges per hr

droplet precautions

-protect against droplets larger than 5 mcg (streptococcal phryngitis or pnemonia, scarlet fever, rubella, pertussis, mumps, mycoplasma, pneumonia, meningococcal pneumonia/sepsis, pneumonic plague) -require a private room or room with clients with the same infectious disease and masks for providers and visitors

contact precautions

-protect visitors and caregivers against direct client/environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, scabies, multidrug-resistant organisms) -require a private room or a room with other clients with the same infection, gloves and gowns worn by caregivers and visitors, and disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag

transporting client in infection control/isolation

-if movement is unavoidable, take precautions to ensure that the environment is not contaminated -for example surgical mask placed on client with airborn or droplet infection and a draining wound is well covered

guidelines for cleaning contaminated equipment

-always wear gloves -rinse 1st in cold water -wash the article in hot water with soap -use a brush or abrasive to clean corners or hard-to-reach areas -rinse well in warm or hot water -clean the equipment used in cleaning and the sink (still considered dirty unless a disinfectant is used) -remove gloves and perform hand hygiene

reporting communicable diseases

reporting allows officials to: -ensure appropriate medical treatment of diseases (TB) -monitor for common-source outbreaks (foodborne – Hep A) -plan and evaluate control and prevention plans (immunizations for preventable diseases) -identify outbreaks and epidemics -determine public

factors that affect the client’s ability to protect himself include:

-age, with young and old at greatest risk -mobility cognitive -sensory awareness -emotional state -lifestyle -safety awareness

when dealing with safety, all health care workers must be aware of:

-how to assess for and recognize clients at risk for safety issues -procedural safety guidelines -protocols for responding to dangerous situations -security plans -identification and documentation of the incidents and responses per health care agency policy

it is the ___’s ___ to assess, report, and document client allergies and to provide client care that avoids exposure to allergens

provider’s responsibility

equipment should only be used by the nurse after:

a safety inspection and instruction


-older adults at increased risk due to decreased strength, impaired mobility and balance, and endurance limitations combined with decreased sensory perception -other clients at increased risk include those with decreased visual acuity, generalized weakness, urinary frequency, gait and balance problems, and cognitive dysfunction; also side effects of some medications -clients are at greater risk when >1 of the risk factors are present -fall prevention is a major nursing priority

complete a fall-risk assessment ___ ___ & at ___ ___ to limit risk of falls

upon admission & at regular intervals

general measures to prevent falls includes:

-be sure client knows how to use call light, it is within reach, and encourage its use -respond to call lights in a timely manner -orient client to setting and assistive devices -place clients at risk for falls near nursing station -ensure bedside table and frequently used items are within client’s reach -maintain bed in low position -for clients who are sedated, unconscious, or otherwise compromised, bed rails are kept up and bed kept in low position -avoid use of full side bedrails for clients who get out of bed or attempt to get out of bed without assistance -provide nonskid footwear -keep floor free of clutter with a clear path to the bathroom -keep assistive devices nearby after validation of safe use by client and family -educate client and family/caregivers on identified risks and plan of care -lock wheels on beds, wheelchairs, and carts -use chair or bed sensors for clients at risk for getting up unattended

report and document ___ incidents per facility policy


seizure precautions include:

-ensure rescue equipment is at bedside -inspect client’s environment for items that may cause injury in event of seizure -assist client at risk for seizure with ambulation and transferring -advise all caregivers and family not to put anything in client’s mouth in event of seizure (with exception of status epilepticus) -advise caregivers and family not to restrain in event of seizure but to lower to bed/floor, protect head, move nearby furniture, provide privacy, put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movement -after seizure, explain what happened to client and provide comfort and quiet -document the seizure along with precipitating factors along with description of event and report it to provider

seclusion and restraints

-must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min

seclusion and/or restraint must never be used for:

-convenience of the staff -punishment for the client -clients who are extremely physically or mentally unstable -clients who cannot tolerate the decreased stimulation of a seclusion room

restraints should:

-never interfere with treatment -restrict movement as little as is necessary to ensure safety -fit properly -be easily changed to decrease the chance of injury and to provide for the greatest level of dignity

the following must occur in order for seclusion or restraint to be used:

-all other less restrictive means have to be exhausted -the treatment must be prescribed by provider in writing based on a face-to-face assessment of the client (exception is in emergency situation where client is a danger to himself or others and providers order must be written asap) -rx must include reason, type, location, how long it may be used, and type of behavior that warranted the restraint -provider must rewrite the rx every 24hrs or as specified by the facility -PRN rx is not allowed

nursing responsibilities in regards to isolation/restraints:

-must be identified in the protocol -include how often the client should be: assessed; offered food/fluid; provided for means of hygiene/elimination; monitored for vital signs; offered ROM of extremities

other responsibilities of health care providers when dealing with isolation/restraints include:

-always explain need to client and family -obtain signed consent from client or guardian, if required -review manuf. instructions for correct application -remove or replace restraints frequently to ensure good circulation and full ROM of restricted limb -pad bony prominences -use quick-release knot to tie restraints to bed frame -ensure restraint is loose enough for ROM and 2 fingers can fit between device and the client -regularly assess need for continued need -never leave client unattended w/o the restraint

complete documentation of isolation/restraint use includes a description of:

-precipitating events and behavior prior to seclusion/restraints -alternative actions taken to avoid seclusion/restraint -time restraints applied and removed (if discontinued) -type of restraint and location -client’s behavior while restrained -type and frequency of care -client’s response when restraint removed -meds administered

all staff must be instructed in fire response procedures including:

-location of exits, fire extinguishers, and O2 shut-off valves -evacuation plan for the unit and facility

the fire response in the health care setting always follows the ____ sequence

RACE -Rescue: protect and evacuate clients in close proximity to the fire -Alarm: report the fire by setting off the alarm -Contain: close doors and windows as well as turning off any oxygen sources; clients on life support are ventilated with bag-valve mask -Extinguish: extinguish the fire if possible using an appropriate fire extinguisher

The 3 classes of fire extinguishers:

-Class A: for paper, wood, upholstery, rags, or other types of trash fires -Class B: for flammable liquids and gas fires -Class C: for electrical fires

to use a fire extinguisher:

PASS -pull the pin -aim at the base of the fire -squeeze the levers -sweep back and forth over the fire

home safety risks for infants and toddlers include:

-aspiration -suffocation -poisoning -falls -motor vehicle/injury -burns

home safety risks for preschoolers and school-age children include:

-drowning -motor vehicle/injury -burns -poison

home safety risks for adolescents include:

-motor vehicle/injury -burns

home safety risks for young and middle age adults include:

-motor vehicle crashes -occupational injury -high alcohol consumption -suicide

home safety risks for older adults include:

-physical, cognitive and sensory changes -changes in musculoskeletal and logical systems -impaired vision and/or hearing -nocturia and incontinence

prevention education for risk of aspiration in infants and toddlers:

-keep small objects out of reach -check toys for loose parts -do not feed infant hard candy, peanuts, popcorn, or whole/sliced pieces of hot dog -do not place infant in supine position while feeding or prop the bottle -pacifiers should be constructed of one piece -provide information on prevention of lead poisoning

prevention education for risk of suffocation in infants and toddlers:

-keep plastic bags out of reach -ensure crib mattress fits snugly and no more than 2 2/3 inches between crib slats -never leave alone in bathtub -remove crib toys, including mobiles, as soon as infant begins to push up -keep latex balloons out of reach -fence swimming pools and use locked gate -begin swimming lessons as soon as developmental status allows -keep toilet lids down and bathroom doors shut

prevention education for risk of poisoning in infants and toddlers:

-keep house plants and cleaning agents out of reach -place poisons, paint, and gas in locked cabinets -keep medication in child-proof containers and locked up -dispose of meds which are no longer used or out of date

prevention education for risk of falls in infants and toddlers:

-keep crib and playpen rails up -never leave unattended on changing table or other high surface -restrain while in high chair, swing, stroller, etc -place in low bed when toddler starts to climb

prevention education for risk of motor vehicle/injury in infants and toddlers:

-use backward facing car seat until yr old and weighs at least 20 lbs -all car seats should be federally approved and be placed in the back seat

prevention education for risk of burns in infants and toddlers:

-test temp of formula and bath water -place pots on back burner and turn handle away from front of stove -supervise use of faucets

prevention education for risk of drowning in preschoolers and school-age children:

-ensure child knows how to swim and knows rules of water safety -locked fences around home and neighborhood pools

prevention education for risk of motor vehicle/injury in preschoolers and school-age children:

-use booster seats for children < 4’9" and <40 lbs -use seat belts properly after booster seats no longer necessary -use protective equipment when participating in sports or riding/passenger on a bike -supervise and teach safe use of equipment -teach to play in safe areas, rules of the road, and what to do if approached by a stranger -begin sex education for school-ages children

prevention education for risk of burns in preschoolers and school-age children:

-reduce setting on water heater to no higher than 120 deg F -teach dangers of playing with matches, fireworks, fire arms, etc -teach school-aged children how to use microwave and other cooking instruments

prevention education for risk of poison in preschoolers and school-age children:

-teach about hazards of alcohol, prescription, non-prescription, and illegal drugs -keep potentially dangerous substances out of reach

prevention education for risk of motor vehicle/injury in adolescents

ensure teen has completed driver’s ed -set rules on # of people in car, seat belt use, and to call for ride home if driver is impaired -reinforce teaching on proper use of protective equipment used in sports -be alert to signs of depression -teach about hazards and safety precautions of firearms -teach to check water depth before diving

prevention education for risk of burns in adolescents

-teach to use sunblock and protective clothing -teach dangers of sun bathing and tanning beds -educate on hazards of smoking

safety prevention education for young and middle age adults includes:

-remind clients to drive defensively and not to drive after drinking -reinforce teaching about long term effects of high alcohol consumption -monitor for s/s of depression/suicide and refer as appropriate -encourage clients to be proactive about safety in workplace -ensure understanding of hazards of excessive sun exposure and the need to use sun block and protective clothing

safety prevention education/modifications for older adults includes:

-home hazard evaluation conducted by nurse, physical therapist, occupational therapist if deemed necessary -remove items that could cause client to trip, such as throw rugs and loose carpets -place electrical cords against wall and behind furniture -ensure steps and sidewalks in good repair -place grab bars near toilet and in tub/shower and installing a stool riser -non-skid mat in tub or shower -place shower chair in shower -ensure lighting is adequate inside and outside home

home fire safety plan should include:

