Focus Topic: Fundamentals of Nursing

Functional health patterns are the basis for a series of questions that the nurse asks the patient to develop an in-depth nursing assessment. These questions help the nurse gain a better idea of the patient’s overall health and lifestyle. They are part of the admission process when a patient is admitted to the hospital. The functional health patterns encompass the patient’s general health, nutrition, elimination, activity, sleep, cognition, living environment, abuse, sexuality, spiritual/cultural beliefs, coping mechanisms, hygiene, and self-perception. They give the nurses and team a better understanding of the patient’s situation in order to address problems and develop a plan for proper care, planning, and safety. It’s like my mom used to say, “If you don’t ask, you won’t know!” It is important to maintain patient privacy while asking about these topics. If family members are present, you may want to ask them to step out of the room while these questions are asked.

I am warning you, as you review your packet of health patterns and the questions that are asked, that not all of the topics covered by these questions will be comfortable ones for you to discuss. I have to admit that, as a nursing student and as a nurse, I would blush when discussing sexuality with my 80- or 90-year-old patients. Most would reply, “Great, that’s why I take Viagra.” Never a dull moment in nursing, I will tell you that! Now I will not go into depth on each health pattern. Refer to your packet or book for the questions that should be asked. Again, you will not be tested on your knowledge of each question; rather, the goal is to become familiar with the health patterns and to become comfortable obtaining the information from patients during your assessment.

Fundamentals of Nursing: CULTURAL DIFFERENCES

Focus Topic: Fundamentals of Nursing

As a nurse and student, it is important to be aware of the cultural diversity among patients. It is important to identify and respect each patient’s culture, religion, and beliefs. When obtaining a patient’s past medical history, you should ask about and identify any spiritual or cultural beliefs. If there is a language barrier, use the interpreter services provided by your hospital or facility for assistance. Here are some important and common cultural beliefs to remember:

  • In many Asian cultures, making direct eye contact can be offensive.
  • In the Muslim religion, pork and pork products are prohibited.
  • People who practice as Jehovah’s Witnesses do not receive blood products.
  • For many cultures, in the interest of modesty, men are not allowed to be the caretakers of women; in these cases, a woman caretaker is preferred.

Fundamentals of Nursing: NUTRITION

Focus Topic: Fundamentals of Nursing

It is important to monitor the intake and output of all patients, making sure that patients have the correct amount of calories for their weight. A diet will be ordered for your patient based on his or her condition and medical history. For example, a patient who is admitted with cardiac complications will receive what is called a cardiac diet, which is low in sodium and fat. Patients who are malnourished will be placed on a high-calorie diet and may need IV nutrition. Also, pay attention to any cultural preferences that may be needed for a patient’s diet. Listed here are some common diets you will see ordered:

  • Regular diet: There are no restrictions to diet or calories.
  • Cardiac diet: For cardiac patients, includes food low in `sodium and fat.
  • Clear/full liquid: Ordered for patients before any GI diagnostics or after surgery. Clear liquid includes anything clear such as apple juice, tea, broth, popsicles, ginger ale, or Sprite. Avoid any liquids that are flavored or colored red for patients with gastrointestinal bleeds. Full liquids include liquid foods; there are no restrictions.
  • Soft/mechanical soft diets: These consist of foods that are easy to swallow and chew. Mechanical soft include mashed potatoes, ground meats, and other easy-to-swallow foods.
  • Renal diet: These consist of foods that are low in sodium and potassium. Protein intake is also monitored. When monitoring a patient’s nutrition, also be aware of any precautions such as those required for patients who are at risk for aspiration or who have difficulty chewing. Assist patients who need to be fed, as well. It is the nurse’s responsibility to assess for any changes in feeding ability and nutritional status.

Fundamentals of Nursing: URINARY AND BOWEL FUNCTION

Focus Topic: Fundamentals of Nursing

Assessing a patient’s intake and output is very important. Most physicians will order strict intake and output on patients, especially surgical or renal patients. It is the nurse’s responsibility to make sure that the patient is urinating and having regular bowel movements every shift or daily. There are various reasons why a patient’s urinary or bowel elimination may be disrupted. For example, renal patients who are on dialysis are anuric (or have little output). It is important to monitor any patient who has not had a bowel movement for several days as this may indicate a small bowel obstruction or severe constipation. During your assessment, it is important to ask the patient whether he or she is urinating regularly and having regular bowel movements. Remember, each patient is different; ask your patients what their normal habits are.

