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303 Cards in this Set

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What is a synonym for critical thinking?
Reasoning
What are the 5 steps of the Nursing Process in order?
1. Assessment
2. Diagnosis(analysis)
3. Planning
4. Implementation
5. Evaluation
The nursing diagnosis is a blueprint for ____?
critical thinking
What is critical thinking?
A combo. of reasoned thinking, openness to alternatives, an ability to reflect, and a desire to seek truth.
List 7 principles that define Critical Thinking in Nursing.
-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.
What is clinical judgment?
Nursing opinion and/or nursing decision made about person, family or group in a certain period of time.
What is the nursing process?
~problem-solving process based on the scientific method
~the way one thinks like a nurse
~not the care plan, not the charting
Why do we need to know the nursing process?
~It's the conceptual framework of all nursing curricula.
~Nurse Practice Acts
~Standards of Clinical Practice of ANA
~JCAHO
When do we use the nursing process?
~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.
__% of ____ in the elderly occur in healthcare facilities?
10% of falls.
An increased frequency(3mo. or so) of accidents could mean what?
Vision or neurological problems among other things.
What is the acronym to remember the steps after a fire in a HC facility?
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)
When would it be necessary to have engineering check the equipment in a client's room?
~Should always make sure engineering has approved any equipment.
~Especially when equip. has been brought from home.
What is a pts natural inclination concerning a restraint?
to remove the restraint.
What should you be aware of regarding restraint?
pressure ulcers, contractures, bowel and urinary incontinence, etc.
What is inspection?
a visual exam. of all parts of the body. What you see.
What are some general inspection guidelines?
-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.
What is palpation?
touching-feeling with fingers/hands.
How might you encourage relaxation during palpation?
Palpate tender areas last.
What function does the dorsal surface of the hand have in palpation?
temperature
What function do the finger tips have in palpation?
texture, size, consistency, pulsation, form and shape.
What function does the palmar surface of the hand have in palpation?
vibration
What is percussion?
Tapping the body w/ fingertips to evaluate size, borders, density, air or fluid,
What is auscultation and when is it usually performed?
It is listening to sounds and it is usually performed last after inspection, palpation, and percussion.
What are the 5 major parts of the stethoscope?
-earpieces
-binaurals
-tubing
-bell chestpiece
-diaphragm chestpiece
How long should the apical pulse ALWAYS be taken for?
1 minute.
At what point of the heart would you be able to hear a murmur?
Erb's point
What does Orientation X 3 mean?
When you ask Person, Place and Time while doing a neurological assessment.
What are crackles and when you would be most likely to hear it?
It's air moving thru fluid in the lungs. More likely to hear on inspiration.
What are rhonchi and when would you be more likely to hear them?
mucus in the lungs, generally heard in smokers and ppl w/ bronchitis. More likely to hear during exhalation.
What are Critical thinking skills used in the problem solving process?
-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
What are six critical thinking attitudes?
-independent thinking
-intellectual curiousity
-intellectual humility
-intellectual empathy
-intellectual courage
-intellectual perseverance
-fair-mindedness
What are comorbidities?
concurrently occurring health problems
What six things make a client unique and influence how they respond to illness or healthcare intervention?
~individual differences
~culture
~the client's role
~age
~personal bias
~previous experience w/ healthcare problems
What two things make critical thinking important for nurses?
~nurses deal w/ complex situations daily
~each client is unique
What are 3 things about nursing itself that require the nurse to be a critical thinker?
~Nursing is an applied discipline.
~Nursing uses knowledge from other fields.
~Nursing is fast-paced.
What is theoretical knowledge?
~information, facts, principles and theories in nursing and related disciplines.
What does theoretical knowledge consist of?
~Research findings
~Rationally constructed explanations of phenomena.
What is practical knowledge?

