Chapter 8: Planning

Prioritize diagnosis→short term goals→long term goals→outcome indicators→interventions

• Planning: third step of the nursing process; process in which the nurse prioritizes the pts.’
nursing diagnostics, determine goals, identifies outcome indicators, list nursing
interventions
• 8.1 The planning process
o Nurse prioritizes each nursing diagnosis and establishes goals with patients
o Allowing patient to participate lets them be aware of identified needs, accept
realistic and measureable goals, and embrace interventions to best achieve the
mutually agreed-on goals
• 8.2 Prioritizing care
o First step of the planning process
o Maslow’s hierarchy of needs: basic needs (physiological) come before lower needs
(self-esteem)
o Life threatening concerns vs. routine care
▪ ABC’s (airway, breathing, circulation)
▪ In clinical situations, the steps of the nursing process are performed
through instant clinical reasoning and do not require pt. input
▪ Conflicting priorities: explain the importance of interventions to pt.
• 8.3 Goal Development
o SMART (specific, measureable, attainable, realistic, time manageable)
o A goal must be realistic and one that the patient has cognitive and sociocultural
potential to reach.
• 8.4 Outcome identification and goal attainment
o Involves listing observable behaviors or items that indicate attainment of goal
o Nursing Outcomes Classification (NOC) = standardized vocabulary used for
describing patient outcomes
o Outcome indicators: Criteria by which goal attainment is observed and
measureable
o Eg: NOC vital signal outcome indicator: temperature
o Use measureable verbs: administer, ambulate, inject, administer, attend
• 8.5 Care plan development
o Nurse identifies key assessment data, nursing diagnostic, statements, goals,
intervention for care, and evaluation of outcomes
• 8.6 Types of interventions
o Independent interventions: nurse initiates care that they recognize as essential in
meeting patient needs or preventing complications, does not require order from
health care provider. Eg: consultations w/ social workers, preadmission teaching)
 o Dependent interventions: originate from health care provider and followed by the
nurse. Eg: oxygen administration, dietary requirements, diagnostic tests
o Collaborative interventions: includes activities such as physical therapy, home
health care
o 5 elements of nursing interventions: patient assessment findings, underlying
etiology in each nursing diagnosis, realistic patient outcomes, evidence-based
practice, and expertise of the nurses and other health care providers
o Nurses should use interventions designed to reduce drug side effects, treatment
duplication, and hospital readmission
o Consultation process
identify the general problem area→the patient is referred to the right professional
→ the consultant should be provided with relevant information about the problem
area, without influencing the consultant with personal judgments→The findings and
recommendations of the consultant should be discussed, and conclusions should be
made.
o Use of evidence-based practice includes
▪ Developing comprehensive skill sets.
▪ Have an excellent, thorough understanding of the nursing process that is
backed by extensive research.
▪ Communicate the patient’s plan of care during the shift change. This
ensures that the patient receives care according to the diagnoses and
planned interventions
▪ Integrating the evidence-based care plan into the electronic health
record
• 8.7 Planning throughout pt. care
o Care planning begins when a pt. first interacts w/ nurse and continues until pt. does
not require care
o Health literacy plays a big role on this whole process, make sure pt. understands
everything you have said
o Care plan: includes diagnosis , goals, goal outcomes, nursing interventions
o Involving patients in planning their care helps them to (1) be aware of identified
needs, (2) accept realistic and measurable goals, and (3) embrace interventions to
best achieve the mutually agreed-on goals. Inclusion of patients in the planning
process tends to improve goal attainment and patient cooperation with
interventions. By accepting guidance and input from patients during the planning
process, the nurse provides them with a greater sense of empowerment and
control.

