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303 Cards in this Set
- Front
- Back
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What is a synonym for critical thinking?
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Reasoning
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What are the 5 steps of the Nursing Process in order?
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1. Assessment
2. Diagnosis(analysis) 3. Planning 4. Implementation 5. Evaluation |
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The nursing diagnosis is a blueprint for ____?
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critical thinking
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What is critical thinking?
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A combo. of reasoned thinking, openness to alternatives, an ability to reflect, and a desire to seek truth.
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List 7 principles that define Critical Thinking in Nursing.
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-Purposeful outcome-directed thinking.
-Driven by patient, family and community needs. -Based on principles of nursing practice. -Requires knowledge, skills and experience. -Guided by professional standards and ethics codes. -Requires strategies that max. human potential & compensate for human probs. -Is constantly reevaluating, self-correcting, and striving to improve. |
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What is clinical judgment?
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Nursing opinion and/or nursing decision made about person, family or group in a certain period of time.
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What is the nursing process?
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~problem-solving process based on the scientific method
~the way one thinks like a nurse ~not the care plan, not the charting |
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Why do we need to know the nursing process?
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~It's the conceptual framework of all nursing curricula.
~Nurse Practice Acts ~Standards of Clinical Practice of ANA ~JCAHO |
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When do we use the nursing process?
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~Every contact we have w/ the pt; not just the formal written care plan.
~Expert nurses unaware of separate steps; it has become integrated into their thinking. |
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__% of ____ in the elderly occur in healthcare facilities?
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10% of falls.
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An increased frequency(3mo. or so) of accidents could mean what?
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Vision or neurological problems among other things.
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What is the acronym to remember the steps after a fire in a HC facility?
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R-rescue and remove all clients in immediate danger.
A-activate alarm. C-confine fire by closing doors and turning off oxygen and electric equipment. E-extinguish fire(if small) |
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When would it be necessary to have engineering check the equipment in a client's room?
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~Should always make sure engineering has approved any equipment.
~Especially when equip. has been brought from home. |
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What is a pts natural inclination concerning a restraint?
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to remove the restraint.
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What should you be aware of regarding restraint?
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pressure ulcers, contractures, bowel and urinary incontinence, etc.
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What is inspection?
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a visual exam. of all parts of the body. What you see.
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What are some general inspection guidelines?
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-We inspect for size, shape, color, symmetry, position, abnormalities.
-Compare w/ same area on opposite side of body. -Use additional light if needed and for body cavities. |
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What is palpation?
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touching-feeling with fingers/hands.
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How might you encourage relaxation during palpation?
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Palpate tender areas last.
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What function does the dorsal surface of the hand have in palpation?
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temperature
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What function do the finger tips have in palpation?
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texture, size, consistency, pulsation, form and shape.
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What function does the palmar surface of the hand have in palpation?
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vibration
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What is percussion?
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Tapping the body w/ fingertips to evaluate size, borders, density, air or fluid,
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What is auscultation and when is it usually performed?
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It is listening to sounds and it is usually performed last after inspection, palpation, and percussion.
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What are the 5 major parts of the stethoscope?
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-earpieces
-binaurals -tubing -bell chestpiece -diaphragm chestpiece |
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How long should the apical pulse ALWAYS be taken for?
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1 minute.
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At what point of the heart would you be able to hear a murmur?
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Erb's point
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What does Orientation X 3 mean?
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When you ask Person, Place and Time while doing a neurological assessment.
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What are crackles and when you would be most likely to hear it?
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It's air moving thru fluid in the lungs. More likely to hear on inspiration.
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What are rhonchi and when would you be more likely to hear them?
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mucus in the lungs, generally heard in smokers and ppl w/ bronchitis. More likely to hear during exhalation.
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What are Critical thinking skills used in the problem solving process?
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-objectively gathering info.
-recognizing need 4 more info -recognizing gaps in own knowledge -listening carefully,reading thoughtfully -separating relevant from irrelevant data -organizing or grouping info. in meaningful ways -making inferences about the meaning of info -integrating new info w/ prior knowledge -visualizing potential solns to a prob -evaluating credibility and usefulness of sources of info |
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What are six critical thinking attitudes?
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-independent thinking
-intellectual curiousity -intellectual humility -intellectual empathy -intellectual courage -intellectual perseverance -fair-mindedness |
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What are comorbidities?
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concurrently occurring health problems
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What six things make a client unique and influence how they respond to illness or healthcare intervention?