What does it consist of?
knowing what to do and how to do it.

consists of processes and procedures.
What is ethical knowledge?
knowledge of obligation, or right and wrong.
What does ethical knowledge consist of?
consists of info. about moral principles and processes for making moral decisions.
Which part of the stethoscope would you use to hear low-pitched sounds?
the bell
Which part of the stethoscope would you use to hear high-pitched sounds?
the diaphragm.
What are the 3 essential components of the Nursing Assessment?
~Health history
~Physical and psychosocial assessment
~Analysis of lab and diagnostic tests
What is subjective data?
what the patient tells you.
What is objective data?
What you can see.
What are some variables that you should consider when performing a physical assessment?
~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.
What are 3 successful techniques to encourage assessment?
-encouraging verbalization
-reflection
-active listening
What are 3 techniques that inhibit assessment?
-leading/biased questions
-giving advice/opinions
-providing unrealistic reassurance
What are the 6 data collection methods used during assessment?
-nursing history
-observation
-inspection
-palpation
-percussion
-auscultation
What is observation?
process of gathering info that can be perceived by 1 or more senses.
ex: odor, pallor, coughing
What are some guidelines to follow when carrying out observation?
~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)
What 9 things should be asked when taking a chronological acct. of a patient's chief complaint?
-Location
-Radiation
-Quality
-Quantity
-Assoc. manifestations
-Aggravating factors
-Alleviating factors
-Setting
-Timing
What things should be asked when taking a Past Health History?
-Medical
-Surgical
-Meds(OTC,herbal and RX)
-Communicable diseases
-Allergies
-Injuries/accidents
-Disabilities/handicaps
-Childhood illnesses
-Immunizations
What things should be asked when taking a Social History?
-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
What should be asked about the pts Health Maintenance Activities during the interview?
-Sleep
-Diet
-Exercise
-Stress Mgmt.
-Use of safety devices
-Health checkups
What is 1 respiration?
1 respiratory cycle=1 inspiration + 1 expiration
Define respiration rate.

Normal range?
# of respiratory cycles in 1 minute.

Normal range is 12-20/minute
Define respiration rhythm.

Normal?
Pattern of respirations and intervals between.

Normal is regular.
Define pulse rate.

Normal range?
# of pulse beats in 1 minute.

normal range is 60-100 beats/min.
Define pulse rhythm.

Normal?
pattern of pulses and intervals between.

Normal is regular.
Define pulse volume.

Normal?
pulse strength or amplitude.

Normal: 2+
What 3 terms are used to describe respirations?
-Rate
-Rhythm
-Depth
What 3 terms are used to describe pulse?
-Rate
-Rhythm
-Volume
Is it normal for temp. to be lower in morning and higher in evening?
Yes.
Name 3 things that temp. can be raised by.
-Hormones
-Meds.
-Exercise
What is the oral temp range?

What is the avg. oral temp?
Range: 96.8-100.4 F

Average: 98.6
What is the rectal temp. range?

What is the avg. rectal temp?
Range: 98.0-101.6

Average: 99.5
What is the axillary temp. range?

Avg. axillary temp?
Range: 95.8-99.4

Average: 97.7
What 4 things will you look for when assessing skin color?
-Cyanosis
-Pallor
-Jaundice
-Erythema
What is pallor?
extreme paleness;loss of pink or yellow tones;a loss of red tones
What can cause an abnormal pallor?
Poor circulation or a low hemoglobin level(anemia)
What are the best sites to assess for pallor?
the oral mucous membranes, conjuctiva, nail beds, palms, and soles of feet.
What is cyanosis?
A blue-gray coloration of the skin, often described as ashen
Where is cyanosis seen and what can cause it?
-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.
What is jaundice and what is it normally assoc. w/?
A yellow-orange cast to the skin.
Normally assoc. w/liver disorders.
What are the best sites to assess for jaundice?
sclera, mucous mem,hard palate of the mouth, palms, and soles.
What is erythema and what is is assoc. w/?
A reddened area.
Assoc. w/ rashes, skin inf, and prolonged pressure on the skin.
What 6 things are we going to assess skin for besides color?
-Temp.
-Moisture
-Texture
-Edema
-Turgor
-Vascularity/bruising/lesions
What is turgor?

What does it provide data about?
skin elasticity

hydration status
What is tenting?
If skin sticks up for a few seconds when checking for turgor.
What things are important to document when you encounter a lesion?
-type of lesion
-specific location
-pattern
distribution
What is a macule?
flat and colored, nonpalpable

ex: freckle, birthmark
What is a papule?
elevated and raised but superficial, palpable

ex:mole,psoriasis
What is a cyst?
palpable,fluid-filled,encapsulated
What is the difference bw a papule and a patch?
have same qualities but a papule is <1cm and a patch is >1cm.
What is 1 respiration?
1 respiratory cycle=1 inspiration + 1 expiration
Define respiration rate.