-emergency numbers near the phone -ensure number and placement of fire extinguishers and smoke alarms are adequate and that they are operable -set specific time to check batteries in alarms and operation of extinguishers -have family plan for evacuation and practice regularly -review "stop, drop, and roll" to extinguish fire of clothing or skin -review oxygen safety measures

oxygen safety measures:

-use/store according to manufacture’s recommendations -place a NO SMOKING sign near front door of home and on door of client’s bedroom -inform client and family of smoking in presence of oxygen and that smokers should smoke outdoors -ensure electrical equipment is in good repair and well grounded -replace bedding that can generate static electricity (wool, nylon, synthetics) with cotton -keep flammable items (such as heating oil and nail polish remover) away from client when O2 in use -follow general safety measures for fire safety

additional safety risks in home/community include:

-passive smoking -carbon monoxide poisoning -food poisoning -bioterrorism

passive smoking

-unintentional inhalation of tobacco smoke -exposure can put one at risk for numerous diseases including: cancer, heart disease, and lung infections -low-birth weight, prematurity, stillbirths, and SIDS have been associated with maternal smoking -smoking in presence of children is associated with development of bronchitis, pneumonia, middle ear infections, and an increase in frequency/severity of asthma attacks

the nurse should inform the client who smokes and his/her family about:

-hazards of smoking -available resources for smoking cessation -the effect of visiting or riding in a car with a smoker can have on a non-smoker

carbon monoxide poisoning

-carbon monoxide binds with hemoglobin and reduces oxygen supply to tissues -cannot be seen. smelled, or tasted -s/s include: nausea, vomiting, headache, weakness, and unconsciousness -death may occur with prolonged exposure -prevention by ensuring proper ventilation when using fuel-burning devices -gas-burning devices should be inspected annually -flues and chimneys should be unobstructed -carbon monoxide detectors should be installed and inspected regularly

food poisoning

-most cases caused by bacteria such as E. coli, Listeria monocytogenes, and Salmonella -healthy individuals usually recover in a few days -very young, very old, pregnant, or immunocompromised clients at highest risk for complications -clients who are especially at risk are instructed to follow a low-microbial diet -most cases due to unsanitary food practice -can be prevented by proper hand hygiene, cooking meats/fish to correct temp, handling raw and fresh foods separately to avoid cross-contamination, and proper refrigeration


-the dissemination of harmful toxins, bacteria, viruses, and pathogens for the purpose of causing illness or death -examples include anthrax, variola, Clostridium botulism, and Yersinia pestis

steps of mobility assessment

-range of motion -moving from supine to sitting on side of bed -gait -exercise tolerance

transfers and use of assistive devices

-assess client’s ability to help with transfers (balance, muscle strength, endurance) -determine need for additional help or assistive devices (transfer belt, hydraulic lift, sliding board) -assist and monitor the client’s proper use of mobility aids (canes, walkers, crutches) -include assistance or mobility aids needed for safe transfers and ambulation in the care plan

semi-fowler’s position

-client lies supine with head of bed elevated approx 30 degrees and knees may be slightly elevated (about 15 degrees) -position frequently used to prevent regurgitation of tube feedings and aspiration in clients with difficulty swallowing

fowler’s position

-client lies supine with head of bed elevated approx 45 degrees and knees may be slightly elevated (about 15 degrees) -position frequently used during procedures such as NG tube insertion and suctioning; also allows for better chest expansion & ventilation, as well as better dependent drainage, after abdominal surgeries

high-fowler’s position

-client lies supine with head of bed elevated approx 90 degrees, and knees may or may not be elevated -position promotes lung expansion by lowering the diaphragm and used for clients experiencing severe dyspnea

supine or dorsal recumbent position

-client lies on his back with head and shoulders elevated on a pillow; client’s forearms may be placed on pillows or placed at side; foot support prevents footdrop and maintains proper alignmentl

prone position

-client lies flat on abdomen with head to one side -position promotes drainage from the mouth of clients following throat or oral surgery, but inhibits chest expansion

lateral or side-laying position

-client lies on side with most of weight on the dependent hip and shoulder; arms should be flexed in front of the body; pillow placed under head & neck, the upper arm, and under the leg & thigh to maintain body alignment -this is a good sleeping position but the client must be turned regularly to prevent development of pressure ulcers on dependent areas; 30 degree lateral position is recommended for clients at risk for pressure ulcers

sims’ or semi-prone position

-client lies on side halfway between lateral and prone positions; weight is on anterior ileum, humerus, and clavicle; lower arm behind client while upper arm is in front; both legs flexed but upper at greater anger than lower at hip and knee -this is a comfortable sleeping position for many clients and promotes oral drainage

orthpneic position

-client sits in the bed or at bedside; pillow placed on over-bed table, which is placed over client’s lap; client rests arms on the over-bed table -position allows for chest expansion and is especially beneficial to clients with COPD

trendelenburg position

-entire bed is tilted with head of bed lower than the foot of the bed -position used during postural drainage, and facilitates venous return

reverse trendelenburg

-entire bed is tilted with the foot of the bed lower than the head -position promotes gastric emptying and prevents esophageal reflux

a disaster is a ___ ___ or ___-___ event that overwhelms or interrupts, at least temporarily, the normal flow of services of a hospital and include ___ &amp; ___ emergencies

– mass casualty -intra-facility -internal -external

internal emergencies include:

-loss of electric power or potable water and -severe damage or casualties w/in the facility related to fire, weather, an explosion, or terrorist act

internal emergency readiness includes:

-safety and hazardous materials protocols and infection control policies and practices

external emergencies include:

-hurricanes -floods -volcano eruptions -earthquakes -pandemic flu -industrial accidents -chemical plant explosions -major transportation accidents -building collapse -terrorist acts (including biological and chemical warfare)

external emergency readiness includes:

a plan for participation in community-wide emergencies and disasters

standards for emergency preparedness mandated by the Joint Commission require procedures be set for:

-notifying and assisting personnel -notifying external authorities of emergencies -managing space and supplies and providing security -isolating and decontaminating radioactive or chemical agents -evacuating and setting up alternative care site when the environment cannot support adequate client care and treatment -performing triage -managing clients during emergencies -interacting with families and news media -identifying backup resources for utilities and communication -orienting and educating personnel participating in emergency preparedness plan -providing crisis support for health care workers -providing performance monitoring and evaluations related to emergency preparedness -conducting 2 emergency preparedness drills each year

categories of triage during mass casualty events

-emergent category (class I): highest priority given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized -urgent category (class II): 2nd highest priority is given to clients who have major injuries that are not yet life threatening and can usually wait 45-60 mins for treatment -nonurgent category (class III): the next highest priority is given to clients who have minor injuries that are not life threatening and do not need immediate attention -expectant category (class IV): the lowest priority is given to clients who are not expected to live and will be allowed to die naturally; comfort measures may be provided, but restorative care will not

criteria to follow when identifying clients who can be safely discharged in an emergency situation

-ambulatory clients requiring minimal care should be discharged or relocated first -clients requiring assistance should be next and arrangements made for continuation of their care -clients who are unstable and/or require nursing care should not be discharged or relocated unless they are in imminent danger

if evacuation of a unit is necessary due to fire:

-horizontal evacuation is done 1st -lateral evacuation is done if client safety cannot be maintained

during a severe thunderstorm or tornado

-draw shades and close drapes to protect against shattering glass -lower beds to lowest position and move away from windows -place blankets over clients confined to bed -close all doors -move as many ambulatory clients as possible into the hallways (away from windows) -do not use elevators -monitor for severe weather warnings using tv, radio, or internet

biological incidents

-take measures to protect self and others -recognize s/s of infection/poisoning and appropriate treatments -incidents include: inhalational anthrax, botulism, smallpox, and ebola

inhalational anthrax

-S/S: sore throat, fever, muscle aches, severe dyspnea, meningitis, shock -treatment/prevention: IV ciprofloxacin


-S/S: difficulty swallowing, progressive weakness, nausea, vomiting, abdominal cramps, difficulty breathing -treatment/prevention: airway management, antitoxin, elimination of toxin


-S/S: high fever, fatigue, severe headache, rash (starts centrally and spreads outward) that turns to pus-filled lesions, vomiting, delirium, excessive bleeding -treatment: no cure -supportive care: hydration, pain medication, antipyretics -prevention: vaccine


-S/S: sore throat, headache, high temprature, nausea, vomiting, diarrhea, internal and external bleeding, shock -treatment: no cure -supportive care: minimize invasive procedures -prevention: vaccine

chemical incidents

-take measures to protect yourself and to avoid contact -assess and intervene to maintain the client’s ABCs and admin first aid as needed -effectively remove the offending chemical/decontaminate -gather specific history of the injury, if possible -in the event of chemical warfare, have knowledge of which facilities are open to exposed clients and which are open to unexposed clients only -follow facility’s emergency ops plans

hazardous material incidents

-take measures to protect self and avoid contact -approach scene cautiously -try to identify the material and have knowledge of where MSDS manual is located -try to contain material to one area as much as possible until haz-mat team arrives -if individuals are contaminated, decontaminate as much as possible at the scene or as close to the scene as possible

radiological incidents

-amount of exposure is related to time exposed, distance from source, and amount of shielding -facility treating victims should activate interventions to prevent exposure to treatment areas -staff should wear water-resistant gowns, double glove, and fully cover bodies with caps/shoe covers/masks/goggles -staff should wear radiation or dosimetry badges to monitor amount of exposure -clients should be initially surveyed with radiation meter to determine amount of contamination -decontamination should occur prior to entering the hospital with soap, water, and disposable towels -after decontamination, client should be resurveyed and washed until free of all contamination

bomb threat

-when a phone call is received: >lengthen conversation as much as possible >listen for distinctive background noise >be alert for distinguishing voice characteristics >ask where the bomb will explode and at what time >note if the caller indicates knowledge of the facility by his description of the location -if what appears to be a bomb is found, don’t touch, clear the area, isolate it, and obtain professional assistance -notify authorities and key personnel -cooperate with police and others -keep elevators available for authorities -remain calm and alert and try not to alarm clients

the International Association for Healthcare Security &amp; Safety (IAHSS) provides:

recommendations for the development of security plans

Nurses should be aware that security measures include:

-an identification system that identifies authorized personnel -electronic security systems in high-risk areas

Nurses should be aware that all health care institutions have color-codes designated for emergencies: some examples include:

-code red (fire) -code pink (newborn abduction) -code orange (chemical spill) -code blue (mass casualty incident) -code gray (tornado) *may vary by institution*

risk factor assessment should assess the following:

