Transcript Nursing

Nursing
STANDARD 2.1-2.6
Nursing
Registered nurses (RNs) provide and coordinate patient care, educate patients and the public
about various health conditions, and provide advice and emotional support to patients and their
family members.
Duties:
Registered nurses typically do the following:
•Record patients' medical histories and symptoms
•Administer patients’ medicines and treatments
•Set up plans for patients’ care or contribute to existing plans
•Observe patients and record observations
•Consult with doctors and other healthcare professionals
•Operate and monitor medical equipment
•Help perform diagnostic tests and analyze results
•Teach patients and their families how to manage illnesses or injuries
•Explain what to do at home after treatment
Nursing
Most registered nurses work as part of a team with physicians and other healthcare
specialists. Some registered nurses oversee licensed practical nurses, nursing assistants,
and home health aides.
Registered nurses' duties and titles often depend on where they work and the patients
they work with. They can focus in the following areas:
•A specific health condition, such as a diabetes management nurse who helps patients
with diabetes or an oncology nurse who helps cancer patients
•A specific part of the body, such as a dermatology nurse working with patients who have
skin problems
•A specific group of people, such as a geriatric nurse who works with the elderly or a
pediatric nurse who works with children and teens
•A specific workplace, such as an emergency or trauma nurse who works in a hospital or
stand-alone emergency department or a school nurse working in an elementary, middle,
or high school
Jobs
Some registered nurses combine one or more of these specific areas. For example, a
pediatric oncology nurse works with children and teens who have cancer.
Many possibilities for working with specific patient groups exist. The following list includes
just a few other examples:
Addiction nurses care for patients who need help to overcome addictions to alcohol,
drugs, tobacco, and other substances.
Cardiovascular nurses care for patients with heart disease and people who have had
heart surgery.
Critical care nurses work in intensive care units in hospitals, providing care to patients
with serious, complex, and acute illnesses and injuries that need very close monitoring and
treatment.
Genetics nurses provide screening, counseling, and treatment of patients with genetic
disorders, such as cystic fibrosis.
Neonatology nurses take care of newborn babies.
Nephrology nurses care for patients who have kidney-related health issues stemming from
diabetes, high blood pressure, substance abuse, or other causes.
Rehabilitation nurses care for patients with temporary or permanent disabilities.
Education
In all nursing education programs, students take courses in anatomy, physiology, microbiology, chemistry,
nutrition, psychology and other social and behavioral sciences, as well as in liberal arts. BSN programs typically
take 4 years to complete; ADN and diploma programs usually take 2 to 3 years to complete. All programs also
include supervised clinical experience.
Bachelor's degree programs usually include additional education in the physical and social sciences,
communication, leadership, and critical thinking. These programs also offer more clinical experience in
nonhospital settings. A bachelor's degree or higher is often necessary for administrative positions, research,
consulting, and teaching.
Generally, licensed graduates of any of the three types of education programs (bachelor's, associate’s, or diploma)
qualify for entry-level positions as a staff nurse. However, some employers may require a bachelor’s degree.
Many registered nurses with an ADN or diploma choose to go back to school to earn a bachelor’s degree through
an RN-to-BSN program. There are also master’s degree programs in nursing, combined bachelor’s and master’s
programs, and programs for those who wish to enter the nursing profession but hold a bachelor’s degree in
another field. Some employers offer tuition reimbursement.
Certified nurse specialists (CNSs) must earn a master’s degree in nursing. CNSs who conduct research typically
need a doctoral degree.
Licensing
In all states, the District of Columbia, and U.S. territories, registered nurses must have a nursing
license.
To become licensed, nurses must graduate from an approved nursing program and pass the
National Council Licensure Examination, or NCLEX-RN.
Other requirements for licensing vary by state. Each state's board of nursing can give details. For
more on the NCLEX-RN examination and a list of state boards of nursing visit the National
Council of State Boards of Nursing.
Nurses may become certified through professional associations in specific areas, such as
ambulatory care, gerontology, and pediatrics, among others. Although certification is usually
voluntary, it demonstrates adherence to a higher standard, and some employers may require it.
CNSs must satisfy additional state licensing requirements. They may choose to earn certification
in a specialty.
Advancements
Some RNs choose to become nurse anesthetists, nurse midwives, or nurse practitioners, which,
along with certified nurse specialists, are types of advanced practice registered nurses (APRNs).
APRNs may provide primary and specialty care, and, in most states, they may prescribe
medicines. For example, clinical nurse specialists provide direct patient care and expert
consultations in one of many nursing specialties, such as psychiatric-mental health.