Normal range?
# of respiratory cycles in 1 minute.

Normal range is 12-20/minute
Define respiration rhythm.

Normal?
Pattern of respirations and intervals between.

Normal is regular.
Define pulse rate.

Normal range?
# of pulse beats in 1 minute.

normal range is 60-100 beats/min.
Define pulse rhythm.

Normal?
pattern of pulses and intervals between.

Normal is regular.
Define pulse volume.

Normal?
pulse strength or amplitude.

Normal: 2+
What 3 terms are used to describe respirations?
-Rate
-Rhythm
-Depth
What 3 terms are used to describe pulse?
-Rate
-Rhythm
-Volume
Is it normal for temp. to be lower in morning and higher in evening?
Yes.
Name 3 things that temp. can be raised by.
-Hormones
-Meds.
-Exercise
What is the oral temp range?

What is the avg. oral temp?
Range: 96.8-100.4 F

Average: 98.6
What is the rectal temp. range?

What is the avg. rectal temp?
Range: 98.0-101.6

Average: 99.5
What is the axillary temp. range?

Avg. axillary temp?
Range: 95.8-99.4

Average: 97.7
What 4 things will you look for when assessing skin color?
-Cyanosis
-Pallor
-Jaundice
-Erythema
What is pallor?
extreme paleness;loss of pink or yellow tones;a loss of red tones
What can cause an abnormal pallor?
Poor circulation or a low hemoglobin level(anemia)
What are the best sites to assess for pallor?
the oral mucous membranes, conjuctiva, nail beds, palms, and soles of feet.
What is cyanosis?
A blue-gray coloration of the skin, often described as ashen
Where is cyanosis seen and what can cause it?
-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.
What is jaundice and what is it normally assoc. w/?
A yellow-orange cast to the skin.
Normally assoc. w/liver disorders.
What are the best sites to assess for jaundice?
sclera, mucous mem,hard palate of the mouth, palms, and soles.
What is erythema and what is is assoc. w/?
A reddened area.
Assoc. w/ rashes, skin inf, and prolonged pressure on the skin.
What 6 things are we going to assess skin for besides color?
-Temp.
-Moisture
-Texture
-Edema
-Turgor
-Vascularity/bruising/lesions
What is turgor?

What does it provide data about?
skin elasticity

hydration status
What is tenting?
If skin sticks up for a few seconds when checking for turgor.
What things are important to document when you encounter a lesion?
-type of lesion
-specific location
-pattern
distribution
What is a macule?
flat and colored, nonpalpable

ex: freckle, birthmark
What is a papule?
elevated and raised but superficial, palpable