-genetics: a predisposition to various illnesses can be attributed to heredity (heart disease, cancer) -gender: some specific diseases are more common in one gender than the other (autoimmune disorders, suicide rates) -physiologic factors: various physiologic states place a client at greater risk for health problems (BMI, pregnancy) -environmental factors: presence of toxic substances and chemicals can affect health where clients work and live; water quality, pesticide exposure, and air pollution should be commonly assessed -lifestyle-risk behaviors: stress, substance abuse, diet deficiencies, lack of exercise, and sun exposure age- early disease detection and intervention is facilitates by following screening guidelines

screenings and exams for clients who are asymptomatic

-routine physical: (f) every 1-3 years beginning at 20/annually beginning at 40; 9m) every 5 years starting at 20/annually beginning at 40 -dental assessment: (f&m) every 6 months -blood pressure: (f&m) starting at 20, each routing health care visit, min of every 2 yrs -BMI: (f&m) starting at 20, each routing health care visit -blood cholesterol: (f&m) starting at 20, a min of every 5 yrs -blood glucose: (f&m) starting at 45, min of every 3 yrs -colorectal screening: (f&m) fecal occult blood test annually at 50 AND flexible sigmoidoscopy every 5 yrs or colonoscopy every 10 yrs or double contrast barium enema every 5 yrs -colonoscopy: (f&m) starting at 50, every 1-10 yrs depending on test used -pap test: (f) starting at 21 (or earlier if sexually active) every 1-2 yrs; after 30 every 1-3 yrs depending on provider/test used -clinical breast exam: (f) starting at 20, every 3 yrs; at 40, annually -mammogram: (f) starting at 40, annually -clinical testicular exam: (m) starting at 20, annually -prostate-specific antigen test & digital rectal exam: (m) starting at 50, as indicated by provider

primary prevention

-addresses the needs of healthy clients to promote health and prevent disease with specific precautions -examples: immunizations programs; child car seat education; nutrition and fitness activities; health education in schools

secondary prevention

-focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent worsening health status -examples: communicable disease screening and case finding; early detection and treatment of diabetes; exercise programs for older adult clients who are frail

tertiary prevention

-aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning -examples: prevention of pressure ulcers as complication of a spinal cord injury; promoting independence for the client who has traumatic brain injury

behavior-change strategies nurses can use in health promotion/disease prevention

-identify client’s readiness to receive and act upon health info -identify interventions acceptable to the client -help motivate the client to change by setting realistic timelines -reinforce steps the client makes toward change -encourage the client to maintain the change

promote healthy lifestyle behaviors by instructing clients to:

-minimize or reduce stress -get adequate sleep/rest – eat a nutritious diet to achieve and maintain a healthy weight -avoid saturated fats -participate in regular physical activity most days of the week -while outdoors, wear protective clothing, use sunscreen, and avoid sun exposure between 10am and 4pm -wear safety gear while participating in physical activity -avoid substances such as tobacco products, alcohol, and illegal drugs -practice safer sex -seek medical care when necessary, and visit provider for routine screenings

___ is an interactive process driven by specific client goals


___ is an intentional gain of new information and represents a change in behavior


___ influences how much and how quickly a person learns


___ ___ can be used to enhance access to and delivery of knowledge

information technology

purposes of client teaching include:

-providing clients with info and skills to maintain and promote health, and prevent illness (immunizations, lifestyle change, prenatal care) -providing clients with info about how to restore health (teaching how to admin insulin) -providing clients with info about how to adapt to permanent illness or injury (ostomy care, learning swallowing techniques, speech therapy)

the 3 domains of learning are:

cognitive, affective, and psychomotor

cognitive learning

-obtaining new info, being able to apply the info, and being able to evaluate the info -example: client is taught s/s of hypoglycemia and then can verbalize when to notify provider

affective learning

-involves feelings, beliefs, and ideals -example: a client listens to the nurse explain life changes necessary to manage diabetes and then discusses feelings regarding the diagnosis

psychomotor learning

-learning how to complete a physical activity or motor skill -example: client practices preparing insulin injections

assessment/data collection related to client education includes:

-assess/monitor the client’s learning needs -assess the learning environment -assess/monitor the client’s learning style (auditory, visual, kinesthetic) -identify areas of concern -assess/monitor available resources (financial, social, community) -identify the client’s developmental stage -determine the client’s physical and cognitive ability -identify special needs (visual impairment, decreased manual dexterity) -determine the client’s motivation and readiness to learn

planning related to client education includes:

-identify mutually agreed upon client outcomes -prioritize the learning objectives with the client’s needs in mind -use methods that emphasize the client’s learning style -select age-appropriate teaching methods/material -provide electronic educational resources as appropriate -demonstrate use of the internet as in regard to accessing info and support services and how to recognize reliable sources -organize learning activities to move from simple to more complex tasks, and known to unknown concepts -incorporate active participation in the learning process – schedule teaching sessions to coincide with the client’s daily activities

implementation related to client education includes:

-create an environment conducive to learning (reduce distractions and interruptions, provide privacy) -use therapeutic communication to develop a trusting relationship that allows client to express concern -review previous knowledge and experiences -explain the therapeutic regimen or procedure -present steps building to more complex tasks -demonstrate psychomotor skills -allow time for return demonstration -provide positive reinforcement

evaluation related to client education includes:

-ask client to explain info in his own words -observe the client demonstrating the learned activity -use written tools to measure accuracy of info -request client’s self-evaluation of progress -observe verbal and nonverbal communication -determine client’s ability to use info over time but re-evaluate learning during follow-ups -revise care plan as needed

factors that enhance learning:

-perceived benefit -cognitive and physical ability -health and cultural beliefs -active participation -age/educational level-appropriate methods

barriers to learning:

-fear, anxiety, depression -physical discomfort, pain, fatigue -environmental distractions -health and cultural beliefs -sensory and perceptual deficits -psychomotor deficits

expected physical development (size): infant (birth-1 yr)

-posterior fontanel closes by 2-3 months -anterior fontanel closes by 12-18 months -weight: gains 150-210 g (5-7 oz) per month for 1st 6 months; birth weight should double by 4-6 months and triple by the end of the 1st year -height: grows about 2.5 cm (1 in) per month for 1st 6 months; then about 1.25 (0.5 in) per month til the end of 1st yr -head circumference: increases about 1.25 cm (0.5 in) per month for 1st 6 months; then about 0.5 cm (0.2 in)between 6-12 months)

expected physical development (dentition): infant (birth-1 yr)

-6 to 8 teeth erupt in the infant’s mouth by end of 1st yr -teething pain can be eased using cold teething rings, OTC teething gels, acetaminophen and/or ibuprofen; ibuprofen given only to children over 6 months -clean teeth using cool, wet washcloth -bottles should not be given when they are falling asleep; prolonged exposure to milk/juice can cause dental caries

expected physical development (fine and gross motor development): infant (birth-1 yr)

-1 month: (g) demonstrates head lag; (f) has a present grasp reflex -2 month: (g) lifts head off mattress; (f) holds hands in an open position -3 month: (g) raises head and shoulders off mattress: (f) no longer has grasp reflex, keeps hands loosely open -4 month: (g) rolls from back to side; (f) places objects in mouth -5 month: (g) rolls from front to back; (f) uses palmer grasp dominantly -6 month: (g) rolls from back to front; (f) holds bottle -7 month: (g) bears full weight on feet; (f) moves objects from hand to hand -8 month: (g) sits unsupported; (f) begins using pincer grasp -9 month: (g) pulls to standing position; (f) has crude pincer grasp -10 month: (g) changes from prone to sitting position; (f) grasps rattle by its handle -11 month: (g) walks while holding on to something; (f) can place objects into container -12 month: (g) sits down from standing position w/o assistance; (f) tries to build two-block tower w/o success

expected cognitive development (Piaget: sensorimotor stage from birth to 24 month): infant (birth-1 yr)

-separation: when infants learn to separate themselves from other objects in the environment -object permanence: occurs at about 9 months; the process by which an infant knows the object still exists when it is hidden from view -mental representation: recognition of symbols

expected cognitive development (language development): infant (birth-1 yr)

-responds to noises -vocalizes with "ooos" and "aahs" -laughs and squeals -turns head to sound of a rattle -pronounces single-syllable words -begins speaking two and then three-word phrases

expected psychosocial development (Erikson: trust vs mistrust): infant (birth-1 yr)

-infants trust that their feeding, comfort, stimulation, and caring needs will be met -social development initially influenced by infant’s reflexive behavior and includes attachment, separation recognition/anxiety, and stranger fear -attachment seen when infant begins to bond with parents; this development occurs w/in 1st month; process is enhanced when the infant and parents are in good health, have positive feeding experiences, and receive adequate rest -separation recognition occurs during the 1st year as learning physical boundaries from that of other people; learning how to respond to people is next phase in development; positive interactions with parents, siblings, and other caregivers help est. trust -separation anxiety develops between 4-8 months; will protest loudly when separated from parents -stranger fear becomes evident between 6-8 months when children are less likely to accept strangers

expected psychosocial development (self-concept development): infant (birth-1 yr)

-by end of 1st year will be able to distinguish themselves as being separate from their parents

expected psychosocial development (body-image problems): infant (birth-1 yr)

-infant discovers mouth is a pleasure producer -hands and feet are seen as objects of play -discovers smiling causes others to react

expected age-appropriate activities: infant (birth-1 yr)

-infants have short attention spans and participate in solitary play -appropriate toys and activities: rattles, mobiles, teething toys, nesting toys, pat-a-cake, playing with balls, reading books

health promotion (immunizations): infant (birth-1 yr)

-birth: Hep B -2 month: DTaP, rotavirus vaccine (RV), inactive poliovirus (IPV), Haemophilus influenzae type B (Hib), pneumococcal vaccine (PCV), and Hep B -4 month: DTaP, RV, IPV, Hib, PVC -6 month: DTaP, IPV (6-18 months), PVC, Hep B (6-12 months), RotaTeq (alt to RV which required 3 doses completed by 32 weeks) -6-12 month: seasonal flu yearly, trivalent inactivated influenza vaccine (TIV) is available as IM injection

health promotion (nutrition-feeding alternatives): infant (birth-1 yr)

-breastfeeding provides complete diet during 1st 6 months and is recommended -iron-fortified formula is an acceptable alternative; cow’s milk is not recommended

health promotion (nutrition-solids): infant (birth-1 yr)