Chapter 9: Implementation and evaluation

• Review and revision steps
o Reassess the pt.→ review the care plan→compare findings to validate existing
nursing diagnoses →Decide if the nursing interventions remain appropriate
• 9.1 implementation of nursing care
o Implementation: performing task (giving backrub, repositioning, giving meds)
and documenting all of them
• 9.2 Direct care
o Direct care: refers to interventions that are carried out by having personal
contact w/ pts.
o Reassessment: continual reassessment is required to detect noticeable changes
in pt.s’ condition. This leads to adjustments of interventions in plan care
o Activities of daily living: nurse should note where deficits exist and determine
whether pt. requires long-term or short term goals to address their needs
o Many interventions are based on physical care
▪ Invasive procedures: starting and IV line or inserting catheter
▪ Noninvasive procedures: administering oral meds. And repositioning pt.
o Informal counseling: Process through which nurses use professional guidance to
address personal conflicts or emotional problems. Nurses should encourage pts.
To express their concerns and emotions. Eg: encouraging a cancer pt. to explore
options for care
o Teaching: each interaction w/ the patient is an opportunity to teach. The nurse
should keep in mind the best way pt. learns, the patient’s educational and
knowledge level, cultural considerations, potential communication barriers, and
their readiness to learn
• 9.3 Indirect care
o Indirect care: nursing interventions that are performed to benefit the pt. but do
not involve face-to-face contact. Eg: giving change of shift report,
communicating and collaborating with other members
o Communication and collaboration: Eg: sending pt. to a psychologist/specialist
o Referrals: nurses initiate referrals for specific dietary request and care devices
(bedside commodes)
o Research: nurses should always use evidence-based practice
o Advocacy: needs negotiating skills
o Delegation of task: while delegating keep in mind the 5 rights ( Right task,
circumstances, person, direction or communication, supervision or evaluation)
o Prevention-oriented interventions: any intervention that is implemented to
prevent illness or complications. Eg: immunizations, cleansing incision
• 9.4 independent nursing interventions
o Nurses should know how to perform interventions before implementing them
and keep their scope of practice while doing it.
• 9.5 dependent interventions
o Standing orders: a nurse should always reassess individual pts and should not
blindly follow standing orders.
o Medication administration: Nurse should always check the order first, patient’s
allergies, expiration date and then the six rights (right drug, dosage, route,
patient, time, documentation)
o Medical treatments: eg: urinary catheters, dressing changes, incision irrigation
• 9.6 Documentation of interventions
o ALWAYS DOCUMENT OR IT DID NOT HAPPEN
• 9.7 evaluation of the nursing care plan
o final step in the nursing process
o review→evaluate→compare→judge→determine
o evaluation begins with determining whether the goals were attained
o when a patient goal is unmet or partially met the plan of care may need to be
revised to support goal attainment
o reassessment should occur every time the nurse interacts with the pt. or reviews
updated labs or test results
o Discharge documents includes necessary rehabilitation techniques to support
adaptation to the environment, counseling regarding nutrition and diet, and
information about safe and effective use of medications
• 9.8 care plan modification and quality improvement
o Care plans should be updated regularly after pt. evaluations
o Quality improvement (QI): formal way to look at the pt. and treatment
outcomes and determine what can be done differently to affect the situation in
a positive way

Chapter 10: Documentation, electronic health records & reporting

The documentation made by the nurse should conform to the standards of The Joint
Commission the principles of the ANA