Pay
The median annual wage for registered nurses was $65,470 in May 2012. The median wage is the wage at which half of the workers in an
occupation earned more than that amount and half earned less. The lowest 10 percent earned less than $45,040 and the top 10 percent
earned more than $94,720. In May 2012, the median annual wages for registered nurses in the top five industries in which they worked
were as follows:
Government $68,540
Hospitals; state, local, and private 67,210
Home health care services 62,090
Nursing and residential care facilities 58,830
Offices of physicians 58,420
Many employers offer flexible work schedules, childcare, educational benefits, and bonuses. Because patients in hospitals and nursing care
facilities need round-the-clock care, nurses in these settings usually work in rotating shifts, covering all 24 hours. They may work nights,
weekends, and holidays. They may be on call, which means they are on duty and must be available to work on short notice. Nurses who
work in offices, schools, and other places that do not provide 24-hour care are more likely to work regular business hours.
In 2012, about 1 out of 5 registered nurses worked part time.
Job Outlook
Employment of registered nurses is projected to grow 19 percent from 2012 to 2022, faster than
the average for all occupations. Growth will occur for a number of reasons.
Demand for healthcare services will increase because of the aging population, since older
people typically have more medical problems than younger people. Nurses also will be needed
to educate and to care for patients with various chronic conditions, such as arthritis, dementia,
diabetes, and obesity. In addition, the number of individuals who have access to healthcare
services will increase, as a result of federal health insurance reform. More nurses will be needed
to care for these patients.
HEAD TO TOE ASSESSMENT IN 5 MINUTES or MORE
Introduction to Assessment
T he head to toe assessment provides baseline data about your patient. It is the standard of
c are to assess eac h patient in your c are. Only by evaluating your patient c an you determine
if c hanges have oc c urred. Sinc e lic ensed personnel often have responsibility for many
patients, a c omprehensive, systematic method is nec essary to assure a c omplete
assessment in a timely manner. T he following is a suggested format for patient assessment:
Washed Hands
Washing hands between eac h patient is the single most signific ant fac tor in preventing the
spread of disease. Utilize Standard Prec autions in assessing the patient.
Introduction to the Patient
Introduc ing yourself to the patient and explaining the purpose of the head to toe
assessment helps the patient to know y our role and why you are c ompleting this
assessment. At times, the patient may feel that there is something wrong with them or their
c ondition has c hanged when they are frequently assessed. Explaining to the patient the
need for the assessment to identify c hanges in c ondition often allays the anxiety.
General Survey
Look at the patient for eye c ontac t, appearanc e, hygiene and appropriateness for personal
spac e. T he general survey c an often be a key to observing mental status.
Head and Neck
Palpate the head for tenderness, bumps, and abraisons. Observe for head lic e. Observe the
ears for signs of skin breakdown or abraisons.
Vital Signs
Basic vital signs are c onsidered to be the temperature, pulse, respiration, and blood
pressure. Pain assessment has now been added as the 5th vital sign. Assessing vital signs is
'vital' to determining c hanges in c ondition. Vital signs provide a baseline physiologic
parameter.
Orientation
Orientation is c hec ked by determining if the patient c an state their name, the day or date,
where they are, and the purpose. T his is doc umented as oriented times 4. When assessing
orientation, use open- ended statements. For example, "T ell me your name", " What year is
this?", "T ell me where you are." “T ell me why you are here.” Y ou don't wa nt to say "Is your
name Mrs. Jones?", sinc e a yes/no answer is not an ac c urate measure of orientation.
Pupil Check
Pupils are c hec ked in a number of ways. One ac ronym used is PERRLA
Pupils Equal in size Round Reac t to light Ac c ommodation
Pupils are c hec ked by shining a light in from the side. As you view eac h pupil, note equality
of size. When the light is shone, do the pupils reac t equally by c onstric ting. Is this reac tion
sluggish, normal, or brisk? Is there no c hange in pupil size when the light is sho ne? A
millimeter sc ale is often used to c hec k pupil size. For example the pupils may c hange from 4
mm to 3 mm with the light. Ac c ommodation tests the ability of the pupils to c onstric t to a
c loser moving objec t. Have the patient follow a pen or your finger as you bring the objec t
c loser to the patient. T he pupils will c onstric t as the objec t c omes c loser. Ac c ommodation
c annot be c hec ked if the patient is c onfused, blind, c omatose, or unable to follow the objec t.
In that c ase, c hart PERRL, and leave the 'A' off.