-can be introduced between 4-6 months -indicators for readiness include voluntary control of head and trunk, hunger less than 4 hrs after vigorous nursing or intake of 8 oz of formula, interest of the infant -iron-fortified rice offered 1st -new foods introduced 1 at a time over a 5-7 day period to assess for allergies or intolerance; veggies or fruits introduced between 6-8 months and after both have been introduced, then meats -milk, eggs, wheat, citrus fruits, peanuts, peanut butter, and honey delayed till after 1st year -chopped, cooked, and unseasoned table foods by 9 months -appropriate finger foods include: ripe bananas, toast strips, graham crackers, cheese cubes, noodles, peeled chunks of apples/pears/peaches -breast milk/formula decreased as solid food intake increases -parents encouraged to use iron-enriched foods after 6 months of age

health promotion (nutrition-weaning): infant (birth-1 yr)

-can be accomplished when infant is able to drink from a cup (sometime after 6 months) -replace 1 feeding with breast milk/formula in a cup -bedtime feeding is last to be replaced

health promotion (injury prevention-aspiration of foreign objects): infant (birth-1 yr)

-avoid small objects (such as grapes, coins and candy) that can become lodged in throat -provide age-appropriate toys -check clothing for safety hazards (loose buttons)

health promotion (injury prevention-bodily harm): infant (birth-1 yr)

-keep sharp objects out of reach -keep infant away from heavy objects that can be pulled down onto her -do not leave alone with animals -monitor for shaken baby syndrome

health promotion (injury prevention-burns): infant (birth-1 yr)

-check temp of bath water -turn down thermostat on hot water heater -have working smoke detectors in the home -turn handles of pots/pans to back of stove -apply sunscreen when outdoors during daylight hours -cover electrical outlets

health promotion (injury prevention-drowning): infant (birth-1 yr)

-do not leave infant unattended in bath tub

health promotion (injury prevention-falls): infant (birth-1 yr)

-keep crib mattress in lowest position with rails all the way up -use restraints in infant seats -place infant seat on ground/floor if used outside of car and do not leave on elevated surfaces unattended -use safety gates across stairs

health promotion (injury prevention-poisoning): infant (birth-1 yr)

-avoid exposing to lead paint -keep toxins/plants out f -use safety locks on cabinets (esp containing cleaners/chemicals) -keep poison control number near phone -keep meds in childproof containers and out of reach -have working carbon monoxide detectors in the home

health promotion (injury prevention-MVA): infant (birth-1 yr)

-use approved rear-facing car seat in the back seat (pref in middle) -infants in rear facing for 1st year until weighing 9.1 kg (20 lbs) rear-facing recommended till child reaches weight limit -in addition, a 5point harness or T-shield should be a part of the convertible restraint

health promotion (injury prevention-suffocation): infant (birth-1 yr)

-avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothing

expected physical development (size): toddler (1-3 yrs)

-anterior fontanel closes by 18 months -weight: should be 4 times birth weight at 24 months -height: grows by 7.5 cm (3 in) per year

expected physical development (fine and gross motor skills): toddler (1-3 yrs)

-15 month: (g) walks w/o help, creeps up stairs; (f) uses cup well, builds two-block tower -18 month: (g) assumes standing position, jumps in place with both feet; (f) manages spoon without rotation, turns pages in book 2-3 at a time -2 year: (g) walks up and down stairs; (f) builds 6-7 block tower -2.5 year: (g) jumps with both feet, stands on 1 foot momentarily; (f) draws circles, has good hand-finger coordination

expected cognitive development (Piaget: sensorimotor transitions to preoperational): toddler (1-3 yrs)

-concept of object permanence is developed fully -have and demonstrate memories of events that relate to them -domestic mimicry is evident (playing house) -preoperational thought does not allow to understand other viewpoints, but does allow to symbolize objects and people in order to imitate activities seen previously

expected cognitive development (language development): toddler (1-3 yrs)

-language increases to about 400 words with toddlers speaking in 2-3 word phrases

expected psychosocial development (Erikson: autonomy vs shame and doubt): toddler (1-3 yrs)

-independence is paramount for toddler who is attempting to do everything for himself -separation anxiety continues when parent leaves child

expected psychosocial development (moral development): toddler (1-3 yrs)

-closely associated with cognitive development -egocentric: unable to see another’s perspective; can only view things from their POV -punishment and obedience orientation begins with sense that good behavior is rewarded and bad behavior is punished

expected psychosocial development (self-concept development): toddler (1-3 yrs)

-progressively see themselves as separate from their parents and increase their exploration away from them

expected psychosocial development (body-image changes): toddler (1-3 yrs)

-appreciates the usefulness of various body parts -develop gender identity by age 3

expected age-appropriate activities: toddler (1-3 yrs)

-solitary play evolves into parallel play where toddler observes other children and then may engage in activities nearby -appropriate activities include: filling and emptying containers, playing with blocks, looking at books, toys that can be pushed and pulled, tossing a ball -temper tantrums result when frustrated with independence restrictions; providing consistent, age-appropriate expectations helps them work through frustrations -toilet training can begin when it is recognized that child has sensation of needing to urinate/defecate; parents should demonstrate patience and consistency; nighttime control may be last to develop -discipline should be consistent and with well defined boundaries established to develop appropriate social behavior

health promotion (immunizations): toddler (1-3 yrs)

-12-15 month: IPV (6-18 month), Hib, PCV, MMR, varicella -12-23 month: Hep A (given in 2 doses at lease 6 months apart) -15-18 month: DTaP -12-36 month: yearly seasonal TIV; at age 2, toddlers can receive the live, attenuated influenza vaccine (LAIV) by nasal spray

health promotion (nutrition): toddler (1-3 yrs)

-picky eaters; repeated requests for favorite foods -consume 24-30 oz of milk/day; may switch from whole milk to 2% at age 2 -limit juice to 4-6 oz/day -food serving size is 1 tbsp for each yr of age -exposure to new food may take 8-15 times before acceptance -if there is a family history of an allergy to a certain food, gradually introduce while monitoring for reactions -finger foods may be preferred due to increasing autonomy -regular meal times and nutritious snacks best meet nutrient needs -avoid snacks/desserts high in sugar, fat, sodium -avoid foods that are potential choking hazards -always provide supervision during snack/mealtimes -cut small bite-size pieces to make them easier to swallow and prevent choking -do not allow drinking/eating during play or while lying down -suggest parents follow USDA nutrition guidelines

health promotion (injury prevention-aspiration of foreign objects): toddler (1-3 yrs)

-avoid small objects that can become lodged in throat -keep toys with small parts out of reach -provide age-appropriate toys -check clothes for choking hazards -keep balloons out of reach

health promotion (injury prevention-bodily harm): toddler (1-3 yrs)

-keep sharp objects out of reach -keep firearms in locked box/cabinet -do not leave unattended with animals -teach stranger safety

health promotion (injury prevention-burns): toddler (1-3 yrs)

-check temp of bath water -turn thermostat down on water heater -have working smoke detectors in the home -turn pot handles to back of stove -cover electrical outlets -use sunscreen when outside

health promotion (injury prevention-drowning): toddler (1-3 yrs)

-do not leave unattended in bathtub -keep toilet lids closed -closely supervise at pool/other body of water -teach how to swim

health promotion (injury prevention-falls): toddler (1-3 yrs)

-keep doors and windows locked -keep crib mattress in lowest position with rails all the way up -use safety gates across stairs

health promotion (injury prevention-MVA): toddler (1-3 yrs)

-used approved car seat in back seat away from airbags -should be rear facing till reaches 9.1 kg (20 lbs) and is 1 yr old; then can use forward facing seat in back seat-usually until 4 yo old 40 lbs -children who meet weight but not age requirement of 1 yr should remain rear facing and a 5 point harness or T-shield should be a part of convertible harness

health promotion (injury prevention-poisoning): toddler (1-3 yrs)

-avoid exposure to lead paint -place safety locks on cabinets with household cleaners/chemicals -keep plants out of reach -keep poison control number by phone -keep meds in childproof container and out of reach -have working carbon monoxide detector in home

health promotion (injury prevention-suffocation): toddler (1-3 yrs)

-avoid plastic bags -be sure crib mattress fits tightly -ensure crib slats no further apart than 6 cm (2.4 in) -keep pillows out of crib -remove drawstrings from jackets and other clothing

expected physical development (size): preschooler (3-6 yrs)

-weight: should gain about 2-3 kg (4.5-6.5 lbs) per year -height: should grow about 6.2-7.5 cm (2.5-3 in) per year

expected physical development (gross and fine motor skills): preschooler (3-6 yrs)

-should show great improvements in fine motor skills such as copying figures on paper and dressing themselves -3 years: (g) rides tricycle, jumps off bottom step, stands on 1 foot for a few seconds -4 years: (g) skips and hops on 1 foot, throws ball overhead -5 years: (g) jumps rope, capable of walking backward with heel to toe, moves up and down stairs easily

expected cognitive development (Piaget: still in preoperational phase&gt;preconceptual though to intuitive thought): preschooler (3-6 years)

-preconceptual thought (2-4 year): make judgments based on visual apperances; misconceptions in thinking include artificialism (everything is made by humans), animism (inanimate objects are alive), and imminent justice (a universal code exists that determines law and order) -intuitive thought (4-7 year): can classify information and become aware of cause-and-effect relationships

expected cognitive development (time): preschooler (3-6 years)

-begins to understand the concepts of past, present, and future -by end of preschool years, child may comprehend days of the week

expected cognitive development (language): preschooler (3-6 years)

-vocabulary continues to increase -can now speak sentences, is able to identify colors, enjoys talking

expected psychosocial development (Erikson: initiative vs guilt): preschooler (3-6 years)

-may take on new experiences despite not having all physical abilities needed to be successful at everything -guilt may occur when unable to accomplish a task and believe they have misbehaved -guiding to attempt activities within their capabilities while setting limits is appropriate

expected psychosocial development (moral development): preschooler (3-6 years)

-continues in the good-bad orientation of toddler years but begins to understand behaviors in terms of what is socially acceptable

expected psychosocial development (self-concept development): preschooler (3-6 years)

-feels good about self with regard to mastering skills, such as dressing and feeding, that allow independence -during stress, insecurity, or illness, may regress to previous immature behaviors or develop habits like nose picking, bed wetting, or thumb sucking

expected psychosocial development (body-image changes): preschooler (3-6 years)

-mistaken perceptions of reality coupled with misconceptions in thinking lead to active fantasies and fears -greatest fear is that of bodily harm, thus fear of the dark and animals -sex-role identification is occurring

expected psychosocial development (social development): preschooler (3-6 years)

