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17 Cards in this Set
- Front
- Back
THE NURSING PROCESS (ADPIE)
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THE NURSING PROCESS (ADPIE)
A = Assessment D = Diagnoses P = Planning I = Implementation E = Evaluation |
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SUBJECTIVE vs. OBJECTIVE DATA
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SUBJECTIVE vs. OBJECTIVE DATA
SUBJECTIVE DATA - symptoms - patient's feelings, or individual perception of problems and needs OBJECTIVE DATA - signs - physical exam, laboratory findings, direct observation |
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DIAGNOSTIC STATEMENT (PES)
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DIAGNOSTIC STATEMENT
(PES Format) P = Problem E = Etiology S = Signs & Symptoms |
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OPEN ENDED Q's vs. CLOSE ENDED Q's
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OPEN ENDED Q's - general info
- not useful when interviewing a confused pt/emergent situation CLOSE ENDED Q's - fact finding - focus on ceratin area/concern to elicit infor quickly & efficiently |
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PHYSICAL EXAMINATION TECHNIQUES (IPPAM)
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PHYSICAL EXAMINATION TECHNIQUES (IPPAM)
1. Inspection 2. Palpation 3. Percussion 4. Auscultaion 5. Measurement |
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HEAD EXAMINATION
(HEENT) |
HEAD EXAMINATION
(HEENT) H = Head... Condition of hair and scalp. Symmetry of face E = Eyes Do conjunctiva and sclera appear normal in color and hydration? Are pupils PERLA? E = Ears... Hearing aids, impairment, pain, drainage N = Nose... Congestion, drainage, sense of smell T = Dentures, musous membranes pink & hydrated, odor, hygiene, JVD, tracheal alignment, retractions |
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3 TYPES OF NORMAL BREATH SOUNDS
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3 TYPES OF NORMAL BREATH SOUNDS
1. Bronchial (Tracheal/Tubular) 2. Bronchovesicular 3. Vesicular |
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4 TYPES OF ABNORMAL/ADVENTITIOUS LUNG SOUNDS
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4 TYPES OF ABNORMAL/ADVENTITIOUS LUNG SOUNDS
1. Crackles (rales)- simulated b rolling a lock of hair near the ear between two fingers. Best heard on inspiration in the lower bases. Not relieved by coughing. 2. Ronchi - Coarse, arsh, loud gurgling. Best heard on expiration over bronchi and trachea. May be relieved b coughing. 3. Wheezes: high pitched squeeky sound. Best heard on expiration over all ling fields. Unrelieved by coughing. 4. Stridor - Harsh, high pitched sound heard during both inspiration and expiraion. Can easily be heard without a stethoscpoe and is inidcative of a progressive narrowing of the upper airway. Can be an indication of upper airway obstruction and can be life threatening, requiring immediate attention. |
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EXAMINATION OF THE ABDOMEN
(IAPP) |
EXAMINATION OF THE ABDOMEN
(IAPP)- look, listen and feel 1. Inspect - skin distention, scars, obesity, herniations, etc. 2. Auscultate - BS -> hypo: every minute; normal: every 15-20 sec; hyper: about every 3 sec 3. Percuss Dullness - solid organ Tympany - air filled, bowels Resonance - lungs Flatness - muscle, bone 4. Palpate - pulsation, masses, tenderness, rigidity. When assessing pain, always work from area of least pain towads area of most pain. |
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PQRST
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PQRST
P = Provokes/point Q = Quality R = Radiation/relief S = Severity/s&s T = Time/onset |
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COLDERRA
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COLDERRA
C = Characteristics O = Onset L = Location D = Duration E = Exacerbation R = Radiation R = Relief A = Associated s&s |
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NEUROVASCULAR STATUS: Checking the 6 P's
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NEUROVASCULAR STATUS: Checking the 6 P's
1. Pain 2. Pallor 3. Polar 4. Paresthesia 5. Paralysis 6. Pulse |
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Normal ARTERIAL BLOOD GAS (ABG) values for adults
pH pCO2 HCO3 pO2 SaO2 Anion gap Base excess |
Normal ARTERIAL BLOOD GAS (ABG) values for adults
pH (arterial) = 7.35 - 7.45 pCO2 (mmHg) = 35 - 45 HCO3 (mEq/L) = 22 - 26 pO2 (mmHg) = 75 - 100 SaO2 (%) = 95 100 Anion gap Base excess = 10 - 12 mEq/L; (+/- 2mEq/L) |
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ELECTROLYTES
Sodium (Na) Potassium (K) CO2 combining power Calcium, total (Ca) Calcium, ionized Magnesium (Mg) |
ELECTROLYTES
Sodium (Na) = 135 - 145 mEq/L Potassium (K) = 3.5 - 5.1 CO2 combining power = 22-30mEq/L Calcium, total (Ca) = 4.5 - 5.5 mEq/L Calcium, ionized = 2.2 - 2.5 mEq/L Magnesium (Mg) 1.5 - 2.5 mEq/L |
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GLUCOSE
Fasting (FNS) (serum, plasma) (whole blood); (elderly) panic values: Fingerstick glucose (self monitoring device) |
GLUCOSE
Fasting (FNS) 70 - 110mg/dl (serum, plasma) 60 - 100mg/dl (whole blood); 70 - 120mg/dl (elderly) panic values: <40 or >700mg/dl Fingerstick glucose (self monitoring device) 60 - 100mg/dl |
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HEMATOLOGY
WBC RBC (men),(women) Hemoglobin (Hgb) (men),(women) Hematocrit (Hct)(men),(women) Platelet count: Neutrophils: (absolute count) |
HEMATOLOGY
WBC = 5,000 - 10,000, 4,500-11,500/mm3 RBC = 4.5 - 5.3 million or mm3 (men), 4.1-5.1 milliom or mm3 (women) Hemoglobin (Hgb) 13.0-18.0 g/100ml (men), 12-16g/100ml (women) Hematocrit (Hct)37-49% (men), 36-46% (women) Platelet count: 150,000-400,000/mm3 Neutrophils: 1,935-7,942 (absolute count) or 45-75% |
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ALBUMIN (Description)
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ALBUMIN
- component of protein synthesized by the liver - responsible for increasing osmotic pressure to maintain intravascular fluid retention and transportation of hormones, fatty acids, bilirubin, meds, & substances insoluble in water; a decrease in albumin will cause fluid shifts from the blood vessels into the tissues causing edema formation |