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~individual differences
~culture ~the client's role ~age ~personal bias ~previous experience w/ healthcare problems |
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What two things make critical thinking important for nurses?
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~nurses deal w/ complex situations daily
~each client is unique |
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What are 3 things about nursing itself that require the nurse to be a critical thinker?
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~Nursing is an applied discipline.
~Nursing uses knowledge from other fields. ~Nursing is fast-paced. |
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What is theoretical knowledge?
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~information, facts, principles and theories in nursing and related disciplines.
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What does theoretical knowledge consist of?
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~Research findings
~Rationally constructed explanations of phenomena. |
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What is practical knowledge?
What does it consist of? |
knowing what to do and how to do it.
consists of processes and procedures. |
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What is ethical knowledge?
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knowledge of obligation, or right and wrong.
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What does ethical knowledge consist of?
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consists of info. about moral principles and processes for making moral decisions.
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Which part of the stethoscope would you use to hear low-pitched sounds?
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the bell
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Which part of the stethoscope would you use to hear high-pitched sounds?
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the diaphragm.
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What are the 3 essential components of the Nursing Assessment?
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~Health history
~Physical and psychosocial assessment ~Analysis of lab and diagnostic tests |
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What is subjective data?
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what the patient tells you.
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What is objective data?
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What you can see.
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What are some variables that you should consider when performing a physical assessment?
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~Environment-close curtain/door, make comfortable
~Culture-may not want certain sex of nurse, etc. ~Use of personal space ~Age ~Language and literacy ~Health status-may be too tired for a full assessment @ once. |
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What are 3 successful techniques to encourage assessment?
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-encouraging verbalization
-reflection -active listening |
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What are 3 techniques that inhibit assessment?
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-leading/biased questions
-giving advice/opinions -providing unrealistic reassurance |
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What are the 6 data collection methods used during assessment?
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-nursing history
-observation -inspection -palpation -percussion -auscultation |
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What is observation?
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process of gathering info that can be perceived by 1 or more senses.
ex: odor, pallor, coughing |
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What are some guidelines to follow when carrying out observation?
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~objective rather than subjective data
~observe from general to specific-pt. in pain; where is pain? ~note details of observed event ~be specific(accurate)and objective ~validate observations(double-check yourself) |
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What 9 things should be asked when taking a chronological acct. of a patient's chief complaint?
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-Location
-Radiation -Quality -Quantity -Assoc. manifestations -Aggravating factors -Alleviating factors -Setting -Timing |
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What things should be asked when taking a Past Health History?
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-Medical
-Surgical -Meds(OTC,herbal and RX) -Communicable diseases -Allergies -Injuries/accidents -Disabilities/handicaps -Childhood illnesses -Immunizations |
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What things should be asked when taking a Social History?
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-Alcohol use
-Tobacco use -Drug use(illegal substances) -Sexual practice -Travel history -Work environment -Home environment(who will take care of them,safe at home,live alone?) -Hobbies/leisure activities -Stress -Education -Economic Status -Military service -Religion -Ethnic background -Roles and relationships -Pattern of daily living |
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What should be asked about the pts Health Maintenance Activities during the interview?
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-Sleep
-Diet -Exercise -Stress Mgmt. -Use of safety devices -Health checkups |
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What is 1 respiration?
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1 respiratory cycle=1 inspiration + 1 expiration
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Define respiration rate.
Normal range? |
# of respiratory cycles in 1 minute.
Normal range is 12-20/minute |
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Define respiration rhythm.
Normal? |
Pattern of respirations and intervals between.
Normal is regular. |
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Define pulse rate.
Normal range? |
# of pulse beats in 1 minute.
normal range is 60-100 beats/min. |
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Define pulse rhythm.
Normal? |
pattern of pulses and intervals between.
Normal is regular. |
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Define pulse volume.
Normal? |
pulse strength or amplitude.
Normal: 2+ |
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What 3 terms are used to describe respirations?
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-Rate
-Rhythm -Depth |
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What 3 terms are used to describe pulse?
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-Rate
-Rhythm -Volume |
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Is it normal for temp. to be lower in morning and higher in evening?
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Yes.
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Name 3 things that temp. can be raised by.
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-Hormones
-Meds. -Exercise |
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What is the oral temp range?
What is the avg. oral temp? |
Range: 96.8-100.4 F
Average: 98.6 |
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What is the rectal temp. range?
What is the avg. rectal temp? |
Range: 98.0-101.6
Average: 99.5 |
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What is the axillary temp. range?
Avg. axillary temp? |
Range: 95.8-99.4
Average: 97.7 |
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What 4 things will you look for when assessing skin color?