-do not generally exhibit stranger anxiety and have less separation anxiety; however, prolonged separation (hospitalization) can provoke anxiety but favorite toys and play can help ease fears -pretend play is healthy and allows children to determine the difference between reality and fantasy -sleep disturbances occur frequently and problems range from difficulty going to bed and night terrors -with sleep disturbances, advise parents to: assess if bedtime is too early/late or naps needed (needs about 12 hrs of sleep per day); keep consistent bedtime routine; use a night light; reassure child that is frightened, but avoid having child sleep with them

expected age-appropriate activities: preschooler (3-6 years)

-parallel play shifts to associative play and is not highly organized -appropriate activities include: playing ball, putting puzzles together, riding trike, pretend and dress-up, role play, painting, sewing cards and beads, reading books

health promotion (immunizations): preschooler (3-6 yrs)

-4-6 years: DTaP, MMR, varicella, IPV -yearly: TIV or LAIV (nasally)

health promotion (health screenings): preschooler (3-6 yrs)

-vision: myopia and amblyopia can be detected and treated before poor visual acuity impairs the learning environment

health promotion (nutrition): preschooler (3-6 yrs)

-consumes about 1/2 the cals of an adult (19800 kcal) -picky eating remains a problem for some, but often by 5 they become more willing to sample different foods -need 13-19 g/day of complete protein in addition to adequate calcium, iron, folate, and vitamins A&C -parents need to ensure child receiving balanced nutrition as outlined by USDA

health promotion (injury prevention-bodily harm): preschooler (3-6 yrs)

-keep firearms in locked cabinet/container -teach stranger safety -wear helmets when riding bike/helmet and pads when participating in physical activity

health promotion (injury prevention-burns): preschooler (3-6 yrs)

-turn down thermostat on hot water heater -have working smoke detectors in the home -use sunscreen while outside

health promotion (drowning): preschooler (3-6 yrs)

-do not leave unattended in bathtub -closely supervise while in pool/other body of water -teach how to swim

health promotion (injury prevention-MVA): preschooler (3-6 yrs)

-sit in approved forward-facing car seat in back set away from airbags -can usually sit in seat until 4 yo or 40 lbs -when outgrown, use booster seat in back seat -should be restrained in car seat or booster until adult belt fits correctly (laws vary from state to state)

health promotion (injury prevention-poisoning): preschooler (3-6 yrs)

-avoid exposure to lead paint -keep plants out of reach -place safety locks on cabinets with cleaners and other chemicals -keep poison control number near phone -keep meds in childproof containers and out of reach -have working carbon monoxide detector in home

expected physical development (size/growth): school-age (6-12 yrs)

-weight: will gain about 2-4 kg (4.4-8.8 lb) per year -height: will grow about 5 cm (2 in) per year -puberty changes (male): enlargement of testicles with changes in scrotum; appearance of pubic hair -puberty changes (female): budding breasts; appearance of pubic hair; menarche -permanent teeth erupt -visual acuity improves to 20/20 -auditory acuity and sense of touch is fully developed -fine and gross motor skills: coordination continues to develop

expected cognitive development (Piaget: concrete operations): school-age (6-12 yrs)

-sees weight and volume as unchanging -understands simple analogies -understands time (days/seasons) -classifies more complex information -understands various emotions people experience -becomes self-motivated -is able to solve problems

expected cognitive development (language): school-age (6-12 yrs)

-defines many words and understands rules of grammar -understands that a word can have multiple meanings

expected psychosocial development (Erikson: industry vs inferiority): school-age (6-12 yrs)

-a sense of industry is achieved through advances in learning -motivated by tasks that increase self-worth -fears of ridicule by peer and teachers over school-related issues are common -some manifest nervous behaviors to deal with stress such as nail biting

expected psychosocial development (moral development): school-age (6-12 yrs)

-early on, may not understand the reasoning behind many rules and try to find a way around them -instrumental exchange is in place ("I’ll help you if you help me.") -child wants to make the best deal, and does not really consider elements of loyalty, gratitude, or justice when making decisions -in latter parts of school years, the child moves into a law-and-order orientation with more emphasis placed on justice being administered

expected psychosocial development (self-concept development): school-age (6-12 yrs)

-strive to develop healthy self-respect by finding out in what areas they excel -parents need to encourage regarding educational or extracurricular success

expected psychosocial development (body-image changes): school-age (6-12 yrs)

-solidification of body image occurs -curiosity about sexuality should be addressed with education regarding sexual development and the reproductive process -are more modest than preschoolers and place more emphasis on privacy issues

expected psychosocial development (social development): school-age (6-12 yrs)

-peer groups play an important part in social development -peer pressure begins to take effect -same-gender friendships begin to form; this is time period when clubs and best friends are popular -children prefer company of same-gender companions -most relationships come from school associations -at this age, may rival same-sex parent -conformity becomes evident

expected age-appropriate activities: school-age (6-12 yrs)

-competitive and cooperative play is predominant -activities for 6-9: simple board and number games, hopscotch, jump rope, collections, riding bike, building simple models, joining organized sports (skill building) -activities for 9-12: making crafts, building models, collections/hobbies, jigsaw puzzles, board and card games, organized competitive sports

health promotion (immunizations): school-age (6-12 yrs)

–if not given between 4-5, then by 6 years: DTaP, IPV, MMR, varicella -yearly seasonal TIV or LAIV (nasal spray) -11-12 years: Tdap, meningococcal vaccine (MCV4), HPV2 in 3 doses for females and HPV4 may be given to males

health promotion (health screenings): school-age (6-12 yrs)

-scoliosis: screening for lateral curve before and during growth spurts; can be at school or provider’s office

health promotion (nutrition): school-age (6-12 yrs)

-by end of school-age years is eating adult proportion of food and needs quality nutritious snacks advised parents to: not use food as reward; emphasize physical activity; ensure balanced diet according to USDA recommendations; teach children to make healthy food selections for meals/snacks; avoid frequent meals at fast food; avoid skipping meals -dental health should be encouraged, including: brushing and flossing daily; having regular check-ups and fluoride treatments

health promotion (injury prevention-bodily harm): school-age (6-12 yrs)

-keep firearms in a locked cabinet or box -assist with identifying "safe" play areas -teach stranger safety -teach to wear helmets and pads when needed

health promotion (injury prevention-burns): school-age (6-12 yrs)

-teach fire safety and potential burn hazards -have working smoke and carbon monoxide detectors in the home -use sunscreen when outdoors

health promotion (injury prevention-drowning): school-age (6-12 yrs)

-provide supervision when around pool/near body of water -teach to swim

health promotion (injury prevention-MVA): school-age (6-12 yrs)

-restrained in car seat or booster seat until adult seat belt fits correctly (laws vary from state to state) -under 13 are safest in back seat

health promotion (injury prevention-substance abuse/poisoning): school-age (6-12 yrs)

-keep cleaners or chemicals in locked cabinet and out of reach -teach to say "no" to illegal drugs and alcohol

expected physical development (size/growth): adolescent (12-20 yrs)

-final 20%-25% of height is achieved during puberty -acne may appear -girls may cease to grow about 2-2.5 years after onset of menarche; will grow 5-20 cm (2-8 in) and 7-25 kg (15.5-55 lbs) -in girls, sexual maturation occurs in order of: appearance of breast buds, growth of pubic hair, onset of menstruation -in males, sexual maturation occurs in order of: increased size of testes/scrotum, appearance of pubic hair, rapid growth of genitalia, growth of axillary hair, appearance of downy hair on upper lip, change in voice -changes in sleep habits

expected cognitive development (Piaget: formal operations): adolescent (12-20 yrs)

-capable of thinking at an adult level -able to think abstractly and can deal with principles -able to evaluate the quality of own thinking -has longer attention span -highly imaginative and idealistic -makes decisions through logical operations -is future-oriented -capable of deductive reasoning -understands how the actions of an individual influences others

expected cognitive development (language): adolescent (12-20 yrs)

-develops jargon within the peer group -able to communicate one way with peer group and another way with parents/teachers -development of communication skills is essential

expected psychosocial development (Erikson: identity vs role confusion): adolescent (12-20 yrs)

-develops a sense of personal identity influenced by expectations of the family -group identity: may become part of a peer group that greatly influences behavior

expected psychosocial development : adolescent (12-20 yrs)

-vocationally: work habits begin to solidify; plan for future college and career -sexually: increased interest in opposite gender -health perceptions: may view themselves as invincible to bad outcomes of risky behaviors

expected psychosocial development (moral development): adolescent (12-20 yrs)

-conventional law and order: rules are not seen as absolutes; each situation needs to be looked at and maybe rules adjusted -not all adolescents attain this level during these years

expected psychosocial development (self-concept development): adolescent (12-20 yrs)

-healthy self-concept developed by having healthy relationships with peers, family, and teachers -identifying a skill or talent helps maintain healthy self-concept -participation in sports, hobbies, or the community can have a positive outcome

expected psychosocial development development (body-image changes): adolescent (12-20 yrs)

-seem particularly concerned with body images portrayed by the media -changes during puberty result in comparisons between the child and surrounding peer group -parents also give input as to hair styles, dress, and activity -may require help if depression or eating disorders result due to poor body image

expected psychosocial development (social development): adolescent (12-20 yrs)

-peer relationships develop -these relationships act as support system for the child -best friend relationships are more stable and long-lasting in comparison to previous years -parent-child relationships change to allow a greater source of independence

expected age-appropriate activities: adolescent (12-20 yrs)

-nonviolent video games -nonviolent music -sports -caring for a pet -career-training programs -reading -social events (going to movies or school dances)

health promotion (immunizations): adolescent (12-20 yrs)

-if not given during 11-12, then years 12-20: Tdap, MCV4, HPV2 series (females), HPV4 (males), yearly seasonal flu TIV or LAIV (nasal)

health promotion (health screenings): adolescent (12-20 yrs)


health promotion (nutrition): adolescent (12-20 yrs)

-nutrient deficiencies tend to be: iron, calcium, and vits A & C -eating disorders commonly develop including: anorexia nervosa, bulimia nervosa, obesity -advise parents: ensure balanced diet according to USDA and teach children to make healthy food choices -encourage dental health including: brushing and flossing daily; having regular check-ups and fluoride treatments

health promotion (injury prevention-bodily harm): adolescent (12-20 yrs)

-keep firearms in locked cabinet or box -teach proper use of sporting equipment prior to use -insist on helmet and/or pads when appropriate -avoid trampolines -be aware of changes in mood and monitor for self-harm in at-risk children (poor school performance, lack of interest in things once interested in, social isolation, disturbances in sleep patterns or appetite, expression of suicidal thoughts)

health promotion (injury prevention-burns): adolescent (12-20 yrs)