ex:mole,psoriasis
What is a cyst?
palpable,fluid-filled,encapsulated
What is the difference bw a papule and a plaque?
have same qualities but a papule is <1cm and a plaque is >1cm.
What is a pustule?
palpable,elevated and filled w/pus.
ex:acne,folliculitis,impetigo
What is a nodule?
palpable,elevated,solid and firm,with depth into dermis.
ex:wart,lipoma
What is a wheal?
elevated,superficial,with localized edema
ex:insect bites,hives
What is a vesicle?
palpable,elevated and filled w/serous fluid.
ex:blister,herpes simplex.
What are 3 things you are inspecting the nails for?
-Color
-Clubbing
-Capillary Refill
What are you looking for when assessing nail color?
Nails are similar to color of the skin. Pale or cyanotic nails beds seen in clients w/ circulatory or respiratory disorders.
What does clubbing of the nail look like?
when the nail plate angle is 180 degrees or more.
What does clubbing indicate?
long-term hypoxic states such chronic lung disease.
What is capillary refill and how do you assess it?
how fast color returns to the nail after you press and quickly release it. Normal refill is <3 seconds.
What does an abnormal capillary refill indicate?
Impaired blood flow to the extremity.
What 5 things are the scalp assessed for?
-lesions
-lumps
-bruises
-lice
-abnormal hair distribution
What is pruritus?
a tingling or faintly burning skin sensation that prompts a person to rub or scratch.
What is hirsutism?
excess facial or trunk hair
What is alopecia?
hair loss.
What is pediculosis?
head lice infestation.
What are primary skin lesions?
develop as a result of disease or irritation.
What are secondary skin lesions?
develop from primary skin lesions as a result of continued illness,exposure,injury, or infection.
ex:crusts that form from ruptured pustules.
What 5 things do you assess the head and neck for?
-size
-symmetry
-presence of nodules
-masses
-bulges
What is acromegaly?
chronic syndrome of growth hormone excess. char. by gradual coarsening and enlargement of bones and facial features.
What is hydrocephalus?
accumulation of excessive amts of CSF w/in ventricles of the brain.
What is microcephaly?
abnormal smallness of head
What is lymphadenopathy?
enlargement of lymphnodes
What is TMJ syndrome?
irregular jaw mvmt or cracking of the jaw.
TMJ=temporomandibular joint
What is diplopia?
2 images of an object seen at the same time.(doublevision)
What is exopthalmos?
abnormal protrusion of the eyeball
What is ptosis?
dropping or drooping of an organ or part.
What is strabismus?
disorder of the eye in which optic axes cannot be directed to the same object.
What is scleral icterus?
jaundice
What can effect the eye causing symptoms such as blurred vision or changes in pupil size and response?
various meds
What 3 things should you note about general eye appearance?
Any irritation,discharge or swelling.
What is nystagmus?
eye quivers
What do we need to inspect when doing an eye assessment?
-external ocular structures
-conjuctiva and sclera,iris and pupil.
What is PERRLA?
PE-pupils equal
R-round
R-react to
L-light and
A-accomadation
What is vertigo?
What is otorrhea?
What is tinnitis?
vertigo-dizziness
otorrhea-drainage
tinnitis-ringing of ears
What 4 things do we inspect the external ear for?
-position
-condition of the skin
-presence of lesions
-drainage
What might low set ears mean?
hearing deficit or genetic problems
What is normal drainage?
there should be no drainage
What is the significance of bloody, purulent or watery drainage from the ear?
bloody may result from trauma. purulent may be seen w/ infection.
What 5 things are we inspecting nose for?
-Placement
-Nasal flaring
-Drainage
-Nasal mucosa
-Deviated septum
What does nasal flaring indicate?
pt. may be having difficulty breathing
What parts of the mouth and oropharynx should you inspect and what are you looking for?
inspect lips,gingiva,buccal mucosa,tongue and pharynx for color,lesions,moistness and exudates.
What is leukoplakia?
white patches on tongue,hard,think,can be pre-cancerous.
What is candidiasis?
fungal inf.
AKA thrush
What is black hairy tongue caused by?
bacterial infection
What are signs of respiratory distress?
-SOB
-restlessness
-decreased mental alertness
-cyanosis
-pallor
-nasal flaring
-orthopnea
-intercostal retractions
-use of accessory muscles
-increased heart rate
What can be the first sign of a lack of oxygen?
restlessness
What subjective data should you ask concerning the thorax and lungs?
-Cough
-chest pain
-history of respiratory infs
-smoking history(pack/years)
-environmental exposure
-self-care behaviors
What is orthopnea?
sitting up, laying on the overbed table to help breathe
What does "use of acessory muscles" mean concerning respiratory distress?
using shoulder,neck muscles to breathe
What is tachypnea?
rapid breathing, no increased depth
What is hyperventilation?
rapid pace and depth
What is bradypnea?
slow breathing
What is hypoventilation?
low. vol. breath, slow respiration
What are Cheyne-Stokes respirations?
a pattern w/ periods of apnea. usually occurs when pt. is terminal
What are Biot's respirations?
has shorter periods of apnea, 10-20 sec.
What are Kussmaul's respirations
rapid,deep breathing w/o pause. Sounds like sighing. Usually in pts. w/ diabetic acidosis.
What do we need to look at when observing chest?
-Shape and symmetry
-swelling,masses,abnormal skin
What is a barrel chest?