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-Cyanosis
-Pallor -Jaundice -Erythema |
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What is pallor?
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extreme paleness;loss of pink or yellow tones;a loss of red tones
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What can cause an abnormal pallor?
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Poor circulation or a low hemoglobin level(anemia)
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What are the best sites to assess for pallor?
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the oral mucous membranes, conjuctiva, nail beds, palms, and soles of feet.
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What is cyanosis?
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A blue-gray coloration of the skin, often described as ashen
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Where is cyanosis seen and what can cause it?
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-If seen in lips, mucous mem and facial features, known as central cyanosis and is assoc. w/ hypoxia.
-May also be seen in the extremities, esp. hands and feet, after exposure to extreme cold. |
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What is jaundice and what is it normally assoc. w/?
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A yellow-orange cast to the skin.
Normally assoc. w/liver disorders. |
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What are the best sites to assess for jaundice?
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sclera, mucous mem,hard palate of the mouth, palms, and soles.
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What is erythema and what is is assoc. w/?
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A reddened area.
Assoc. w/ rashes, skin inf, and prolonged pressure on the skin. |
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What 6 things are we going to assess skin for besides color?
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-Temp.
-Moisture -Texture -Edema -Turgor -Vascularity/bruising/lesions |
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What is turgor?
What does it provide data about? |
skin elasticity
hydration status |
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What is tenting?
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If skin sticks up for a few seconds when checking for turgor.
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What things are important to document when you encounter a lesion?
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-type of lesion
-specific location -pattern distribution |
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What is a macule?
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flat and colored, nonpalpable
ex: freckle, birthmark |
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What is a papule?
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elevated and raised but superficial, palpable
ex:mole,psoriasis |
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What is a cyst?
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palpable,fluid-filled,encapsulated
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What is the difference bw a papule and a patch?
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have same qualities but a papule is <1cm and a patch is >1cm.
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What is 1 respiration?
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1 respiratory cycle=1 inspiration + 1 expiration
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Define respiration rate.
Normal range? |
# of respiratory cycles in 1 minute.
Normal range is 12-20/minute |
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Define respiration rhythm.
Normal? |
Pattern of respirations and intervals between.
Normal is regular. |
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Define pulse rate.
Normal range? |
# of pulse beats in 1 minute.
normal range is 60-100 beats/min. |
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Define pulse rhythm.
Normal? |
pattern of pulses and intervals between.
Normal is regular. |
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Define pulse volume.
Normal? |
pulse strength or amplitude.
Normal: 2+ |
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What 3 terms are used to describe respirations?
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-Rate
-Rhythm -Depth |
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What 3 terms are used to describe pulse?
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-Rate
-Rhythm -Volume |
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Is it normal for temp. to be lower in morning and higher in evening?
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Yes.
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Name 3 things that temp. can be raised by.
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-Hormones
-Meds. -Exercise |
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What is the oral temp range?
What is the avg. oral temp? |
Range: 96.8-100.4 F
Average: 98.6 |
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What is the rectal temp. range?
What is the avg. rectal temp? |
Range: 98.0-101.6
Average: 99.5 |
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What is the axillary temp. range?
Avg. axillary temp? |
Range: 95.8-99.4
Average: 97.7 |
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What 4 things will you look for when assessing skin color?
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-Cyanosis
-Pallor -Jaundice -Erythema |
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What is pallor?
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extreme paleness;loss of pink or yellow tones;a loss of red tones
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What can cause an abnormal pallor?
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Poor circulation or a low hemoglobin level(anemia)
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What are the best sites to assess for pallor?
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the oral mucous membranes, conjuctiva, nail beds, palms, and soles of feet.
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What is cyanosis?
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A blue-gray coloration of the skin, often described as ashen
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Where is cyanosis seen and what can cause it?
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-If seen in lips, mucous mem and facial features, known as central cyanosis and is assoc. w/ hypoxia.
-May also be seen in the extremities, esp. hands and feet, after exposure to extreme cold. |
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What is jaundice and what is it normally assoc. w/?
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A yellow-orange cast to the skin.
Normally assoc. w/liver disorders. |
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What are the best sites to assess for jaundice?
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sclera, mucous mem,hard palate of the mouth, palms, and soles.
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What is erythema and what is is assoc. w/?
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A reddened area.
Assoc. w/ rashes, skin inf, and prolonged pressure on the skin. |
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What 6 things are we going to assess skin for besides color?
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-Temp.