Neck Veins
Nec k veins should be c hec ked by having the patient sit at a 45 degree angle. In this
position, the jugular veins should be flat. Distended nec k veins at 45 degrees are an
indic ator of over hydration or fluid overload.
Heart Tones
Heart tones are c hec ked by listening to the apic al pulse. T his pulse is ausc ultated with the
diaphragm and the bell of the stethosc ope. Chec k the apic al pulse for rate, rhythm, and
c larity of the sounds of the S1 and S2 otherwise known as "lub and dub". Any abnormalities
should be reported.
Bilateral Checks
Bilateral c hec ks for c omparison need to be done for:
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radial pulses - c hec k rate, strength, and regularity
hand strength - have patient grip two of your fingers at the same time. Chec k
for equality in strength. Never offer a patient your entire hand to grasp. A
patient with a strong grip c an injure your hand, but c annot hurt two fingers.
leg strength - plac e your hands on the patient's thighs. Have the patient push
legs against the resistanc e of your hands. Chec k for equality in strength.
pedal pulses - are loc ated on the top of the foot. Chec k rate, strength, and
regularity
c apillary refill - c an be done on the fingers or toes. Press down on the nail
bed. T he c olor will blanc h. Assess the time for the c olor to return. Capillary
refill should return in 3 sec onds or less. A delay in c apillary refill may indic ate
impaired c irc ulation.
Skin
Skin turgor is checked to determine hydration. Delayed skin turgor may
indicate dehydration. Skin turgor should return within 1 to 3 seconds.
Although you may have learned to check for skin turgor on the hands, the
sternum is not as affected by aging changes. Assess skin turgor by gently
pinching the sternum. Indicate the time it takes for the skin to go back to the
baseline. Since not everyone is 'pink', skin color is best checked by observing
mucous membranes on the inside of the lip or the conjunctiva. Despite skin
pigmentation, the mucous membranes are the same for all of us. Skin color
can generally be described as pink, pale, jaundiced, or cyanotic. Skin
temperature is checked by using the back of your hand placed on the patient's
skin. Skin can be hot, warm, or cool.
Breath Sounds
The diaphragm of the stethosc ope is used for assessing breath sounds. The apic es of the
lungs are very high, extending above the c lavic les. Assess anterior and posterior breath
sounds listening for side to side c omparisons. The right middle lobe is assessed by listening
on the patient's right side. Have the patient take deep breaths in and out of their mouth.
Patients often want to help, and eac h time we plac e the stethosc ope on the c hest the
patient takes a deep breath. Be c areful not to move the st ethosc ope to rapidly to avoid
hyperventilating the patient. Nose breathing c an c reate air turbulenc e that may alter the
sounds. Breath sounds should be c lear bilaterally with good air flow.
Bowel Sounds
To assess bowel sounds, the abdomen is divided into 4 quadrants, using the umbilic us as
the mid point. It is very important to ausc ultate the abdomen before touc hing. Palpation of
the abdomen prior to ausc ultation may disrupt normal sounds. If the patient is on
nasogastric suc tion, turn the mac hine off prior to listening for bowel sounds. Bowel sounds
c an be desc ribed as hypoac tive, ac tive, hyperac tive, or absent. To c hart absent bowel
sounds, eac h quadrant must be assessed for 5 minutes. In other words, absent bowel
sounds infers a 20 minute assessment.
Peripheral Edema
Edema, or fluid in the tissues tends to go to dependent areas of the body. This may be the
hands, feet or sac rum. For the bed rest patient, the dependent area is most often the
sac rum. To c hec k for edema push your finger down on the feet, ha nds, and sac rum.
Observe for indentation or pitting.
Assessing for Pain - Pain is the 5th Vital Sign
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Ask the patient if they are having any pain. Assess for loc ation, duration,
radiation, alleviating fac tors, prec ipitating fac tors, quality and intensity.
Where is the pain, how long has it lasted?
Does the pain travel anywhere?
What makes the pain feel better, what makes the pain worse?
Desc ribe how the pain feels. Is it sharp, dull, pressure, stabbing?
On a sc ale of 1 to 10, with 10 being the worst pain you c ould possible have,
tell me the level of pain you are experienc ing."
Skin Breakdown Check
Check the entire body for redness or skin breakdown. Be sure to check bony
prominences.
Homan's Sign
Homan's sign indicates possible thrombophlebitis. Ask the patient to dorsiflex
both feet. Ask the patient if there is any pain in the calf. Calf pain may
indicate thrombophlebitis.
Closure
Let the patient know you are finished and when you will be back. Leave the
bed down, rails up as indicated, and the call light within reach.