• Health care documentation describes the pt., the patient’s health, and the care and services
provided, including the dates of care
• Facilities information flow and supports the continuity, quality, and safety of care
• Accurate documentation is needed for reimbursement of care, evidence of care provided,
promotion of continuity of care, and for communication between health care providers
• 10.1 documentation standards and principles
o Medical records for each patient is accessed by authorized personnel only
o ANA’s model for high-quality nursing documentation reflects the nursing process
and includes accessibility, accuracy, relevance, auditability, thoughtfulness,
timeliness, and retrievability
• 10.2 The medical record
o Document w/ comprehensive info. About a patient’s health care encounter, as well as
demographic, administrative, and clinical data.
o Written medical records
o Electronic health records
▪ Electronic medical records (EMR): record of one episode of care, such as
inpatient/outpatient appointment
▪ Electronic health record (EHR): longitudinal record of health that includes the
information from inpatient and outpatient episodes of health care from one
or more care settings
• 10.3 nursing documentation
o Documentation guidelines require accessible, accurate, timely nursing documentation
that is clear, concise, complete and objective
o Should occur ASAP after assessment, evaluation, interventions, and condition changes
o Documentation errors include
o Documentation formats
▪ Problem-oriented medical record (POMR): integrates charting from the
entire care team in the same section of the record
▪ Narrative charting: chronologic, w/ baseline recorded on shift-by-shift basis.
Data is recorded in progress notes at times w/o organizing framework
▪ Source oriented: gives each profession a separate section of the record in
which to do narrative charting
▪ Formatted charting:
• PIE Notes
o Problem, intervention and evaluation
o APIE: assessment + pie
• SOAP notes Subjective data, Objective data, Assessment, & Plan
o SOAPIE: includes interventions and evaluations
o SOAPIER: includes revision
• DAR: data, action, and response
▪ Charting by exception: records only abnormal or significant data, Documents
deviations, uses a shorthand method
▪ Case management documentation: includes realistic patient- and family-
centered outcomes, documenting high-quality, cost effective delivery patient
care
▪ Flow sheets: used to document routine care and observations (vital signs,
meds. , and intake/output measurement
▪ Admission and discharge summaries
 • Admission: includes patient’s history, a medication reconciliation,
and an initial assessment that addresses the patients problems,
including plan care planning and discharge planning
• Discharge: home care is noted. Dietary restrictions, follow-up care,
and emergency contact numbers should be included
• 10.4 Confidentiality and privacy (HIPAA)
o Health info. Is only used for treatment, payment, or health care
operations(supervisors)
o Patient’s rights include obtaining, viewing, or updating a copy of their own medical
records
• 10.5 Hand-off reports
o They need to provide accurate and timely info. About the care, treatment and
services rendered to a pt. , addressing the pt. current condition and anticipated
changes
o Sentinel event: an event that involves death or serious physical/psychological injury
or the risk of injury
o Nurses should teach pt. to participate in handoff reports; eg: participate w/ staff
during bedside rounds, ask pts. To validate the information shared during the
rounding process, and ask questions during the rounding process
o SBAR
o ANTICipate Model
▪ Administrative data should be accurate, New clinical info. Must be
updated, Task performed by provider should be explained clearly, Illness
severity must be communicated, Contingency plans for changes in clinical
status must be outlined.
• 10.6 verbal and telephone orders
o Nurse should take the order and document that it was verbal, then the physician
needs to cosign
• 10.7 incident reports
o eg: a pt. or family member falling
o factual, accurate, truthful
o Helps in providing good quality health care
o Helps to identify the need to change a procedure or policy
o Helps in identifying loopholes in the operation of the health care system
Nursing documentation is an important part of effective communication among nurses
and with other health care providers. Documentation should be factual and
nonjudgmental, with proper spelling and grammar. Events should be reported in the
order they happened, and documentation should occur as soon as possible after
assessment, interventions, condition changes, or evaluation. Each entry includes the
date, time, and signature with credentials of the person documenting. Double
 documentation of data should be avoided because legal issues can arise as a result of
conflicting data.