-Moisture -Texture -Edema -Turgor -Vascularity/bruising/lesions |
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What is turgor?
What does it provide data about? |
skin elasticity
hydration status |
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What is tenting?
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If skin sticks up for a few seconds when checking for turgor.
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What things are important to document when you encounter a lesion?
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-type of lesion
-specific location -pattern distribution |
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What is a macule?
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flat and colored, nonpalpable
ex: freckle, birthmark |
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What is a papule?
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elevated and raised but superficial, palpable
ex:mole,psoriasis |
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What is a cyst?
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palpable,fluid-filled,encapsulated
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What is the difference bw a papule and a plaque?
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have same qualities but a papule is <1cm and a plaque is >1cm.
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What is a pustule?
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palpable,elevated and filled w/pus.
ex:acne,folliculitis,impetigo |
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What is a nodule?
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palpable,elevated,solid and firm,with depth into dermis.
ex:wart,lipoma |
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What is a wheal?
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elevated,superficial,with localized edema
ex:insect bites,hives |
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What is a vesicle?
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palpable,elevated and filled w/serous fluid.
ex:blister,herpes simplex. |
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What are 3 things you are inspecting the nails for?
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-Color
-Clubbing -Capillary Refill |
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What are you looking for when assessing nail color?
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Nails are similar to color of the skin. Pale or cyanotic nails beds seen in clients w/ circulatory or respiratory disorders.
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What does clubbing of the nail look like?
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when the nail plate angle is 180 degrees or more.
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What does clubbing indicate?
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long-term hypoxic states such chronic lung disease.
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What is capillary refill and how do you assess it?
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how fast color returns to the nail after you press and quickly release it. Normal refill is <3 seconds.
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What does an abnormal capillary refill indicate?
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Impaired blood flow to the extremity.
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What 5 things are the scalp assessed for?
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-lesions
-lumps -bruises -lice -abnormal hair distribution |
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What is pruritus?
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a tingling or faintly burning skin sensation that prompts a person to rub or scratch.
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What is hirsutism?
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excess facial or trunk hair
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What is alopecia?
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hair loss.
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What is pediculosis?
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head lice infestation.
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What are primary skin lesions?
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develop as a result of disease or irritation.
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What are secondary skin lesions?
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develop from primary skin lesions as a result of continued illness,exposure,injury, or infection.
ex:crusts that form from ruptured pustules. |
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What 5 things do you assess the head and neck for?
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-size
-symmetry -presence of nodules -masses -bulges |
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What is acromegaly?
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chronic syndrome of growth hormone excess. char. by gradual coarsening and enlargement of bones and facial features.
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What is hydrocephalus?
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accumulation of excessive amts of CSF w/in ventricles of the brain.
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What is microcephaly?
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abnormal smallness of head
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What is lymphadenopathy?
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enlargement of lymphnodes
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What is TMJ syndrome?
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irregular jaw mvmt or cracking of the jaw.
TMJ=temporomandibular joint |
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What is diplopia?
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2 images of an object seen at the same time.(doublevision)
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What is exopthalmos?
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abnormal protrusion of the eyeball
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What is ptosis?
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dropping or drooping of an organ or part.
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What is strabismus?
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disorder of the eye in which optic axes cannot be directed to the same object.
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What is scleral icterus?
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jaundice
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What can effect the eye causing symptoms such as blurred vision or changes in pupil size and response?
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various meds
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What 3 things should you note about general eye appearance?
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Any irritation,discharge or swelling.
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What is nystagmus?
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eye quivers
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What do we need to inspect when doing an eye assessment?
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-external ocular structures
-conjuctiva and sclera,iris and pupil. |
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What is PERRLA?
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PE-pupils equal
R-round R-react to L-light and A-accomadation |
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What is vertigo?
What is otorrhea? What is tinnitis? |
vertigo-dizziness
otorrhea-drainage tinnitis-ringing of ears |
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What 4 things do we inspect the external ear for?
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-position
-condition of the skin -presence of lesions -drainage |
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What might low set ears mean?
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hearing deficit or genetic problems
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What is normal drainage?
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there should be no drainage
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What is the significance of bloody, purulent or watery drainage from the ear?
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bloody may result from trauma. purulent may be seen w/ infection.
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What 5 things are we inspecting nose for?
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-Placement
-Nasal flaring -Drainage -Nasal mucosa -Deviated septum |
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What does nasal flaring indicate?
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pt. may be having difficulty breathing
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What parts of the mouth and oropharynx should you inspect and what are you looking for?