-teach fire safety -use sunscreen when outside

health promotion (injury prevention-drowning): adolescent (12-20 yrs)

-teach to swim -teach not to swim alone

health promotion (injury prevention-MVA): adolescent (12-20 yrs)

-encourage attendance in driver’s ed -emphasize need for adherence to seat belt use -discourage use of cell phones while driving -teach dangers of combining substance abuse with driving

health promotion (injury prevention-substance abuse): adolescent (12-20 yrs)

-monitor for s/s of substance abuse in at-risk children -teach to say "no" to drugs and alcohol -present a no tolerance attitude

health promotion (injury prevention-STDs): adolescent (12-20 yrs)

-provide education and resources for treatment

health promotion (injury prevention-pregnancy prevention): adolescent (12-20 yrs)

-provide education

expected physical development: young adult (20-35 yrs)

-growth has concluded around age 20 -physical senses peak -cardiac output and efficiency peak -muscles function optimally at ages 25-30 -metabolic rate decreases 2%-4% every decade after age 20 -libido higher for men -libido for women peaks during the latter part of this stage -time for childbearing is optimal -pregnancy-related changes occur

expected cognitive development (Piaget: formal operations): young adult (20-35 yrs)

-optimal time for education, both formal and informal -critical thinking skills improve -memory peaks in the 20s -increased ability for creative thought -values/norms of friends (social groups) are relevant

expected psychosocial development (Erikson: intimacy vs isolation): young adult (20-35 yrs)

-pass through two stages of development: intimacy vs isolation -may take on more adult commitments and responsibilities -may make occupational choices characterized by: high goals/dreams and exploration/experimentation

expected psychosocial development (moral development): young adult (20-35 yrs)

-may personalize values and beliefs -reasoning may be based on ethical fairness principles, such as justice

expected psychosocial development (self-concept development): young adult (20-35 yrs)

formation of healthy self-concept influenced by: -avoidance of substance abuse -late formation of a family -frequent interactions with family and friends -choosing to behave in an ethical manner

expected psychosocial development (body-image changes): young adult (20-35 yrs)

-greatly influenced by what young adults eat and how much exercise they get -pregnancy related body changes may also occur

expected psychosocial development (social changes): young adult (20-35 yrs)

-may leave home early and establish independent living situation -may establish close friendships (intimacy) -may transition from being single to being member of new family -may question their ability to parent -may experience increased anxiety and/or depression, esp. after the birth of a child

health promotion (alterations in health): young adult (20-35 yrs)

-substance abuse -periodontal disease due to poor oral hygiene -unplanned pregnancies (a source of high stress) -STDs -infertility -work-related injuries or exposures

health promotion (immunizations): young adult (20-35 yrs)

-Td booster: ever 10 yr; for adults who did not receive 1 dose of Tdap previously, sub 1 Td booster dose with Tdap -MMR: 1 dose 1 dose at 19-49 with 2nd dose 4 wks later if adult is a postsecondary student, healthcare worker, or plans to travel abroad -Varicella vaccine: 2 doses to adults who do not have evidence of previous infection; 2nd dose should be given 4-8 weeks after 1st to adults who had only 1 previous dose -MCV: students entering college and living in dorm if not previously vaccinated -HPV2 or HPV4: 3 doses, recommended for females up to age 26 who were not vaccinated as a child; HPV4 may be given to males up to 26 -seasonal flu vaccine: 1 yearly

health promotion (health screenings): young adult (20-35 yrs)

-should follow age-related guideline -routine health care visits should include: height, weight, and VS; stress screenings; education related to STDs, substance abuse, and contraception; encouragement of good nutrition and regular physical activity

health promotion (nutrition): young adult (20-35 yrs)

-monitor adequate nutrition and proper physical activity -women: monitor calcium intake

health promotion (injury prevention): young adult (20-35 yrs)

-avoid drugs, inc alcohol, that can lead to substance abuse -avoid taking drugs and drinking alcohol while driving -wear a seat belt while operating vehicle -wear helmet while riding bike, skiing, or snowboarding -installing smoke and carbon monoxide detectors in the home -securing firearms in a safe location

expected physical development: middle adult (35-65 yrs)

typically experience decreases in: -skin turgor and moisture -subcutaneous fat -melanin in hair (graying) -hair -visual acuity -auditory acuity -sense of taste -skeletal muscle mass -height -calcium/bone density -blood vessel elasticity -respiratory vital capacity -large intestine muscle tone -gastric secretions -estrogen/testosterone -glucose tolerance

expected cognitive development: middle adult (35-65 yrs)

-Piaget: formal operations -reaction time/speed of performance slows slightly -memory is intact -crystallized intelligence remains (stored knowledge) -fluid intelligence (how one learned and process new info) declines slightly

expected psychosocial development (Erikson-generativity vs stagnation): middle adult (35-65 yrs)

-middle adults strive for generativity -use life as an opportunity for creativity and productivity -have concerns for others -consider parenting an important task -contribute to well-being of the next generation -strive to do well in one’s own environment -adjust to changes in physical appearance and abilities

expected psychosocial development (moral development): middle adult (35-65 yrs)

-religious maturity -spiritual beliefs and religion may take on added importance -may become more secure in convictions -often have advanced moral development

expected psychosocial development (self-concept): middle adult (35-65 yrs)

may experience issues related to: -menopause -sexuality -depression -irritability -difficulty with sexual identity -job performance and ability to provide support -marital changes with death of a spouse or divorce

expected psychosocial development (body-image changes): middle adult (35-65 yrs)

-women: symptoms of menopause may represent loss of reproductive role or femininity and/or new interest in intimacy -men: decreasing strength may be frustrating or frightening -decreased sex drive may occur as a result of declining hormones, chronic disease, or meds -changes in physical appearance may raise concerns about desirability

expected psychosocial development (social development): middle adult (35-65 yrs)

-a need to maintain and strengthen intimacy -provide assistance to aging parents, adult children, and grandchildren

health promotion (alterations in health): middle adult (35-65 yrs)

-obesity and type 2 diabetes mellitus -CV disease -cancer -substance abuse (alcoholism) -psychosocial stressors

health promotion (immunizations): middle adult (35-65 yrs)

-Td booster: ever 10 yr; for adults who did not receive 1 dose of Tdap previously, sub 1 Td booster dose with Tdap -MMR: 1 dose 1 dose at 19-49 with 2nd dose 4 wks later if adult is a postsecondary student, healthcare worker, or plans to travel abroad -Varicella vaccine: 2 doses to adults who do not have evidence of previous infection; 2nd dose should be given 4-8 weeks after 1st to adults who had only 1 previous dose -pneumococcal polysaccharide vaccine (PPV): if not previously vaccinated, vaccinate once at 65 -seasonal flu vaccine: yearly; LAIV (nasal spray) only under 50 and not pregnant or immunocompromised -herpes zoster vaccine: 1 dose over age 60

health promotion (health screenings): middle adult (35-65 yrs)

-follow age-related guidelines -dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis -eye exam for glaucoma and other disorders every 2-3 years or annually depending on provider -mental health screening for depression

health promotion (nutrition): middle adult (35-65 yrs)

-obtain adequate protein intake -increase consumption of whole grains -increase consumption of fresh fruits and veggies -limiting fat and cholesterol -increasing vit D and calcium supplementation (esp for women)

health promotion (injury prevention): middle adult (35-65 yrs)

-avoid drugs, inc alcohol, that can lead to substance abuse -avoid taking drugs and drinking alcohol while driving -wear a seat belt while operating vehicle -wear helmet while riding bike, skiing, or snowboarding -installing smoke and carbon monoxide detectors in the home -securing firearms in a safe location

expected physical development: older adult (65+ yrs)

-decrease in skin turgor and subcutaneous fat, which leads to wrinkles and dry skin -loss of subcutaneous fat makes it more difficult to adjust to cold temps -thinning and graying of the hair, as well as more sparse distribution -thickening of finger and toe nails -decrease in chest wall movement, vital capacity, and cilia, which increases risk for respiratory infection -slower reaction time -decrease in touch, smell, and taste sensation -decrease in production of saliva -decline in visual acuity -decreased ability for eyes to adjust from dark to light, leading to night blindness -inability to hear high pitched sounds (presbycusis) -decrease in height due to intervertebral disk changes -decrease in muscle strength and tone -decrease in digestive enzymes -decrease in intestinal motility, which can lead to increased risk of constipation -increase in dental problems -decalcification of bones -degeneration of joints -decrease in bladder capacity -prostate hypertrophy in men -decline in estrogen/testosterone production -decline in tri-iodothyronine T3 production, yet overall function remains effective -decreased sensitivity of tissue cells to insulin -atrophy of breast tissue in women

expected cognitive development: older adult (65+ yrs)

-Piaget: formal operations -many will maintain cognitive function; some decline in speed of cognitive function vs cognitive ability -many factors influence cognitive ability including: overall health, number of stressors present at a given time, client’s life-long mental well-being -slowed neurotransmission, imparied vascular circulation, disease states, poor nutrition, and structural brain changes can lead to delirium, dementia, and depression -delirium: acute, temporary, and usually related to other physiologic problems; is often the first symptom of infection (UTI) in older adults -dementia: chronic, progressive, and possibly with an unknown cause (Alzheimer’s disease) -depression: chronic, acute, or gradual onset (present for at least 6 weeks)

expected psychosocial development (Erikson-integrity vs despair): older adult (65+ yrs)

older adults may need to: -adjust to lifestyle changes related to retirement (decreased income, living situation, loss of work role) -adapt to changes in family structure (may be role reversal in later years) -deal with multiple losses (death of a spouse, friends, siblings) -face death

expected psychosocial development (self-concept development): older adult (65+ yrs)

difficulties including: -seeing oneself as an aging person -finding ways to maintain a good quality of life -becoming more dependent on others for ADLs

expected psychosocial development (body-image changes): older adult (65+ yrs)

-adjustments to decreases in physical strength and endurance may be difficult, esp for older adults who are cognitively active and engaged -many feel frustrated that their bodies are limiting what they desire to do

expected psychosocial development (social development): older adult (65+ yrs)

-find ways to remain socially active and to overcome loneliness -maintain sexual health

health promotion (health risks): older adult (65+ yrs)

-CV diseases include: CAD, HTN, stroke -factors affecting mobility include: arthritis, osteoporosis, falls -mental health disorders include: depression, dementia, suicide -other disorders include: diabetes mellitus, cancers, incontinence, abuse and neglect, cataracts, alcoholism, pain

health promotion (immunizations): older adult (65+ yrs)