Chapter 11 Ethical and legal considerations

• 11.1 Ethics and Ethical issues
o Deontology: the foundation of most professional codes of ethics including the
Code of ethics for nurses; meeting the patient’s needs while maintaining their
right to privacy, confidentiality, autonomy, and dignity
o Utilitarianism: maintains that behaviors are determined to be right or wrong
solely on the basis of their consequences, “the ends justified the means”; the
right action is the one that brings the most happiness to the most people
• 11.2 Essential concepts of ethics in nursing
o Autonomy: self-determination supported by self-confidence and knowledge.
Nurses promote autonomy when they include pt. in the process of developing
care plans with realistic goals and interventions.
o Accountability: willingness to accept responsibility for one’s actions. Nurses w/
this trait are honest, accept consequences, initiate best nursing practices based
on current evidence-based research
o Beneficence: doing good. Acting on behalf of others and placing a priority on the
needs of others rather than on personal thoughts and feelings.
o Confidentially: ethical concept that limits sharing private pt. info.
o Fidelity: keeping promises or agreements made with others; eg: when the nurse
acknowledges the pt. request for pain meds, asses the pt. pain level and quality,
and returns within a few minutes w/ analgesic medications
o Justice: act fairly and equitably. Fairness implies that all individuals should have
ready access to health care regardless of their ability to pay
o Nonmaleficence: requires only the avoidance of harm
o Responsibility: being dependable and reliable
o Veracity: defined by truthfulness
• 11.3 codes of ethics
o First official nursing code of ethics was adopted in 1950 by the American nurses
association (ANA)
o The current nursing code is the Code of Ethics for Nurses with Interpretive
Statements
o Responsibility of nurse educators
▪ Advise and supervise students
▪ Collaborate w/ students to identify individual learning needs in the clinical
setting
▪ Instill in students the values and professional standards of nursing
• 11.4 bioethics challenges in health care
o The study of ethical and philosophical issues in biology and medicine
o End-of-life care
▪ Nurse should provide accurate information regarding the disease process
and treatment options to the patient
▪ Offering support for the patient and family w/o interjecting personal
opinions
▪ Futile care: care that is useless and prolongs the time until death rather
than restoring life
o Ethical decision makers
• 11.5 Legal implications in nursing practice
o Each state has a nurse practice act that establishes the standards of care
required for legal nursing practice
• 11.6 Sources of laws impacting professional nursing
o Constitutional law: derived from a formal, written, constitution that defines the
powers of government and the responsibilities of its elected or appointed
officials
o Statutory law
▪ created by legislative bodies such as the US congress
▪ should be consistent with all federal laws
o Regulatory law
▪ defined by administrative bodies such as the state board of nursing
▪ outlines how the requirements of statutory laws will be met
▪ states the procedure for reporting unsafe or unethical nursing practice
▪ Nurse practice act
o Case law: “common law” ; determined by customs or social mores that were
common at the time
• 11.7 Types of statutory law
o Criminal law
▪ Written to prevent harm to the country, state and the individual citizens
▪ Address crimes such as murder, rape, theft, and practicing w/o a license
I. Misdemeanor: punishable by a fine or incarceration for up to 1 yr
II. Felony: state/federal law for 1 year or more (practicing w/o license, child
abuse, drug abuse)
o Civil law
▪ Governs unjust acts against individuals, rather than federal or state crimes
I. Torts
o Intentional torts
▪ Assault: threat of bodily harm or violence caused by a demonstration
of force by the perpetrator
 ▪ Battery: actual physical harm caused to another person
▪ Defamation of character
I. Libel: written vs. Slander oral
▪ False imprisonment: unauthorized restraint of a person; if the pt.
wants to leave he has to sing the against medical advice (AMA) form
▪ Invasion of privacy
o Unintentional torts
▪ Negligence: creating a risk of harm to others by failing to do
something that is expected or you or doing something that is not
expected of you
▪ Malpractice: negligence by a person functioning in a professional
role. eg; engaging in sexual activity w/ pt, calculating dosages
incorrectly resulting in overdose
Four D’s of negligence
1) DUTY: it must prove that the nurse owed a duty of care to
the accusing pt
2) Dereliction: nurse actions did not meet the standard of care
required or that the care was omitted
3) Damage: actual injury to the accusing pt must be evident
4) Direct cause: casual relationship must be established
between harm of the accusing pt. and the actions of the
nurse
• 11.8 Professional liability issues
o Professional practice conduct
▪ Engaging in excessive self-disclosure of personal info. To a pt
▪ Keeping secrets w/ a pt; limiting others from conversation
▪ Spending excessive time w/ a pt
▪ Failing to protect the pt. from inappropriate sexual involvement
o Accurate and timely documentation
▪ Serious documentation errors include omitting documentation from pt. records ,
recording assessments findings obtain by another nurse, or recording care not yet
provided
• 11.9 legal issues guiding patient care
o Informed consent: permission granted by a pt. after discussing 1) exact details of the
treatment 2) necessity of treatment 3)all known benefits and risk involved 4)
available alternatives 5) risk of treatment refusal with the PHYSICIAN (DR.)
o Nurse only acts as a witness, nurses can be a witness but nursing students cannot
o Patient’s bill of right: informs patients that they should expect 1) excellent care 2) a
safe envi. 3) participation in planning their care 4)privacy 5) help with discharge
arrangement 6) assistance w/ fulfilling financial responsibilities
 o Advance directives
▪ Living will: specifies the treatment a person want to receive when he/she is
unconscious or no longer capable of making decisions
▪ Durable power of attorney: legal document that allows a designated person to
make legal decisions on behalf of an individual unable or not permitted to make
legal decisions independently (spouses , domestic partners)
▪ Health care proxy: specific durable power of attorney for medical care
• 11.10 Laws impacting professional practice
o Standards of care: minimum requirements for providing safe nursing care. The ANA
establishes standards for safe practice
o American recovery and reinvestment act of 2009
▪ Prevents the sale of protected health info. w/o pt. knowledge of payment or
authorization
o Good Samaritan acts
▪ The care is within the professional’s scope of knowledge and standards of care
▪ No fee is received for services
• 12.5 delegation
o Uniform determination of death
▪ All spontaneous respiratory and circulatory function stops
▪ All brain functions, including that of the brainstem, ends.
o Physical restraints
▪ Should be order by physician
▪ Patient has to be harmful to other patients
▪ The physician has to sign the form withing 24 hours