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inspect lips,gingiva,buccal mucosa,tongue and pharynx for color,lesions,moistness and exudates.
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What is leukoplakia?
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white patches on tongue,hard,think,can be pre-cancerous.
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What is candidiasis?
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fungal inf.
AKA thrush |
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What is black hairy tongue caused by?
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bacterial infection
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What are signs of respiratory distress?
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-SOB
-restlessness -decreased mental alertness -cyanosis -pallor -nasal flaring -orthopnea -intercostal retractions -use of accessory muscles -increased heart rate |
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What can be the first sign of a lack of oxygen?
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restlessness
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What subjective data should you ask concerning the thorax and lungs?
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-Cough
-chest pain -history of respiratory infs -smoking history(pack/years) -environmental exposure -self-care behaviors |
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What is orthopnea?
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sitting up, laying on the overbed table to help breathe
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What does "use of acessory muscles" mean concerning respiratory distress?
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using shoulder,neck muscles to breathe
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What is tachypnea?
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rapid breathing, no increased depth
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What is hyperventilation?
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rapid pace and depth
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What is bradypnea?
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slow breathing
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What is hypoventilation?
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low. vol. breath, slow respiration
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What are Cheyne-Stokes respirations?
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a pattern w/ periods of apnea. usually occurs when pt. is terminal
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What are Biot's respirations?
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has shorter periods of apnea, 10-20 sec.
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What are Kussmaul's respirations
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rapid,deep breathing w/o pause. Sounds like sighing. Usually in pts. w/ diabetic acidosis.
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What do we need to look at when observing chest?
|
-Shape and symmetry
-swelling,masses,abnormal skin |
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What is a barrel chest?
When would it be present? |
a rounding in front and back
COPD |
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What are you looking for when palpating the chest?
|
-Masses
-Tenderness -Alignment -Retractions of chest or intercostal spaces |
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What are you using fingertips to feel for when palpating the chest?
|
-lumps,scars,lesions,
ulcerations -temp,turgor,moisture -subcutaneous crepitus |
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What is subcutaneous crepitus?
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air leakage under the skin, feels like rice crispies under the skin
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How do you assess tactile fremitus?
|
-place open palms on both sides of pts back
-Ask pt to say 99 loud enough for you to feel vibrations -repeat on anterior chest |
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What is a pneumothorax?
|
punctured lung
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What are the 4 percussion sounds that you may hear in the chest?
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-resonance
-dull sounds -hyperresonance -abnormal dullness |
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When would you hear resonance in the chest?
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over normal lung tissue
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When would you hear dull sounds in the chest?
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over the heart
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When would you hear hyperresonance in the chest?
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if there is increased air in lung or pleural space.
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When would you hear abnormal dullness in the chest?
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in areas of decreased air in lungs
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When could breath sounds be absent?
|
pneumothorax,lobectomy,mucus plug
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What are adventitous breath sounds?
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sounds heard not in normal breathing pattern
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What are tracheal breath sounds?
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-heard over trachea
-harsh,high-pitched -inspiration<expiration |
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What are bronchial breath sounds?
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-heard next to trachea
-loud,high-pitched -inspiration>expiration |
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What are bronchovesicular breath sounds?
|
-heard next to sternum and between scapulae
-medium in loudness and pitch -inspiration=expiration |
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What are vesicular breath sounds?
|
-heard in rest of lung(periphery)
-soft and low pitched -inspiration>expiration |
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What are 4 types of normal breath sounds?
|
-tracheal breath sounds
-bronchial -bronchovesicular -vesicular |
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What are 5 types of adventitous breath sounds?
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-crackles
-rhonchi -wheezes -stridor -pleural friction rub |
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What are coarse crackles?
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-frying or popping,moist,low-pitched
-inspiration, some expiration |
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What are medium crackles?
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-not as loud as coarse
-found in mid-inspiration |
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What are fine crackles?
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-non-continous,popping,high-pitched
-end of inspiration |
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What are rhonchi?
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-continuous,low-pitched,rattling
-expiration -usually can be cleared by coughing -caused by fluid partially blocking large airways |
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What are wheeezes?
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-continuous,high-pitched
-inspiration or expiration or both -caused by constriction of airway w/ resultant blockage of air flow. |
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What is stridor?
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-continuous,high-pitched,loud
-inspiration -caused by obstruction of airway |
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What is pleural friction rub?
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-low-pitched,grating,rubbing
-inspiration and expiration -caused by infl. of pleura -may have pain in area where heard |
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How do you assess bronchophony?
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have pt repeat 99 while you auscultate lung fields
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How do you assess egophony?
