Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
130 Cards in this Set
- Front
- Back
|
What does SOAPE stand for?
|
subjective data, objective data, assessment, plan, evaluation
|
|
|
What does PIE stand for?
|
problem, intervention, evaluation
|
|
|
What does DAR stand for?
|
data, action response
|
|
|
The Patient Care Partnership
|
related to the patient's Bill of Rights
|
|
|
Patient Self-Determination Act
|
Advance Directions - client must be given written info explaining the right to refuse treatment and establish advance directives
|
|
|
Uniform Anatomical Gift Act
|
allows competent client to make informed decision to donate all or part of body for organo donation or medical research after death
|
|
|
Uniform Determination of Death Act
|
provides consistent definition of death in each state based on a whole-brain or cardiopulmonary definition
|
|
|
Torts
|
civil wrongs against a person or property and are potential areas of nursing liability. Two forms: intentional and unintentional/negligence
|
|
|
Assault
|
a threat to cause harm
|
|
|
Battery
|
purposeful, wrongful touching without consent
|
|
|
Five types of intentional torts
|
assault, battery, invasion of privacy, defamation of character, false imprisonment
|
|
|
what might changing position from lying down to sitting or standing do to the heart?
|
tachycardia
|
|
|
what might changing position from sitting or standing to lying down do to the heart
|
bradycardia
|
|
|
What is the normal range for oral temp?
|
36-38; 37 is normal
|
|
|
What is the normal range for rectal temp?
|
36.5-38.5; 37.5 is normal
|
|
|
What is the normal range for axillary temp?
|
35.5-37.5; 36.5 is normal
|
|
|
conduction
|
transfer of heat from the body to another surface
|
|
|
convection
|
dispersion of heat by air currents
|
|
|
evaporation
|
dispersion of heat through water vapor
|
|
|
radiation
|
transfer of heat from one object to another object without contact between them
|
|
|
What is the normal temp for older adults?
|
36
|
|
|
A fever is harmful if it is over
|
39
|
|
|
Hyperthermia is when the temp is less than
|
35
|
|
|
What is the formula to determine cardiac output?
|
CO (cardiac output) = HR (heart rate) x SV (Stroke Volume)
|
|
|
What is pulse deficient?
|
apical rate > radial rate
|
|
|
Diffusion vs perfussion
|
diffusion = passage of oxygen and carbon dioxide between alveoli and rbc.s; perfussion = flow of blood to and from the pulmonary capillaries
|
|
|
How does pulse oximetry work?
|
measures infrared light absorption by blood
|
|
|
When might pulse oximetry be low?
|
elderly, dark skin, hypothermia, poor peripheral blood flow, too much light, low hgb levels, client movement, edema, nail polish
|
|
|
What is the regular RR for newborns?
|
30-60
|
|
|
What is the regular RR for school children?
|
20-30
|
|
|
What do amphetamines and cocaines do to respiratory rate and depth?
|
increase
|
|
|
What does sickle-cell disease do to RR?
|
increases
|
|
|
What is the formula for B/P?
|
B/P = cardiac output x systemic vascular resistance
|
|
|
What is prehypertension?
|
120-140/80-90
|
|
|
What is Stage 1 HTN?
|
140-160/90-100
|
|
|
What is stage 2 HTN?
|
160+/100+
|
|
|
Hypotension is defined as
|
systolic B/P < 90
|
|
|
What is pulse pressure?
|
systolic - diastolic
|
|
|
What is B/P usually the lowest?
|
in early morning
|
|
|
When is B/P usually the highest?
|
in afternoon
|
|
|
Where should the B/P cuff be applied?
|
2 cm above
|
|
|
What is the order for assessment?
|
inspection, palpation, percussion, auscultation
|
|
|
What is the order for assessment of the abd?
|
inspection, auscultation, percussion, palpation
|
|
|
What results from a too large B/P cuff?
|
false low reading
|
|
|
What results from a too small B/P cuff
|
false high reading
|
|
|
What do opiates do to B/P?
|
decrease
|
|
|
What doe cardiac meds do to B/P
|
decrease
|
|
|
What does cocaine do to B/P?
|
increase
|
|
|
What do cold meds do to B/P?
|
increase
|
|
|
What do oral contraceptives do to B/P?
|
increase
|
|
|
What do antidepressants do to B/P?
|
increase
|
|
|
What part of the hand is most sensitive to temperature?
|
dorsal surface
|
|
|
What part of the hand is most sensitive to vibration>?