Chapter 12 Leadership and management

o Principles of delegation
▪ 1st: Nurses must have knowledge of the nurse practice act in the state
where they are licensed.
2nd: The RN cannot delegate assessment, planning, evaluation, or
accountability for the assigned task.
3rd: The person to whom the assignment was delegated cannot delegate
that assignment to someone else.
o Five rights of safe delegation
▪ Right task , right person, right circumstance, right communication, and
right supervision

Chapter 13 Evidence-based practice and nursing research

 • Magnet recognition: excellent patient outcomes due to nursing, a high level of nursing
job satisfaction with low nurse turnover rate, and appropriate resolution of any
grievances.

Synthesizing
Searching for maintaining
the evidence
Asessing the developing a and the change
and implementing
problem question evaluating and
developing a
evidence reevaluating
plan

1) Assessing the problem: identify the problem, nurse collects data about the current practice to
determine what is being done in response to the identified problem, compare what you have
acquire to what you have.
2) Developing a question: formulate a specific research question so that the nurse can effectively
search the literature databases. To generate a specific question the nurse needs to link the problem
with the interventions and outcomes
o PICO (patient, population/problem, intervention, comparison intervention, outcomes)
3) Searching for and evaluating evidence
o Searching: the nurse needs to consult three categories of information resources
▪ Background: gen. info , types of therapies
▪ Filtered: best treatment or course of action since they provide the best evidence
▪ Unfiltered: used to check if any new studies have been made not available in filtered
resources
o Critically appraising information
▪ Looking for strengths, benefits, weakness and flaws of research
▪ Check for validity
• Internal validity: basis of how the study was conducted; study should address a
clearly focused issue
• Result analysis: size and precision of the treatment effects, significance
• External validity: can the study be applied to any other setting?
4) Synthesizing the evidence and developing a plan
o The nurse needs to design a practice change based on the evidence found in the literature.
o Plan needs to include
▪ How the findings will be conveyed to the nurses who will use the info.
▪ Workshops and in-service or focused training
▪ A bulletin can be provided that list several safe practices concers w/ rationales in the
form of a safe practice alert
5) Implementing the plan
o Nurses begin to use the new info. In their practice.
o Nurse develops a clinical question, seeks answers to verify and support a clinical decision and
ultimately applies the findings to pts
6) Maintaining the change and reevaluating
o Evaluate the effectiveness of the decision in terms of the pts response
 o Any new literature since implementation
o How can the clinical decision be improved or updated