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ask pt to say "E"
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Where is the right base of the heart?
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2nd ICS right sternal border; aortic valve
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Where is the left base of the heart?
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2nd ICS left sternal border; pulmonic valve
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Where is the apex of the heart?
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5th ICS mid clavicular line; mitral valve
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Where is the tricuspid valve located?
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L lateral sternal border; 4th ICS L sternal border
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What is stridor?
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-continuous,high-pitched,loud
-inspiration -caused by obstruction of airway |
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What is pleural friction rub?
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-low-pitched,grating,rubbing
-inspiration and expiration -caused by infl. of pleura -may have pain in area where heard |
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How do you assess bronchophony?
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have pt repeat 99 while you auscultate lung fields
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How do you assess egophony?
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ask pt to say "E"
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Where is the right base of the heart?
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2nd ICS right sternal border; aortic valve
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Where is the left base of the heart?
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2nd ICS left sternal border; pulmonic valve
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Where is the apex of the heart?
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5th ICS mid clavicular line; mitral valve
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Where is the tricuspid valve located?
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L lateral sternal border; 4th ICS L sternal border
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What is the PMI?
Where is it located? |
pt. of maximal pulse
loc. 5th ICS MCL |
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What subjective data should you look out for concerning heart and neck vessels?
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-chest pain
-dyspnea -orthopnea -cough -fatigue -cyanosis or pallor -edema -nocturia -past cardiac history -family cardiac history -personal habits(cardiac risk factors) |
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What are some cardiac risk factors you should be aware?
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-smoking
-diabetes -lack of exercise -age -obesity -previous MI |
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What is a bruit?
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blowing,swishing sound indicating turbulent blood flow.
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What causes the normal heart sounds S1 and S2?
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S1- AV valves close
S2- Aortic valve shuts |
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Where is S1 heard best?
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at the apex
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Where is S2 heard best?
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at the base
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What technique should be used when auscultating the heart?
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-Begin w/ diaphragm
-Listen to 1 sound at a time -Note rate and rhythm *ID S1 and S2 separately -Assess S1 and S2 separately -Listen for extra heart sounds -Listen for murmurs w/ bell |
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What are extra heart sounds?
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S3,S4 and murmurs
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What causes murmurs?
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-increased velocity of blood
-decreased viscosity of blood -structural defects(narrowed or incompetent valve) or unusual openings (wall defect,dilated chamber) |
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Why are we listening to the heart?
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to determine the rate,regularity,to detect the presence of extra heart sounds and to detect the presence of murmurs and rubs.
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How is the presence of S3 determined?
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dull,low-pitched sound heard immediately after S2.
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What could be the significance of S3?
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in adults over 30 indicates ventricular failure(CHF)
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How is the presence of S4 determined?
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low-pitched sound heard late in diastole just before S1
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What could be the significance of S4?
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heard in elderly pts or those w/ previous MI
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What do murmurs sound like?
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gentle,blowing,swooshing sound
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What is the procedure for listening to the carotid artery to detect a bruit?
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use the bell
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What is a thrill and how is it detected?
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an abnormal tremor accompanying a vascular or cardiac murmur, felt on palpation
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What is the significance of distended jugular veins?
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means R side of heart is congested due to inadequate pump function
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When is it normal to have distended jugular veins?
When is it abnormal? |
when client lays flat.
when the client is in an upright position. |
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What are all the pulses you need to be able to palpate?
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-temporal
-carotid -apical -brachial -radial -femoral -popliteal -pedal *dorsalis pedis *posterior tibial |
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How do you assess Homan's sign?
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-w/ client in supine position,dorsiflex foot towards tibia
-calf pain may indicate deep vein thrombosis, phlebitis,tendonitis,muscle injury or lumbosacral disorders. -a positive homan's sign occurs in 35% of deep vein thromboses |
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What is phlebitis?
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infl. of a vein
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At what pulse site do we normally determine rate and regularity?
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at radial site
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When would it be important to compare radial pulse to opposite side and to listen to apical pulse?
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if pulse is faint or irregular.
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What are we determining when checking pedal pulses?
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if present and if they are faint or strong.
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What other assessments would indicate poor circulation to the extremities besides faint or absent pulses?
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-Pain
-Pallor -Paresthesia -Temperature |
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What is paresthesia?
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desc. by pts as a numbness or as a prickly,stinging, or burning feeling from injury to 1 or more nerves.
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What does 1+ mean on the pitting edema scale?