Head To Toe Assessment Checklist
Wash Hands
( ) Completed - Standard Precautions
Introduction
( ) Completed - Introduce self & purpose of
assessment to relieve anxiety and role function
identification.
Vital Signs
Pulse__________ Rate, Strength, Regularity
Temperature________ Oral, Rectal, Tympanic
B / P_________ ___Respiration_______________
Orientation
( Oriented x 4 )
What year is this ? ________________________
Tell me your name ?_______________________
Tell me where you are ? ____________________
Tell me why you are here?__________________
Pupil Check
( PERRLA ) Pupils, Equal, Round, React to light,
Accommodate
Sluggish ( ) No Change ( ) Brisk ( ) Normal ( )
Accommodation Yes ( ) No ( )
Neck Veins
Patient at 45o angle ( )
Neck Veins Flat ( ) Distended ( )
Heart Tones
Apical Pulse with Stethoscope
Rate ?_____________ Rhythm ?___________
Clarity of Sounds ? _________ Abnormal ? ( )
Explain ! ____________________________
Bilateral Checks
( Radial Pulses ) - Rate, Strength, Regularity
Right_____________ Left______________
( Hand Strength ) - 2 fingers only
Right Stronger ( ) Left Stronger ( ) Equal ( )
( Pedal Pulses ) - Top of Foot
Right Foot __________ Left Foot ____________
( Capillary Refill ) -On fingers or toes 3 seconds or
less
Right Fingers ( ) sec. Left Fingers ( ) sec.
Right Toes ( ) sec. Left Toes ( ) sec. Delay or
abnormal refill return ? Yes ( )
Skin
Skin Turgor - 1 to 3 second return, on Sternum
Return was ( ) sec. Abnormal ( ) sec.
Skin Color - Check on inside of Lip or Conjunctiva
Lip ( ) Conjunctiva ( )
Pink ( ) Pale ( ) Jaundice ( ) Cyanotic ( )
Breath Sounds
Assess anterior and posterior and from side to
side, also right lobe. Have patient take deep
breaths, do not move stethoscope to rapidly to
avoid hyperventilating on patients part.
Clear Bilaterally ( ) Left only ( ) Right only ( )
Both poor bilaterally ( ) ie.,_________________
Good air flow ( ) Poor air flow ( )
Bowel Sounds
Assess all 4 quadrants, do not touch stomach
before auscultation, as it may disrupt normal
sounds. If irregular, 5 minute assessment on each
quadrant. Umbilicus is mid point.
( Stomach ) - Check for condition
Soft ( ) Hard ( ) Distended ( ) Other
RUQ Active ( ) Absent ( ) Hyperactive ( )
Hypoactive ( )
RLQ Active ( ) Absent ( ) Hyperactive ( )
Hypoactive ( )
LUQ Active ( ) Absent ( ) Hyperactive ( )
Hypoactive ( )
LLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive
( )
Peripheral Edema
Edema is found in dependent areas such as the
feet, hands, sacrum. Check with finger by pressing
down. Observe for pitting or indentation.
Feet Yes ( ) No ( ) Pitting ( ) R ( ) L ( )
Hands Yes ( ) No ( ) Pitting ( ) R ( ) L ( )
Sacrum Yes ( ) No ( ) Pitting ( ) Indent ( )
Assessing For Pain
Where is the pain ?________________________
How long has it lasted ?____________________
Does the pain travel anywhere ?_____________
What makes it feel better ?__________________
What makes pain worse ?___________________
Descrip. of pain ? Sharp ( ) Stabbing ( ) Dull ( )
On a scale of 1 - 10, 10 being the worst _______
Skin Breakdown Check
Check entire body for redness or skin breakdown.
Check all prominences.
Normal ( ) Abnormal ( ) Explain condition and area
effected_________________________
Homan's Sign
Ask patient to dorsiflex both feet.
Pain in right calf Yes ( ) No ( )
Pain in both calfs Yes ( ) No ( )
Closure
Let the patient know you are finished and when
you will be back.
Bedrails up ( )Bed in low position ( )Call light in
reach ( )
Pupil Check
Neck veins
Capillary refill
Turgor
Conjunctiva color
Peripheral edema
Homan’s sign
ASSIGNMENT
Students will perform a head to toe assessment on their partner. You will document medical
history, vital signs(B/P, pulse, respiration), Orientation, Pupil Check, Neck Veins, Bilateral Checks,
Skin color, Breath Sounds, Bowel Sounds, Peripheral Edema, Pain Assessment, Skin Break down,
and Homan’s Sign. Your chart will be graded on Monday!! The partner with the longest hair will
be the patient first.