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34 Cards in this Set
- Front
- Back
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Gordon's
Functional Health Patterns |
activity/exercise/sleep/rest
cognitive/perceptual stress/coping psychosocial nutritional/metabolic Sexuality/Reproduction Values/Beliefs |
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Nursing Process
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Assessment
Diagnosis Planning Intervention Evaluation |
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Nursing Diagnosis
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Diagnosis R/T Etiologies(may have secondary to) AMB specific s/s
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SOAP/IER charting
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Subjective
Objective Assessment Plan Intervention Evaluation Revision |
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PIE charting
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Problem
Interventions Evaluation |
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CBE charting
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Charting by Exception
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SBAR charting
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Situation
Background Assessment Recommendation |
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included in skin assessment
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color
moisture turgor temperature texture edema lesions nail: color, shape, texture |
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bronchial breath sounds
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loud, high pitched, tubular sounds
expiration longer than inspiration air moving through trachea |
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bronciovesicular breath sounds
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medium pitched
equal inhale/exhale air mvmt thru lrg airways |
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vesicular breath sounds
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soft, low pitched, breezy
lengthy inspiration/brief expiration air mvmt thru sm. airways |
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Heart Sounds
upon auscultation |
Aortic- 2nd ICS R sternal border
Pulmonic- 2nd ICS L sternal border Tricuspid- 4th ICS L sternal border Mitral- 5th ICS midclavicular |
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1st heart sound
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"lub"
closure of AV values beginning of systole |
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2nd heart sound
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"dub"
closure of semilunar valves beginning of diastole |
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effects of pH on medication absorption
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acidic meds better in stomach
basic meds better in sm intestine |
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6 rights of medication administration
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patient
medication dosage time route documentation |
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three checks of medication administration
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BEFORE you remove meds
AFTER you prepare meds AT THE BEDSIDE before admin |
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Infant nutrition
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Iron stores depleted 4-6 mo
Calcium Vitamin C Vitamin D highest nutritional needs |
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Toddler/Preschooler nutritihttp://www.flashcardexchange.com/mycards/add/942716on
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commonly low: iron, calcium, Vit A, Vit D
autonomy impacts diet |
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school-age nutrition
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nutrient needs slower
more independent food choices |
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adolescent nutrition
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need: protein, calcium, iron, Vit B, Vit D
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adult nutrition
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need: calcium, folic acid, iron
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older adult nutrition
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sl. reduced energy requirements
calcium important need: complex carbs esp fruit & veg diminished senses alter eating |
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pregnancy/ lactation nutrition
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dramatic increase in needs
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clear liquid diet
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does not supply adequate nutrition
water, tea, coffee, broth, clear juice, popsicles, carbonated drinks, gelatin |
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full liquid diet
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clear liquids + anything that is liquid at room temp
for short term use |
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mechanical soft diet
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for chewing difficulties
full liquid + soft fruits/veggies, breads, pastries, eggs, cheese, chopped/ground/shredded meat risk for constipation |
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pureed diet
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blended diet- any food as long as it is blended
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BMI
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wt in kilograms/ (ht in meters) squared
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hypoglycemia
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below 70
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hyperglycemia
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above 109 fasting
above 126 random |
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normal blood sugar
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70-120
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hemoglobin male
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14-18
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hemoglobin female
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12-16
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