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(1cm) mild pitting,slight indentation,no swelling of leg
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What does 2+ mean on the pitting edema scale?
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(2cm) moderate pitting, indentation leaves quickly
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What does 3+ mean on the pitting edema scale?
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(3cm) Deep pitting, indentation remains for a while and leg appears swollen
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What does 4+ mean on the pitting edema scale?
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(4cm) very deep pitting, indentation remains for a long time, leg very swollen
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What you inspect the abdomen what are you looking for?
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-symmetry,contour
-discomfort,splinting, guarding -lesions,scars -bruising,discoloration -swelling,bulges,distention -ostomies,drains,dressings |
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What are you listening for when you auscultate the bowel sounds?
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-character
-frequency |
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What is the bowel sound frequency scale?
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5-35=normal
>35=hyperactive:loud,high-pitched,rushing,tinkling <5=hypoactive:can happen after surgery 0,absent:listen for 5 min. |
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How would you recognize ascites?
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abdomen taut and shiny
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What is CVA tenderness?
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tenderness at the costovertebral angle
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What subjective data do you need to be aware of when assessing the neurologic system?
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-headache
-head injury -vertigo -seizures -tremors -weakness -incoordination -numbness or tingling -difficulty swallowing -difficulty speaking -significant past history -environmental/occupational hazards |
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What neurological objective data do you need to assess?
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-level of consciousness
-orientation x 3 -glasgow coma scale -speech -memory lapses,deficits -coordination and balance |
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What does the Glasgow Coma scale determine?
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~eye-opening response
~motor response ~verbal response A fully alert,normal person's score is 15. |
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How do you assess deep tendon reflexes?
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w/ a rubber percussion hammer.
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What can put a pt at high rick for safety issues?
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-debilitated from illness,pain,etc.
-outside normal environment -hazards in HC environment -med treatments/processes |
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What are some characteristics that can put a client at a safety risk that should be assessed on admission?
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-age
-blindness -confusion -dz. consequences -emotional state -frequency of accidents -gait -habits/lifestyle -insufficient knowledge |
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What can you do to plan care to reduce risk/prevent injury?
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~be pro-active:look for safety hazards applicable to your client and their environment
~individualize care ~practice codes ~monitor systems/processes:monitor "near-misses" and actual accidents |
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What can you do to implement care w/ safety in mind?
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follow guidleines w/in procedure manuals
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What should you do to evaluate client status and safety risk?
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-continuous reassessment
-Are we meeting goal:pt will remain safe and free from injury. |
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What is our primary concern?
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patient safety
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What was the IOM report?
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"To err is human"
-medical errors are the 8th leading cause of death in US -80% of errors due to system or process failure |
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What is an adverse event?
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an injury caused by med. management rather than by the underlying dz or cond of the pt
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What is a sentinel event?
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an unexpected occurence involving death ot serious physical or psychological injury, or the risk thereof.
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How can we improve accuracy of pt identification?
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~Use at least 2 identifiers
-not room # -not verbal self-id. ~Should be specific to: -organization -resident |
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What are 4 approved pt identifiers?
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-pt name
-account # -MRI # -Date of birth |
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What are 4 examples of sentinel events?
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-falls
-med errors -wrong-site surgery -suicide |
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How can we improve effectiveness of comm. among caregivers?
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-telephone orders/telephone reporting of critical test results
-prohibited abreviations and acronyms -improve timeliness of reporting critical test results -standardized approach to "hand-off" comm -opportunity for question |
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What is the most frequently reported reason for sentinel events?
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ineffective communication
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How can you assure accuracy of verbal orders?
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-verify the full name of pt and person giving the order
-READ back the entire order to the caller to verify accuracy |
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What should you do when your pt has a critical value?
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notify doc if the current plan of care does not address the critical value.
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What info do you communicate when someone else assumes care of the pt?
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-current and past info about care,treatment,and cond including any recent or anticipated changes.
-must be minimal interruption and an opportunity to ask questions. |
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What does SBAR stand for and what is it used for?
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S-situation
B-background A-assessment R-recommendation ~used as a guideline when nurse is talking to doc about a pt situation and what they think should be done |
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How can we improve the safety of using meds?
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-standardize and limit the # of drug conc. available in hospital.
-ID a list of "look-alike-sound-alike drugs used in hospital -label all meds,meds containers,and solns on and off sterile field |
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What must a drug label include?
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drug name,strength amt,expiration date and time IF the meds will expire in less than 24 hours
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How can we reduce pt. harm assoc. w/ the use of anticoagulant therapy?