Fundamentals of Nursing: Urinary Elimination

Focus Topic: Fundamentals of Nursing

An adult patient’s urinary output should total at least 30 mL every hour. This is measured by asking the patient to void in a plastic container that is placed in the toilet for accurate measurement; if the patient has a Foley catheter, the measurement is taken from the Foley drainage bag. Males may use urinals to measure accurate output. It is important to look at the urine; normal urine is yellow and clear. The presence of blood in the urine or cloudy or foul-smelling urine can signify a urinary problem or infection. A Foley catheter may be ordered for various reasons. Surgical, urinary incontinence, ICU patients, and others may require a Foley catheter during their hospital stay. Refer to your class notes and visual images in your textbook on how to insert a Foley catheter. (I could write the procedure out for you, but, to be honest, you really need a visual picture in order to understand it.) Common urinary complications that can occur are:

  • Urinary tract infection (UTI): An infection in the urinary tract that causes burning during urination, hematuria, foul-smelling urine. Elderly patients who present with a UTI may have confusion as an associated symptom.
  • Incontinence: A person’s inability to control the function of urination. In many cases, briefs are worn to prevent urinary leakage.

Fundamentals of Nursing: Bowel Elimination

Focus Topic: Fundamentals of Nursing

This topic and discussing a patient’s bowel movements may not be the highlight of your day. But it is important to ask patients if they are having daily movements and making sure they are staying regular. Although it is not always necessary to assess the stool, complications can arise for which you will have to obtain a specimen or check the stool. Common bowel complications are:

  • Constipation: The inability to have a bowel movement. Stool softeners, prune juice, or laxatives may be given to promote bowel movements. Common causes of constipation are pain medications, immobility, or bowel obstruction.
  • Occult stool: Blood in the stool caused by various conditions such as hemorrhoids or ulcers.
  • Diarrhea: Loose bowel movements that vary in severity. Can be caused by medications, food poisoning, viruses, and bacteria such as Clostridium difficile (C. diff).

Fundamentals of Nursing: VITAL SIGNS

Focus Topic: Fundamentals of Nursing

Vital signs, by definition, are a person’s temperature, pulse/heart rate (HR), respiration rate, blood pressure (BP), and pain level. A person’s vital signs reflects his or her respiratory function, cardiac stability, and hemodynamic status. Changes in vital signs can indicate disorders such as hypertension (high BP), hypotension (low BP), dehydration, respiratory distress, hypoxemia (low O2 levels), tachycardia (increased pulse), and bradycardia (low HR). You will need to become familiar with these signs and practice obtaining accurate results. You will have plenty of time to practice on other students and those good-looking mannequins in the lab. At the end of the semester, you will go to the hospital or nursing home to practice on patients.

Time for a funny story that I know some of you will relate to. I had almost completed my fundamentals course and was at a local nursing home assessing a patient’s vital signs. I felt comfortable and confident because I thought I had this skill down pat. When I exited the room, one of the nurses on the floor walked up and asked, “Did you take his temperature with the red thermometer?” My response, with hesitation, was yes. She chuckled a little and said, “Well, those red thermometers are used only for rectal temperatures.” I was mortified, even though the thermometer was clean and capped. I was thinking to myself that it would have been nice if someone had told me. My confidence level went from 100% to 0% in no time. It is true that we learn from our mistakes, because I never made that mistake again. So always remember when you see a red thermometer, red stands for “rectal.” With that said, let’s go on to describe each vital sign.

Fundamentals of Nursing: Body Temperature

Focus Topic: Fundamentals of Nursing

Definition: A measurement of the body’s temperature in degrees. The body’s temperature is controlled by the hypothalamus. This is in the preoptic part of the brain. The hypothalamus is able to detect when the body’s temperature is too high, indicating a fever, or too low, indicating hypothermia. A normal temperature on average is about 98.6°F (36°C).