When would it be present?
a rounding in front and back

COPD
What are you looking for when palpating the chest?
-Masses
-Tenderness
-Alignment
-Retractions of chest or intercostal spaces
What are you using fingertips to feel for when palpating the chest?
-lumps,scars,lesions,
ulcerations
-temp,turgor,moisture
-subcutaneous crepitus
What is subcutaneous crepitus?
air leakage under the skin, feels like rice crispies under the skin
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
What is a pneumothorax?
punctured lung
What are the 4 percussion sounds that you may hear in the chest?
-resonance
-dull sounds
-hyperresonance
-abnormal dullness
When would you hear resonance in the chest?
over normal lung tissue
When would you hear dull sounds in the chest?
over the heart
When would you hear hyperresonance in the chest?
if there is increased air in lung or pleural space.
When would you hear abnormal dullness in the chest?
in areas of decreased air in lungs
When could breath sounds be absent?
pneumothorax,lobectomy,mucus plug
What are adventitous breath sounds?
sounds heard not in normal breathing pattern
What are tracheal breath sounds?
-heard over trachea
-harsh,high-pitched
-inspiration<expiration
What are bronchial breath sounds?
-heard next to trachea
-loud,high-pitched
-inspiration>expiration
What are bronchovesicular breath sounds?
-heard next to sternum and between scapulae
-medium in loudness and pitch
-inspiration=expiration
What are vesicular breath sounds?
-heard in rest of lung(periphery)
-soft and low pitched
-inspiration>expiration
What are 4 types of normal breath sounds?
-tracheal breath sounds
-bronchial
-bronchovesicular
-vesicular
What are 5 types of adventitous breath sounds?
-crackles
-rhonchi
-wheezes
-stridor
-pleural friction rub
What are coarse crackles?
-frying or popping,moist,low-pitched
-inspiration, some expiration
What are medium crackles?
-not as loud as coarse
-found in mid-inspiration
What are fine crackles?
-non-continous,popping,high-pitched
-end of inspiration
What are rhonchi?
-continuous,low-pitched,rattling
-expiration
-usually can be cleared by coughing
-caused by fluid partially blocking large airways
What are wheeezes?
-continuous,high-pitched
-inspiration or expiration or both
-caused by constriction of airway w/ resultant blockage of air flow.
What is stridor?
-continuous,high-pitched,loud
-inspiration
-caused by obstruction of airway
What is pleural friction rub?
-low-pitched,grating,rubbing
-inspiration and expiration
-caused by infl. of pleura
-may have pain in area where heard
How do you assess bronchophony?
have pt repeat 99 while you auscultate lung fields
How do you assess egophony?
ask pt to say "E"
Where is the right base of the heart?
2nd ICS right sternal border; aortic valve
Where is the left base of the heart?
2nd ICS left sternal border; pulmonic valve
Where is the apex of the heart?
5th ICS mid clavicular line; mitral valve
Where is the tricuspid valve located?
L lateral sternal border; 4th ICS L sternal border
What is stridor?
-continuous,high-pitched,loud
-inspiration
-caused by obstruction of airway
What is pleural friction rub?
-low-pitched,grating,rubbing
-inspiration and expiration
-caused by infl. of pleura
-may have pain in area where heard
How do you assess bronchophony?
have pt repeat 99 while you auscultate lung fields
How do you assess egophony?
ask pt to say "E"
Where is the right base of the heart?
2nd ICS right sternal border; aortic valve
Where is the left base of the heart?
2nd ICS left sternal border; pulmonic valve
Where is the apex of the heart?
5th ICS mid clavicular line; mitral valve
Where is the tricuspid valve located?
L lateral sternal border; 4th ICS L sternal border
What is the PMI?