Chapter 14 Health literacy and patient education

• 14.1 Health literacy
o Health literacy: unique ability of a patient to understand and integrate health-
related knowledge
o ACCURATE , ACESSIBLE , ACTIONABLE
• 14.2 Role of the health literacy in nursing and patient education
o Patient education is a primary responsibility of nurses
o Should include issues of access, quality, and affordability
o Preventing disease, promoting health, providing treatment instructions,
clarifying info. , and teaching pts to cope w/ limitations of all components
o Patient should be able to
▪ Read and identify credible health information
▪ Make appts
▪ Understand numbers in the context of the patients health care
▪ Fill out forms
▪ Gather health records and ask appropriate questions
▪ Advocate for appropriate care
▪ Navigate complex insurance programs (medicare/Medicaid)
▪ Use of technology to access info and services
• 14.3 Types of patient education
o Formal: delivered throughout the community in the form of media , in a variety
of educational and group settings; includes goals set by educator
o Informal: usually learner or patient is directed. May occur when patient is asking
about procedure , medication, or treatment
• 14.4 Domains of learning
o Cognitive: compromises knowledge and material that is remembered.
Memorization and recall of info is required
o Psychomotor: physical movement and the use of motor skills in learning; eg:
how to check blood sugar
o Affective: recognizes the emotional component when acquiring new knowledge.
Patient’s feelings, values, motivations, and attitudes
• 14.5 learning styles
o VARK (verbal ,aural, read/write, kinesthetic)
o US population reads below a 5th grade level
• 14.6 Factors affecting health literacy and patient teaching
o Age and development stage
 ▪ Children should not be excluded from learning unless exclusion is
deemed appropriate by parent or caregiver
o Role: patients support system should be taken into consideration
o Environment: location of patient education; should be a quiet and w/ minimum
interruptions
o Timing: most important aspects are taught at the beginning of the session
o Economic resources: resources should be congruent with plan
o Evidence-based practice:
• 14.7 assessment
o Assessment of health literacy occurs w/ each patient encounter
• 14.8 Nursing diagnoses
o Deficient knowledge ________r/t_____________ AEB
o Readiness for enhanced knowledge
o Noncompliance _________ r/t ________ AEB
• 14.9 Planning
o Developing the patient education plan
• 14.10 Implementation and evaluation
o A return demonstration by the patient helps the nurse to assess the level of
learning that has taken place
o Environment
o Pace: focus on one idea at a time and should be kept short
o Data integration: started w/ familiar info. And progressing to the less familiar,
complex, or abstract ideas
o Repetition and demonstration
o Evaluation: Future sessions should review what was learned in previously and
continue to add to do what has been taught
o Documentation: teaching sessions- including topics and skills reviewed, methods
and materials used and patient progress must be documented
o Evaluate if pt is ready to learn, ability to learn, comprehend

Chapter 19: Vital signs

19.1 vital signs measurement
 Temp PULSE RESPIRATIONS SpO2 Blood Pressure Blood Pressure
(bpm) (bmp) (Systolic) (Diastolic)

Adult 35.5 C- 37.5 C 60-100 12-20 >95% 90-120 60-80

(95.9-99.5)
Older Adult 35 C – 37.2 C 60-100 15-20 >95% 90-120 60-80
(95-99)
• Pulse pressure average is 30-50 mm/HG
• Situations that require vital sign assessment
o On admission
o Physical Assessment
o Routine monitoring
o Any change in health status; especially w/ complains of chest pain,sob, feeling
hot, faint, or dizzy
o Before/after surgery or invasive procedures to establish baselines
o Before/after medicines that impact cardiac, respiratory or thermal regulation
o Before/after intervention such as ambulation
o In ongoing care to detect improvement
o Before discharge
• Typically done q 4-8 hrs for stable patients, q 15-60 mins after a procedure and q 5 mins
for a critical or unstable patient

19.2 Temperature

• Afebrile: ranges from 97.6 to 99.6 ; avg: is 98.6

• Convection: the transfer of heat by movement of or circulation of warm matter such as
air or water
• Evaporation: sweating
• Conduction: using ice pack or cool cloth
• Frostbite interventions include pain management, gradual warming, and protection of
injured area