Assessing the Temperature: The four main ways to assess body temperature are (a) oral, (b) rectal (most reliable), (c) axillary (under the arms), and (d) tympanic. Many hospitals use an electronic thermometer to obtain oral temperature readings. Never use a rectal temperature on patients who are immunocompromised (have reduced immune function). When obtaining an oral temperature, make sure that the patient has not had anything hot or cold to drink for 15 minutes before the assessment, as this can alter the temperature. It is important to tell your instructor or the nurse about any changes in a patient’s temperature.

Factors That Affect Temperature: Age, exercise, stress, illness, and infection can all affect the temperature.

Temperature Gone Wrong: Changes can occur, and these are defined as pyrexia, hyperpyrexia, and hypothermia. In reality, nurses just say, “The temperature is high.” But it is important to know these terms. Pyrexia means an elevation in temperature, hyperpyrexia means a critical increase in temperature, and hypothermia is a temperature lower than average.

Fundamentals of Nursing: Pulse

Focus Topic: Fundamentals of Nursing

Definition: When the left ventricle pumps blood through the heart, it causes a pulse. The heart pumps about 5 L of blood per minute. This would be a great time to look over your anatomy and physiology book to review the structures and functioning of the heart. Remember the term cardiac output; this is the term used to describe the amount of blood pumped each minute through the circulatory system. The normal adult pulse ranges from 60 to 100 beats per minute (bpm).

Assessing the Pulse: The pulse can be obtained from various parts of the body. Most commonly used is the radial pulse found on the wrist. You can auscultate (listen to the pulse with a stethoscope), palpate (feel the pulse), or use a Doppler stethoscope to hear the pulse as well. During an assessment, you will have to obtain a pulse from various sites on the body. The apical pulse is located between the fourth and fifth left intercostal space; it is the strongest pulse in the body and provides an accurate indication of the HR. The radial pulse is located at the wrist right below the thumb (most commonly assessed). The brachial pulse is in the pit of the arm, known as the antecubital fossa. Carotid pulses are on the side of the neck. Femoral pulses are in a part the groin known as the inguinal area. The pedal pulses are along the top of the foot, in between the big toe and the second toe.

Factors That Affect Pulse: Age, gender, exercise, medications, stress, anxiety, positional changes, illness, and blood loss can alter pulse rates. Infants have a higher pulse rate of 110 to 160 bpm. School-age children have pulse rates of 75 to 120 bpm on average. Take age into consideration when obtaining a pulse.

Pulse Gone Wrong: An electrocardiogram (EKG) is used to determine a person’s cardiac rhythm and HR. Normal sinus rhythm means the patient has a normal rate and rhythm. Dysrhythmia is a change in the heart’s rhythm or pulse pattern. An increase in the HR (above 100) is termed tachycardia, and a decrease in the HR (below 60) is termed bradycardia. Many changes in rhythm can occur; these are described in further detail in Chapter 3. Patients are often placed on cardiac monitors or telemetry to monitor irregular pulses or heart rhythms.


Fundamentals of Nursing: Respirations

Focus Topic: Fundamentals of Nursing

Definition: Gas exchange is the exchange of carbon dioxide with oxygen in the lungs. It is the body’s way of regulating oxygen through the circulatory system to maintain healthy cells through inspiration and exhalation. Here is a little exercise: Take a deep breath in; this is called inspiration. Now breathe out; this is called exhalation. A normal respiratory rate is 16 to 20 breaths per minute.

Assessing Respirations: The first step is to assess the patient. Is the patient breathing normally? Is the patient having difficulty breathing? Are the breaths shallow? Is there use of accessory muscles in breathing? These can all be assessed by looking at the patient and listening to his or her lungs. You can also ask the patient for a past medical history of respiratory problems, such as asthma, or inquire whether he or she smokes, because that can affect respiration. After a visual assessment, auscultate, or listen to the patient’s lungs by placing the stethoscope on the upper chest and lower chest and counting the breaths per minute. An easy way to determine the respiration rate is by counting the number of breaths for 30 seconds and then multiplying by 2 to get a full minute rate. Have the patient sit upright and instruct the patient not to speak during the assessment.

Factors That Affect Respirations: Smoking, stress, anxiety, exercise, temperature, infection, pneumonia, asthma, underlying physiological causes, and medications affect respiration. There are a lot more factors that can change a patient’s respiration, but these are the most common. I am going to share with you the biggest nursing secret of all time: During an exam, when you are asked a priority question such as which patient to see first, always choose the answer that refers to a patient with a compromised respiratory system! Choose answers that coincide with the “ABCs” (airway, breathing, and circulation). Always help the patient who is in respiratory distress first.