-Td booster: every 10 years -varicella vaccine: 2 doses given to those w/o evidence of previous infection; 2nd dose 4-8 weeks after 1st for those who only had 1 previous dose -PPV: if not previously vaccinated, once at age 65 -seasonal flu vaccine: 1 dose annually -herpes zoster vaccine: 1 dose for all adults over 60

health promotion (health screenings): older adult (65+ yrs)

-follow age-related guidelines -DEXA screening for osteoporosis -eye exam for glaucoma every 2-3 years or annually depending on provider -mental health screening for depression

health promotion (nutrition): older adult (65+ yrs)

factors that influence nutrition include: -GI alterations -difficulty getting to and from supermarket to shop for food -low income -impaired mobility -depression or dementia -social isolation (preparing meals for 1 and eating alone) -meds that alter taste or appetite -prescribed diets that are unappealing -incontinence that may cause a person to limit fluid intake -constipation -metabolic rates decline so caloric intake should decline and be pf good nutritional value -nutritional recommendations include: increasing intake of vit D, B6 and calcium; increasing fluid intake to minimize dehydration and prevent constipation; take low-dose multivitamin along with mineral supplementation; follow provider;s recommendation for sodium intake

health promotion (psychosocial interventions to improve self-concept &amp; alleviate social isolation): older adult (65+ yrs)

-therapeutic communication -touch -reality orientation -validation therapy -reminiscence therapy -attending to physical appearance -assistive devices (canes, walkers, hearing aids)

health promotion (injury prevention): older adult (65+ yrs)

-install bath rails, grab bars, and hand rails on stairways -remove throw rugs -eliminate clutter from walkways/hallways -remove extension and phone cords from walkways/hallways -instruct on proper use of ambulation-assistive devices -ensure adequate lighting -remind clients to wear eyeglasses and hearing aids -avoid drugs, including alcohol; prevent substance abuse -avoid taking drugs and/or drinking while driving -wear seat belt when operating a vehicle -wear helmet when riding bike, skiing, snowboarding -install smoke and carbon monoxide detectors in home -secure firearms in safe location

the correct order for completing a physical assessment (with exception to the abdomen):

Inspect, Palpate, Percuss, Auscultate

the correct order for performing abdominal assessment techniques is:

Inspect, Auscultate, Percuss, Palpate

during palpation, the dorsal surface of the hand detects:


during palpation, the ulnar surface of the hand and the base of the fingers detect:


during palpation, the fingertips detect:

pulsation, position, texture, size, and consistency

during palpation, the fingers and thumb are used to grab:

an organ or mass

direct percussion involves:

striking the body to elicit sounds

indirect percussion involves:

placing a hand flatly on the body, as the striking surface, for sound production

fist percussion is used to assess:

for tenderness over the kidneys, liver, and gallbladder

tympany from percussion is expected to be found:

over a gastric bubble

resonance from percussion is expected to be found:

over the lungs

dull percussion sounds are expected to be found:

over the liver

flat percussion sounds are expected to be found:

over muscles

expected oral temperature ranges:

36 to 38 C (96.8 to 100.4 F) is acceptable. The average is 37 C (98.6 F)

expected rectal temperatures are usually:

0.5 C (0.9 F) higher than oral temps

expected axillary and tympanic temperatures are usually:

0.5 C (0.9 F) lower than oral temps

expected temporal temperatures are usually:

close to rectal temps, but they are nearly 0.5 C (1 F) higher than oral temps, and 1 C (2 F) higher than axillary temps

heat loss- conduction is:

transfer of heat from the body directly to another surface (when the body is immersed in cold water)

heat loss- convection is:

dispersion of heat by air currents (wind blowing across exposed skin)

heat loss- evaporation is:

dispersion of heat through water vapor (sweating and diaphoresis)

heat loss- radiation is:

transfer of heat from one object to another object without contact between them (heat loss from the body to a cold room)

newborns’ temperature should be maintained between

36.5 and 37.5 C (97.7 and 99.5 F)

an older client’s average body temperature is

36 C (96.8 F)

with menopause, intermittent body temperature may increase by up to

4 C (7.2 F)

fever is the body’s response to infectious and/or inflammatory processes but may be blunted in the ___ population

elderly (geriatric)

fever is not usually harmful unless it exceeds

39 C (102.2 F)

hyperthermia is

an abnormally elevated body temp

hypothermia is

an abnormally low body temp; a body temp below 35 C (below 95 F)

pulse rate is

the number of times per min the pulse is felt or heard

pulse rhythm can be

regular or irregular; a premature or late heartbeat can result in an irregular interval and can indicate abnormal electrical activity of the heart

pulse strength (amplitude) should be graded on a scale of

0 to 4 0 = absent, unable to palpate 1+ = diminished, weaker than expected 2+ = brisk, expected 3+ = increased 4+ = full volume, bounding

pulse equality: peripheral pulse impulses should be

symmetrical in quality and quantity from right side to left

expected range for an adult client’s pulse is

60-100 bpm at rest

tachycardia is

above expected range or faster than 100 bpm

bradycardia is

below expected range or slower than 60 bpm

dysrhythmia is

an irregular heart rhythm often noted as an irregular radial pulse

pulse deficit is

an apical rate faster than the radial rate; with dysrhythmias, the heart may contract ineffectively, resulting in a beat heard at the apical site with no pulsation felt at the radial pulse point

for an infant the expected pulse rate range is

120-160 bpm

for a child age 12-14 the expected pulse rate range is

80-90 bpm

factors leading to tachycardia include:

-exercise -fever -medications -changing position from lying down to sitting/standing -acute pain -hyperthyroidism -anemia/hypoxemia -stress, anxiety, fear -hypovolemia, shock, heart failure

factors leading to bradycardia include:

-long-term physical fitness -hypothermia -medications -changing position from standing/sitting to lying down -chronic pain -hypothyroidism

always count the apical pulse rate for

1 min

ventilation is

the exchange of O2 and CO2 in the lungs; measure with respiratory rate, rhythm, and depth

diffusion is

the exchange of O2 and CO2 between the alveoli and the RBCs; measure with pulse oximetry

perfusion is

the flow of blood to and from the pulmonary capillaries; measure with pulse oximetry

respiratory rate is

the number of full inspirations and expirations in 1 min; expected reference range for adults in 12-20 rpm

respiratory depth is

the amount of chest wall expansion that occurs with each breath; altered depths are described as deep or shallow

respiratory rhythm is

the observation of breathing intervals; a regular rhythm with an occasional sigh is expected in adults

pulse oximetry is

a noninvasive, indirect measurement of oxygen saturation of the blood (SaO2)

expected pulse oximetry ranges are

reference range: 95%-100% acceptable for some clients: 91%-100% some illnesses allow for: 85%-89% abnormal: <85%

expected newborn respiratory rate

30-60 rpm

expected school-age respiratory rate

20-30 rpm

-pain in the chest wall may ___ respiration depth
-onset of acute pain may ___ respiration rate
-anxiety ___ respiration rate and depth
-smoking causes resting respiration rate to ___
-neuro injury to the brainstem ___ respiratory rate and depth

-decrease -increase -increases -increase -decreases

impaired oxygen-carrying capacity of the blood that occurs with anemia or at high altitudes results in:

increases in the respiratory rate and alterations in rhythm to compensate

hypoxemia is an SaO2 below


cardiac output (CO) is determined by

-HR -contractility -blood volume -venous return

systemic vascular resistance (SVR) is determined by

the amount of constriction or dilation of the arteries

blood pressure (BP) is determined by


normal BP range


prehypertension range

120/80 – 139/89

stage I hypertension

140/90 – 159/99

stage II hypertension


BP classification is based on the

highest reading of either the SBP or DBP (even if either the SBP or DBP falls in a lower classification

a diagnosis of hypertension is made is made if readings are elevated on at least

3 separate occasions over several weeks

hypotension is classified with a reading below

normal; systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation

pulse pressure is the difference between

systolic and diastolic pressure readings

postural (orthostatic) hypotension is a BP that falls when

a client changes position from lying to sitting or standing; may be caused by peripheral vasodilation, medication side effects, fluid depletion, anemia, prolonged bedrest

steps to assessing orthostatic BP changes

1) take client’s BP and HR in the supine position 2) have client change to sitting or standing position 3) wait 1-5 mins 4) reassess BP and HR 5) client is experiencing orthostatic hypotension if SBP decreases >20 mm Hg and/or DBP decreases >10 mm Hg with a 10%-20% increase in HR

infants have a ___ BP that gradually ___ with age

-low -increases

older children and adolescents have varying BP based on

body size (larger children have a higher BP)

adult BP tends to ___ with age and older adults may have a slightly ___ SBP due to ___ elasticity of blood vessels

-increase -elevated -decreased

circadian (diurnal) rhythms affect BP, with BP usually ___ in the early morning hours and ___ during the later part of the afternoon/evening

-lowest -peaking


-olfactory -assess nose for smell


-optic -assess visual acuity -assess visual fields -assess corneal light reflex -assess pupillary reaction to light


-oculomotor -assess corneal light reflex -assess pupillary reaction to light -assess extraocular movements


-trochlear -assess extraocular movements


-trigeminal -assess the face for strength and sensation


-abducens -assess extraocular movements


-facial -assess mouth for taste -assess the face for symmetrical movement


-acoustic -assess ears for hearing


-glossopharyngeal -assess mouth for taste -assess mouth for movement of soft palate and the gag reflex -assess swallowing and speech


-vagus -assess mouth for movement of soft palate and the gag reflex -assess swallowing and speech


-spinal accessory -assess the shoulders for strength


-hypoglossal -assess the tongue for movement and strength

lymph nodes should be ___ &amp; ___; normal nodes are ___ ___

-nonpalpable -nontender -not visible

ROM head: flexion

movement chin to chest

ROM head: lateral flexion

ear to shoulder bilaterally

ROM head: hyperextention

chin up

occipital lymph node located

base of skull

preauricular lymph node located

in front of ear

postauricular lymph node located

over the mastoid

submandibular lymph node located

along base of mandible

tonsillar lymph node located

angle of mandible

submental lymph node located

midline under the chin

anterior cervical lymph node located

along the sternocleidomastoid muscle

posterior cervical lymph node located

posterior to the sternocleidomastoid muscle

supraclavicular nodes located

above the clavicles

client must stand ___ ___ from the Snellen chart

20 feet

the line on the Snellen chart for which ___ or ___ letters are missed is recorded as the visual acuity