|
ulnar surface and base of fingers
|
|
|
macule
|
nonpalpable, skin color change, < 1 cm (freckle)
|
|
|
papule
|
palpable, circumscribed, <0.5 cm (elevated nevi)
|
|
|
nodule/tumor
|
palpable, circumscribed, => 0.5 cm (wart)
|
|
|
vesicle
|
serous fluid-filled, < 1 cm (blister)
|
|
|
pustule
|
pus filled (acne)
|
|
|
wheal
|
palpable, irregular borders, edematous (mosquite bite)
|
|
|
erosion
|
loss of epidermis, moist surface, no bleeding (ruptured vesicle)
|
|
|
crust
|
dried blood, serum, or pus (scab)
|
|
|
scale
|
flakes of skin that exfoliate (dandruff or psoriasis)
|
|
|
fissure
|
linear crack (tinea pedis)
|
|
|
ulcer
|
loss of epidermis and dermis with possible bleeding and scarring (venous stasis ulcer)
|
|
|
primary lesions
|
arise from healthy skin tissue
|
|
|
secondary lesions
|
arise from change in primary lesion
|
|
|
vascular lesions
|
created with aging changes or when damage occurs to blood vessels in or near the skin
|
|
|
spider angioma
|
red with radiating legs
|
|
|
cherry angioma
|
red, 1-3 cm, round, can be raised
|
|
|
spider vein
|
bluish, spider-shaped or linear, with up to several inches in size
|
|
|
petechia/purpura
|
deep reddish purple, flat, petechia = 1-3 mm, purpura > 3 mm'
|
|
|
ecchymosis
|
purple fading to green or yellow over time, variable in size, and flat
|
|
|
hematoma
|
raised ecchymosis
|
|
|
myopia
|
impaired far vision
|
|
|
presbyopia
|
impaired near vision
|
|
|
Rosenbaum chart is held
|
14 inches from eyes
|
|
|
Ishihara test is for
|
color vision
|
|
|
Nystagmus
|
tremor-like movements of eye
|
|
|
ptosis
|
covering of pupil with upper eyelid
|
|
|
palpebral
|
pink
|
|
|
bulbar
|
transparent
|
|
|
partial illumination of iris is indicative of
|
glaucoma
|
|
|
strabismus
|
wandering of eye
|
|
|
What is Rinne's test for?
|
air conduction and bone conduction
|
|
|
What is Weber's test for
|
sound heart equally in both ears
|
|
|
pendulous
|
sagging
|
|
|
Which lung has three lobes
|
right
|
|
|
S(1)
|
closure of mitral and tricuspid
|
|
|
S(2)
|
closure of aoritc and pulmonic
|
|
|
S(3)
|
rapid ventricular filling - in children and young adults
|
|
|
S(4)
|
strong atrial contraction - elderly and athletic
|
|
|
Bruits
|
obstructed peripheral blood flow
|
|
|
Dorsalis Pedis Pulse
|
top of foot
|
|
|
Homan's sign
|
risk for DVT
|
|
|
Striae
|
stretch marks that are silver in color
|
|
|
kyphosis
|
exaggerated curvature of thoracic spine
|
|
|
Lordosis
|
exaggerated curvature of lumbar spine
|
|
|
Obtundation
|
needs to be lightly shaken to respond
|
|
|
Stupor
|
requires painful stimuli for brief response
|
|
|
Best and worst score on Glasgow coma scale
|
best = 15; worst = 3
|
|
|
Romberg test
|
patient stands with eyes closed; should stand without swaying for 5 seconds
|
|
|
Stereognosis
|
patient identified familiar object placed in hand
|
|
|
graphesthesia
|
client identifies number drawn on palm
|
|
|
When is teratogenesis most likely to occur?
|
during first trimester
|
|
|
Where should IV be started?
|
in distal veins on nondominant hand
|
|
|
Never disconect IV tubing for convenience or to position the patient
|
a
|
|
|
how often should site be assessed when heat or cold is applied?
|
every 5-10 minutes
|
|
|
how old should a client be for their pain rating to be useful?
|
older than 7
|
|
|
What is the max. amt of APAP to be given to healthy client?
|
4 grams/day
|
|
|
To prevent gastric upset r/t non-opioids,
|
administer with food
|
|
|
Adjuvant analgesics
|
ehance effects of nonopioids
|
|
|
low serum albumin levels lead to
|
delayed wound healing
|
|
|
hydrocolloid wound dressing
|
occlusive and swells
|
|
|
To prevent pressure ulcers, bed positioning is
|
<30 degrees
|
|
|
What should be done to the heels to prevent ulcers?
|
raise off of bed
|
|
|
What should be done when washing pressure ulcers?
|
tepid water, minimal scrubbing, pat skin dry
|
|
|
Blended families
|
remarriages with stepchildren
|
|
|
Rigid family structure
|
strict
|
|
|
open family structure
|
loose, not strict
|
|
|
family can be considered as
|
context, client, or system
|
|
|
repatterning belief means
|
trying to change a belief
|
|
|
Congruence
|
the balance of life patterns and rhythms; cannot be achieve3d but is constantlyh sought
|
|
|
bereavement
|
includes grief and mourning
|
|
|
mourning
|
outward display of loss
|
|
|
It is an emergency if the O2 sat is below
|
86%
|
|
|
it is life-threatening if the O2 sat is below
|
80%
|
|
|
A patient on oxygen should wear ____, not ____ or ____
|
cotton; not synthetics or wool
|
|
|
hypercarbia
|
elevated levels of carbon dioxide
|
|
|
SaO(2)
|
oxygen saturation
|
|
|
Which is more effective - coughing or suctioning
|
coughing
|