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-implement a define anticoagulant mgmt program
-use only oral unit dose prods and pre-mixed infusions -approved protocols for initiation and maint. of anticoagulant therapy. -policy for baseline and on-going lab tests -education for staff,pts,families |
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How can we reduce the risk of HC assoc. inf?
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-comply w/ current CDC hand hygiene guidelines
-manage as sentinel events all cases of unanticipated death or major perm. loss of function assoc. w/ HC assoc. inf. |
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How can we accurately and completely reconcile meds across the continuum of care?
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-compare meds taken prior to admission with those ordered at admission
-provide list of meds when pt is referred or transferred to another setting,service,practioner or level of care w/in or outside the organization. |
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How can we reduce the risk of pt harm resulting from falls?
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-implement a fall reduction program
-evaluate the effectiveness of the prgram |
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How can we encourage pts active involvement in their own care as a pt safety strategy?
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Define and comm the means for pts and their fams to report concerns about safety and ecourage them to do so.
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How can we recognize and respond to changes in a pts condition?
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-select an early recognition and response method
-criteria for calling additional assistance -formal education in urgent response policies and procedures for requesters and responders -Measure cardiopulmonary arrest, respiratory arrest and mortality rates before and after implementation of early intervention plan |
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What are the Universal Protocols to eliminate wrong site,wrong pt,wrong procedure surgery?
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~pre-operative verification process
~marking the operative site ~time-out immediately b4 starting procedure |
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How should you view the client when doing an assessment and what should you avoid?
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-view them holistically
-avoid assumptions |
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What are 4 sources of data?
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-pt.
-family -diagnostic tests -previous records |
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What are 3 ways to collect data?
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-observation
-interview -exam |
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What kind of data are we collecting during the assessment?
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-subjective vs. objective data
-avoid judgments or conclusions |
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What are defining characteristics?
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observable s/s present to support certain nursing diagnoses.
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What are the steps to formulate a nursing process diagnosis/analysis?
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-identify health probs
-formulate nursing diagnosis -actual or potential prob -write nursing diagnosis |
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How do we ID health problems?
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-analyze and interpret data
-ID broad problem area |
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How do we formulate a nursing diagnosis?
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-has to be soemthing that nurse can treat
-match client symptoms to definig char. |
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What is the difference bw an actual and a potential problem?
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-actual:problem exists
-potential:problem will occur w/o nursing intervention |
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What are we treating w/ a nursing diagnosis?
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pts response to med diagnosis
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What is the nursing diagnosis?
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-statement of a client problem
-actual or potential -w/in scope of nursing practice -directive of nursing intervention |
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What is the nursing diagnosis NOT?
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-a medical diagnosis
-a nursing action:comes from diagnosis -a physician order -a therapeutic treatment |
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What are the related factors in the nursing diagnosis?
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the most common causes for Actual Problem.
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What are the 3 main parts of the nursing diagnosis for an Actual Problem?
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1.Actual Problem
2.Causes (related to) 3.S/S(as evidenced by) ex: Impaired skin integrity related to physical immobility as evidenced by 1 in. circular lesion on R hip. |
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What are the 2 main parts of the nursing diagnosis for a Potential Problem?
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-risk for
-related to ex: Risk for Impaired Skin Integrity related to immobility,poor nutrition,age. |
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What are 2 main things we need to do during planning of the nursing diagnosis?
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-Rank client's needs in order of priority (Maslow)
*to order delivery of nursing care -Help pt set realistic goals/outcomes *guidepost to selection of nursing interventions *criteria for eval. of care |
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What 3 things do we need when writing planning goals?
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-Specific
*realistic *observable *measurable -Action verbs -Time frames *short term *long term |
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What do we need to do cncerning planning once we have the nursing diagnosis and goal?
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-Write a nursing care plan
*select specific nursing interventions *comm. w/ HC team -Discharge planning *begun on admission *continuous through hospital stay *carries over to post-hospitalization |
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Why do we need to begin discharge planning on admission?
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so that goals can be met and carried over if neccessary.
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What does Implementation of the nursing diagnosis involve?
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-carries out interventions
-documents nursing care given ex:give pain inj and doc how they responded to intervention -continues to collect data *revising and updating |
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What does Evaluation mainly mean?
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did pt meet the goal?
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What are you evaluating during Evaluation?
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-evaluate actions
*occurs concurrently while giving care *effective,tolerated by pt -evaluate goals *progress towards outcome *met,partially met,not met -evaluate care plan *changes as pt progresses *new probs,new goals,new actions |