Respirations Gone Wrong: An increase in respirations is referred to as tachypnea (anything greater than 20 breaths per minute). A decrease in respirations is referred to as bradypnea (less than 12 breaths per minute). Remember any words that have the ending –pnea refer to a change in respirations. I know all this information seems like a lot to remember; take a deep breath so you don’t experience any respiratory changes.

Fundamentals of Nursing: Blood Pressure

Focus Topic: Fundamentals of Nursing

Definition: Blood pressure (BP) is the force of blood against the walls of the blood vessels, especially the arteries. Picture a waterslide of blood pushing against the artery walls, creating pressure. Two terms are used to describe BP: diastolic and systolic. A normal BP is anything below 120/80 mmHg. The systolic number, 120 mmHg, indicates the pressure in the circulatory system during the contraction of the heart. The diastolic number, 80 mmHg, is the pressure when the heart is at rest or relaxation.

Assessing the Blood Pressure: Blood pressure is obtained by using a BP cuff, also known as a sphygmomanometer (try saying that three times fast), and a stethoscope. There should be a picture of this device in your class notes or textbook. The part of the cuff that goes around the patient’s upper arm should be placed over two-thirds of the length of the upper arm and cover three-fourths of the circumference of the arm, right above the antecubital fossa (middle part of the arm). The sounds that are heard are called Korotkoff sounds, which can also be visualized on the meter and represent the systolic and diastolic pressures. When the cuff is inflated, the strongest beat will represent the systolic pressure, usually at 120 mmHg, and the deflation of the cuff and the last beat seen on the meter will be the diastolic pressure, at 80 mmHg. When measuring a patient’s BP, use the correct size of cuff for the arm; some patients may require a small cuff. BP should not be taken on the arm on the same side where patients have undergone a mastectomy or where a peripherally inserted central catheter (PICC) line is inserted. Do not leave the cuff inflated as this can cause discomfort. Make sure the BP is taken on the bare skin and not over clothing. If there is a significant change in BP on the electronic cuff, a manual reading is performed through auscultation. Any changes in BP must be reported.

Factors That Affect Blood Pressure: Factors that affect BP are dehydration, stress, medications, illness, surgery, hemorrhage, and pain.

Blood Pressure Gone Wrong: A BP greater than 120/80 mmHg is hypertensive. A BP below 120/80 mmHg is hypotensive. Orthostatic hypotension is a decrease in blood pressure that occurs when patients change from a lying position to a standing position. If a patient is orthostatic, make sure you help them to stand, as a loss of balance or dizziness may occur.

This completes an overview of the vital signs in a nutshell. In hospitals, an electronic Dynamap machine is used to obtain vital signs. It is important to memorize and identify any changes in vital signs and report them immediately. They are called “vital” for a reason: The changes in these signs are usually the first signs that something is wrong in a patient.

Fundamentals of Nursing: Pain

Focus Topic: Fundamentals of Nursing

Pain is sometimes referred to as the fifth vital sign. Use a numeric pain scale to identify the patient’s pain level. Pain can signify that something is wrong; therefore it is important to identify and treat at once. Pain can be acute or chronic. Medicate pain as prescribed. It is important to maintain comfort for the patient and assess pain throughout the shift. Pain medications are ordered based on the patient’s diagnosis and severity. There are five major types of pain:

  • Acute pain: New onset, lasting a short time and usually affecting one area.
  • Chronic pain: Experienced over a long period of time; it is constant and persistent.
  • Neuropathic pain: Caused by damage to the peripheral nerves.
  • Phantom pain: Postamputation, patient can feel pain in the extremity.
  • Nociceptive pain: Pain in the muscles or joints.

Methods of pain relief may include medications, relaxation, and touch. Pain medications ordered can be narcotics or nonnarcotic analgesics. A PCA (patient-controlled analgesic) may be ordered for patients postoperatively to better control pain. It is important to identify where the patient is having pain, have the patient use either the numeric or the FLACC (Face, Legs, Activity, Cry, Consolability) scale to rate the pain, and document.