Axillary Rectal Oral Tympanic Temporal

Disadvantages Only used Contraindicated Not a preferred site Not Covering of
when oral or in newborns, for infants, appropriate for the head
rectal cannot neutropenic unconscious pts. With ear can affect it
be done pts. , or cardiac patients, or people drainage or
patients with seizure eardrum
disorders scarring
advantages Used for Very accurate Readily accessible Core temp. , Not
healthy and comfortable for appropriate for affected by
newborns pt. confused or mild
unconscious perspiration
patients, if used
readings in 2 correctly.
secs could be could be
use in kids >2 used in
mo. infant and
kids
Average 95.9-98.6 93.92-100.04 96.8-99.68 96.08-99.32 96.98-99.14

19.3 Pulse
Apical pulse: central pulse that can be auscultated over the apex of the heart at the PMI;
assessed when an irregular rhythm is detected
Peripheral pulse: can be palpated over arteries located away from the heart (toes/fingers)

• Sites for assessing pulse

o Radial artery: most common site for assessing quality, rate and rhythm of the
pulse ; on the thumb side
o Carotid/femoral: use during an emergency CPR
o Brachial: used in emergency for children; used to measure blood pressure
o Pulse deficit: when the apical pulse rate exceeds the radial pulse rate
o Tachycardia vs. bradycardia
19.4 respirations
• respiratory rate
o eupnea: regular
o apnea: absent
o tachypnea: >24 BPM
o bradypnea: <10 BPM
• Depth of respirations
o Hypoventilation: shallow respirations; associated w/ DO, COPD, and cervical
injury
o Hyperventilation: deep, rapid respirations; cause by stress or anxiety
o Cheyne-stokes respirations: have rhythm; very deep to very shallow or apneic
periods
o Kussmaul’s breathing: respirations abnormally deep,regular, and increased rate
o Biot’s breathing: abnormal shallow for 2-3 breaths then irregular periods of
apnea
19.5 Blood pressure: preferable to be taken on left arm
• An increase/decrease of 20-30 mm hg is a significant change
• Systolic/Diastolic
• Hypotension: systolic<90 or diastolic<60
• Hypertension
o Pre-hypertension: 120-38 / 80-89
o Stage 1 hypertension: 140-159 / 90-99
o Stage 2 hypertension: >160 / >100
• Orthostatic hypotension: sudden drop of 20 mm Hg in systolic pressure or 10 mm HG in
diastolic pressure when a patient moves from lying to siting position; risk factors include
dehydration, immobility, and blood loss , anemia. Wait 1-3 minutes before assessing the
next
• Blood pressure devices errors
o Inappropriate to use an electronic blood pressure device in pts. With an irregular
heart rate, shivering, seizure activity, or BP less than 90 mm HG

1)defective equipment
Inaccurate reading 2)equipment not calibrated
3) improper use
4) pt. not positioned correctly
1)hearing deficit in assessing person
Falsely low reading 2)arm positioned above heart
3) a cuff too wide
4)cuff deflated too rapidly
1)too soon after smoking/ drinking
Falsely high reading coffee
2)cuff too narrow
3) deflating too slowly

19.6 Pain
• Focus on pain (SOCRATES)

Vital Signs Factors that affected

Age:
Exercise: body temp. increases w/ exercise
Hormone fluctuations: women have a higher
temp. during ovulation
Temperature Circadian rhythms: lowest at 0300 highest at
1800
Stress: increases temp,
 Environment
Smoking: decreases body temp.
Age: pulse decrease w/ age
Gender: male lower than females
Fever: increases pulse
Pulse rate Medications
Hypovolemia: increases rate
Hypoxia: increases rate
Stress: increases rate
Pathology
Electrolyte balance: changes in potassium
and calcium affect rate and rhythm
Age
Exercise
Respiratory and Cardiovascular Diseases
Respirations Acid-Base of body fluids
Medications
Pain/emotions

Age: higher age = higher BP

Gender: BP lower in women than men
Race: African americans
Blood pressure Medications
Weight
Circadian rhythm: lower in the AM
Head Injury: increases BP
Food intake: increases after eating
Pain/Emotion
Site Onset Character Radiation Associations Time course Exacerbating Severity
b.The low pulse rate is causing a decreased cardiac output, which has caused a low blood
pressure.