Where is it located?
pt. of maximal pulse

loc. 5th ICS MCL
What subjective data should you look out for concerning heart and neck vessels?
-chest pain
-dyspnea
-orthopnea
-cough
-fatigue
-cyanosis or pallor
-edema
-nocturia
-past cardiac history
-family cardiac history
-personal habits(cardiac risk factors)
What are some cardiac risk factors you should be aware?
-smoking
-diabetes
-lack of exercise
-age
-obesity
-previous MI
What is a bruit?
blowing,swishing sound indicating turbulent blood flow.
What causes the normal heart sounds S1 and S2?
S1- AV valves close
S2- Aortic valve shuts
Where is S1 heard best?
at the apex
Where is S2 heard best?
at the base
What technique should be used when auscultating the heart?
-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
What are extra heart sounds?
S3,S4 and murmurs
What causes murmurs?
-increased velocity of blood
-decreased viscosity of blood
-structural defects(narrowed or incompetent valve) or unusual openings (wall defect,dilated chamber)
Why are we listening to the heart?
to determine the rate,regularity,to detect the presence of extra heart sounds and to detect the presence of murmurs and rubs.
How is the presence of S3 determined?
dull,low-pitched sound heard immediately after S2.
What could be the significance of S3?
in adults over 30 indicates ventricular failure(CHF)
How is the presence of S4 determined?
low-pitched sound heard late in diastole just before S1
What could be the significance of S4?
heard in elderly pts or those w/ previous MI
What do murmurs sound like?
gentle,blowing,swooshing sound
What is the procedure for listening to the carotid artery to detect a bruit?
use the bell
What is a thrill and how is it detected?
an abnormal tremor accompanying a vascular or cardiac murmur, felt on palpation
What is the significance of distended jugular veins?
means R side of heart is congested due to inadequate pump function
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.
What are all the pulses you need to be able to palpate?
-temporal
-carotid
-apical
-brachial
-radial
-femoral
-popliteal
-pedal
*dorsalis pedis
*posterior tibial
How do you assess Homan's sign?
-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
What is phlebitis?
infl. of a vein
At what pulse site do we normally determine rate and regularity?
at radial site
When would it be important to compare radial pulse to opposite side and to listen to apical pulse?
if pulse is faint or irregular.
What are we determining when checking pedal pulses?
if present and if they are faint or strong.
What other assessments would indicate poor circulation to the extremities besides faint or absent pulses?
-Pain
-Pallor
-Paresthesia
-Temperature
What is paresthesia?
desc. by pts as a numbness or as a prickly,stinging, or burning feeling from injury to 1 or more nerves.
What does 1+ mean on the pitting edema scale?
(1cm) mild pitting,slight indentation,no swelling of leg
What does 2+ mean on the pitting edema scale?
(2cm) moderate pitting, indentation leaves quickly
What does 3+ mean on the pitting edema scale?
(3cm) Deep pitting, indentation remains for a while and leg appears swollen
What does 4+ mean on the pitting edema scale?
(4cm) very deep pitting, indentation remains for a long time, leg very swollen
What you inspect the abdomen what are you looking for?
-symmetry,contour
-discomfort,splinting,
guarding
-lesions,scars
-bruising,discoloration
-swelling,bulges,distention
-ostomies,drains,dressings
What are you listening for when you auscultate the bowel sounds?
-character
-frequency
What is the bowel sound frequency scale?
5-35=normal
>35=hyperactive:loud,high-pitched,rushing,tinkling
<5=hypoactive:can happen after surgery
0,absent:listen for 5 min.
How would you recognize ascites?
abdomen taut and shiny
What is CVA tenderness?
tenderness at the costovertebral angle
What subjective data do you need to be aware of when assessing the neurologic system?
-headache
-head injury
-vertigo
-seizures
-tremors
-weakness
-incoordination
-numbness or tingling
-difficulty swallowing
-difficulty speaking
-significant past history
-environmental/occupational hazards
What neurological objective data do you need to assess?
-level of consciousness
-orientation x 3
-glasgow coma scale
-speech
-memory lapses,deficits
-coordination and balance
What does the Glasgow Coma scale determine?
~eye-opening response
~motor response
~verbal response
A fully alert,normal person's score is 15.
How do you assess deep tendon reflexes?
w/ a rubber percussion hammer.
What can put a pt at high rick for safety issues?
-debilitated from illness,pain,etc.
-outside normal environment
-hazards in HC environment
-med treatments/processes
What are some characteristics that can put a client at a safety risk that should be assessed on admission?
-age
-blindness
-confusion
-dz. consequences
-emotional state
-frequency of accidents
-gait
-habits/lifestyle
-insufficient knowledge
What can you do to plan care to reduce risk/prevent injury?
~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
What can you do to implement care w/ safety in mind?
follow guidleines w/in procedure manuals
What should you do to evaluate client status and safety risk?
-continuous reassessment
-Are we meeting goal:pt will remain safe and free from injury.