2 or fewer

the first number of the recorded visual acuity indicates the ___ ___ ___ from the ___ the client is ___

-number of feet -chart -standing

the second number of the recorded visual acuity is the ___ at which a ___-___ ___ can read the line

-distance -normal-sighted person


impaired far vision


impaired near vision or farsightedness

Ishihara test

tests for color vision


bulging eyes


crossed eyes


covering of the pupil by the upper eyelid

in conjunctiva the ___ is pink and the ___ is transparent

-palpebral -bulbar


jerky or tremor-like eye movements

to assess inner ear in children &lt;2 years

pull auricle down and back

to assess the inner ear of adults and children &gt;2 years

pull auricle up and back

-tympanic membranes should be ___ ___ &amp; ___
-light reflex should be ___ and in a ___-___ ___ ___
-___ &amp; ___ landmarks are readily visible
-ear canals are ___ with ___ ___

-pearly gray & intact -visible & well-defined cone shape -umbo & manubrium -pink w/fine hairs

expected findings for the whisper test

the client can hear you whisper softly 30 to 60 cm away

expected findings for the Rinne test

air conduction (AC) greater than bone conduction (BC); 2:1 ration

expected findings for the Weber test

sound is heard equally in both ears (negative Weber test)

frontal sinuses are palpated by

pressing upward with the thumbs from just below the eyebrows on either side of the bridge of the nose

maxillary sinuses are palpated by

pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth

normal percussion of the thorax should result in


percussion of the thorax resulting in dullness is

an abnormal finding and caused by fluid or solid tissue; can indicate pneumonia or a tumor

percussion of the thorax resulting in hyperresonance is

an abnormal finding and caused by the presence of air; can indicate pneumothorax or emphysema

auscultation of the lungs (expected sound): bronchial

loud, high-pitched, expiration heard longer than inspiration over the trachea

auscultation of the lungs (expected sound): bronchovesicular

medium pitch and intensity, equal inspiration and expiration, and heard over the larger airways

auscultation of the lungs (expected sound): vesicular

soft, low-pitched, inspiration three times longer than expiration heard over most of the peripheral areas of the lungs

auscultation of the lungs (abnormal or adventitious sound): crackles or rales

fine to coarse popping heard as air passes through fluid or re-expands collapsed small airways

auscultation of the lungs (abnormal or adventitious sound): wheezes

high-pitched whistling, musical sounds heard as air passes through narrowed or obstructed airways, usually louder on expiration

auscultation of the lungs (abnormal or adventitious sound): rhonchi

coarse sound heard during either inspiration or expiration resulting from fluid or mucus, may clear with coughing

auscultation of the lungs (abnormal or adventitious sound): pleural friction rub

grating sound produced as the inflamed visceral and parietal pleura rub against each other during inspiration or expiration

absence of breath sounds should:

be noted

heart sounds: S1

-"lub" -caused when the closure of the mitral and tricuspid valves signals the beginning of the ventricular systole (contraction) and produces the sound -best heard with the diaphragm of the steth at the apex

heart sounds: S2

-"dub" -caused when closure of the aortic and pulmonary valves signals the beginning of ventricular diastole (relaxation) and produces the sound -best heard with the diaphragm of the steth at the aortic area

heart sounds: S3

-ventricular gallop -produced by rapid ventricular filling -can be a normal finding in children and young adults -best heard with bell of steth

heart sounds: S4

produced by a strong atrial contraction -can be normal finding in older and athletic adults and children -best heard with bell of steth

a murmur sounds like a

-blowing or swishing sound -best heard with bell of steth

-systolic murmurs are heard just after ___
-diastolic murmurs are heard just after ___

-S1 -S2

thrills are:

a palpable vibration that may be present with murmurs or cardiac malformation

bruits are:

produced by an obstructed peripheral blood flow and are heard as a blowing or swishing sound with the bell of the steth

auscultatory sites for the heart: aortic

just right of the sternum at the second ICS

auscultatory sites for the heart: pulmonic

just left of the sternum at the second ICS

auscultatory sites for the heart: erb’s point

just left of the sternum at the third ICS

auscultatory sites for the heart: tricuspid

just left of the sternum at the fourth ICS

auscultatory sites for the heart: apical/mitral

left midclavicular line at the fifth ICS

locations to assess bruits include:

-carotid arteries: over carotid pulses -abdominal aorta: just below xiphoid process -renal arteries: MCL above umbilicus on the abdomen -iliac arteries: MCL below the umbilicus on abdomen -femoral arteries: over femoral pulses

shape/contour of abdomen can be described as:

-flat: lies in horizontal line from the chest to the symphysis pubis -convex: rounded -concave: has sunken appearance -distended: a large protrusion of the abdomen caused by fat, fluid, or flatus that can be differentiated as follows: *fat: client has rolls of fat along sides, and the skin does not look taught *fluid: flanks also protrude, when client turns onto side, the protrusion moves to the dependent side *flatus: protrusion is mainly midline, and the flanks are unchanged *hernias: protrusions through the abdominal muscle wall are visible

rebound tenderness (Blumberg’s sign) is an indication of

irritation or inflammation somewhere in the abdominal cavity


-loss of color: best noted in face, conjunctivae, nail beds, palms -indication of anemia or lack of blood flow


-bluish: best noted in nail beds, lips, mouth, skin -indication of hypoxia or impaired venous return


-yellow: orange of skin, sclera, and mucous membranes -indication of liver dysfunction, red blood-cell destruction


-redness: best noted in face, trauma and pressure sore areas -indication of inflammation

clubbing of the fingernail

-abnormal curvature of the nail with an angle >160* -can be result of chronic low SaO2, emphysema, chronic bronchitis

capillary refill

after blanching nail bed, color should return to normal withing <3 secs

brown pigmentation of skin

changes with venous insufficiency

shiny and translucent skin without hair on toes and foot is seen with

arterial insufficiency

grading of pitting edema:

1+: 2mm/trace, rapid return 2+: 4mm/mild, 10-15 second return 3+: 6mm/moderate, 1-2 min return 4+: 8+mm/severe, 2-5+ min return


-nonpalpable, skin color change, <1cm -example: freckle


-palpable, circumscribed, <0.5cm -example: elevated nevus


-palpable, circumscribed, 0.5cm or > -example: wart


-serous fluid-filled, <1cm -example: blister


-puss-filled -example: acne


-palpable, irregular borders, edematous -example: insect bite


-lost epidermis, moist surface, no bleeding -example: ruptured vesicle


-dried blood, serum, or pus -example: scab


-flakes of skin that exfoliate -example: dandruff or psoriasis


-linear crack -example: tinea pedis


-loss of epidermis and dermis with possible bleeding and scarring -example: venous stasis ulcer or pressure ulcers

spider angioma

-red center with radiating red legs -up to 2 cm -can be raised

cherry angioma

-red -1-3 cm -round -can be raised

spider vein

-bluish -spider-shaped or may be linear -up to several inches in size


-deep reddish/purple -flat -petechiae = 1 to 3 mm -purpura > 3 mm


-purple fading to green or yellow over time -variable in size -flat


-raised ecchymosis


a decrease of the angle


an extension of the angle


an extreme extension


ventral surface is facing up


ventral surface is facing down


movement of extremity away from midline


movement of extremity toward midline


movement toward the dorsum (or top of wrist or foot)

plantar flexion

movement toward the plantar surface (or bottom of the foot)


turning body part away from midline


turning body part toward midline

normal spine curvatures:
-cervical spine: ___
-thoracic spine: ___
-lumbar spine: ___

-concave -convex -concave


-exaggerated curvature of the thoracic spine -common in older adults


-exaggerated curvature of the lumbar spine -common during toddler years and pregnancy


exaggerated lateral curvature


an enlargement of muscle due to strengthening


a decrease in muscle size due to disuse

LOC: alert

-client is responsive and able to fully respond by opening eyes and attending to a normal tone of voice and speech -answers questions spontaneously

LOC: lethargy

-client is able to open eyes and respond, but is drowsy and falls asleep readily

LOC: obtundation

-client needs to be lightly shaken to respond, but may be confused and slow to respond

LOC: stupor

-client requires painful stimuli (pinching a tendon or rubbing sternum) to achieve a brief response -client may not be able to respond verbally

LOC: coma

-there is no response to repeated stimuli -abnormal posturing (decorticate or decerebrate rigidity)

decorticate rigidity

flexion and internal rotation of upper extremity joints and legs

decerebrate rigidity

neck and elbow extension, with wrists and fingers flexed

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

heel-to-toe walk

-ask client to place heel of one foot in front of toes of the other foot as he walks in a straight line -expected finding: client is able to walk in a straight line without losing balance


with eyes closed, client can identify a familiar object that is place in his hand


with eyes closed, client can identify a number drawn on his palm with the blunt end of a pencil

intrapersonal communication


interpersonal communication

communication between two people

public communication

communication that occurs within large groups of people; community settings

transpersonal communication

addresses spiritual needs and provides interventions to meet those needs

small group communication

communication w/in a group of people


the incentive or motivation for communication to occur between one person and another


the person who initiates the message


verbal and/or nonverbal information that is expressed by the sender and intended for the receiver


method of transmitting and receiving a message (received via sight, hearing, and/or touch)


the person to whom the message is aimed at and received by


the emotional and physical climate in which the communication takes place


-may be verbal and/or nonverbal, positive and/or negative -the message returned to the sender by the receiver that indicates the message was received -an essential component of ongoing communication

interpersonal variables

variables that influence communication between the sender and the receiver


words used to communicate either a spoken or written message

denotative/connotative meaning

when communicating, participants must share meanings


the shortest, simplest communication is usually most effective


knowing when to communicate allows the receiver to be more attentive to the message


the rate of speech can communicate a meaning to the receiver


the tone of voice can communicate a variety of feelings

therapeutic communication is

-the purposeful use of communication to build and maintain helping relationships with the client, families, and significant others -client centered: not social or reciprocal -purposeful, planned, and goal-directed

stress may be:

-situational -developmental -caused by sociocultural -a contributor to illness vulnerability


-describes how an individual deals with problems and issues -influencing factors include: number, duration, and intensity of stressors; individual past experiences; current support system; available resources (financial)


coping behavior that describes how an individual handles demands imposed by the environment

components of the General Adaptation Syndrome (GAS)

-Alarm reaction: body functions are heightened to respond to stressors -Resistance stage: body functions normalize while responding to the stressor; the body attempts to cope with the stressor -Exhaustion stage: body functions are no longer able to maintain a response to the stressor


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