What is our primary concern?
patient safety
What was the IOM report?
"To err is human"
-medical errors are the 8th leading cause of death in US
-80% of errors due to system or process failure
What is an adverse event?
an injury caused by med. management rather than by the underlying dz or cond of the pt
What is a sentinel event?
an unexpected occurence involving death ot serious physical or psychological injury, or the risk thereof.
How can we improve accuracy of pt identification?
~Use at least 2 identifiers
-not room #
-not verbal self-id.
~Should be specific to:
-organization
-resident
What are 4 approved pt identifiers?
-pt name
-account #
-MRI #
-Date of birth
What are 4 examples of sentinel events?
-falls
-med errors
-wrong-site surgery
-suicide
How can we improve effectiveness of comm. among caregivers?
-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
What is the most frequently reported reason for sentinel events?
ineffective communication
How can you assure accuracy of verbal orders?
-verify the full name of pt and person giving the order
-READ back the entire order to the caller to verify accuracy
What should you do when your pt has a critical value?
notify doc if the current plan of care does not address the critical value.
What info do you communicate when someone else assumes care of the pt?
-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.
What does SBAR stand for and what is it used for?
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
How can we improve the safety of using meds?
-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
What must a drug label include?
drug name,strength amt,expiration date and time IF the meds will expire in less than 24 hours
How can we reduce pt. harm assoc. w/ the use of anticoagulant therapy?
-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
How can we reduce the risk of HC assoc. inf?
-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.
How can we accurately and completely reconcile meds across the continuum of care?
-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.
How can we reduce the risk of pt harm resulting from falls?
-implement a fall reduction program
-evaluate the effectiveness of the prgram
How can we encourage pts active involvement in their own care as a pt safety strategy?
Define and comm the means for pts and their fams to report concerns about safety and ecourage them to do so.
How can we recognize and respond to changes in a pts condition?
-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
What are the Universal Protocols to eliminate wrong site,wrong pt,wrong procedure surgery?
~pre-operative verification process
~marking the operative site
~time-out immediately b4 starting procedure
How should you view the client when doing an assessment and what should you avoid?
-view them holistically
-avoid assumptions
What are 4 sources of data?
-pt.
-family
-diagnostic tests
-previous records
What are 3 ways to collect data?
-observation
-interview
-exam
What kind of data are we collecting during the assessment?
-subjective vs. objective data
-avoid judgments or conclusions
What are defining characteristics?
observable s/s present to support certain nursing diagnoses.
What are the steps to formulate a nursing process diagnosis/analysis?
-identify health probs
-formulate nursing diagnosis
-actual or potential prob
-write nursing diagnosis
How do we ID health problems?
-analyze and interpret data
-ID broad problem area
How do we formulate a nursing diagnosis?
-has to be soemthing that nurse can treat
-match client symptoms to definig char.
What is the difference bw an actual and a potential problem?
-actual:problem exists
-potential:problem will occur w/o nursing intervention
What are we treating w/ a nursing diagnosis?
pts response to med diagnosis
What is the nursing diagnosis?
-statement of a client problem
-actual or potential
-w/in scope of nursing practice
-directive of nursing intervention
What is the nursing diagnosis NOT?
-a medical diagnosis
-a nursing action:comes from diagnosis
-a physician order
-a therapeutic treatment
What are the related factors in the nursing diagnosis?
the most common causes for Actual Problem.
What are the 3 main parts of the nursing diagnosis for an Actual Problem?
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.
What are the 2 main parts of the nursing diagnosis for a Potential Problem?
-risk for
-related to
ex: Risk for Impaired Skin Integrity related to immobility,poor nutrition,age.
What are 2 main things we need to do during planning of the nursing diagnosis?
-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
What 3 things do we need when writing planning goals?
-Specific
*realistic
*observable
*measurable
-Action verbs
-Time frames
*short term
*long term
What do we need to do cncerning planning once we have the nursing diagnosis and goal?
-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
Why do we need to begin discharge planning on admission?
so that goals can be met and carried over if neccessary.
What does Implementation of the nursing diagnosis involve?
-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
What does Evaluation mainly mean?
did pt meet the goal?
What are you evaluating during Evaluation?
-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