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17 Cards in this Set

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THE NURSING PROCESS (ADPIE)
THE NURSING PROCESS (ADPIE)

A = Assessment
D = Diagnoses
P = Planning
I = Implementation
E = Evaluation
SUBJECTIVE vs. OBJECTIVE DATA
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
DIAGNOSTIC STATEMENT (PES)
DIAGNOSTIC STATEMENT
(PES Format)

P = Problem
E = Etiology
S = Signs & Symptoms
OPEN ENDED Q's vs. CLOSE ENDED Q's
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
PHYSICAL EXAMINATION TECHNIQUES (IPPAM)
PHYSICAL EXAMINATION TECHNIQUES (IPPAM)

1. Inspection
2. Palpation
3. Percussion
4. Auscultaion
5. Measurement
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
3 TYPES OF NORMAL BREATH SOUNDS
3 TYPES OF NORMAL BREATH SOUNDS
1. Bronchial (Tracheal/Tubular)
2. Bronchovesicular
3. Vesicular
4 TYPES OF ABNORMAL/ADVENTITIOUS LUNG SOUNDS
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.
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.
PQRST
PQRST

P = Provokes/point
Q = Quality
R = Radiation/relief
S = Severity/s&s
T = Time/onset
COLDERRA
COLDERRA

C = Characteristics
O = Onset
L = Location
D = Duration
E = Exacerbation
R = Radiation
R = Relief
A = Associated s&s
NEUROVASCULAR STATUS: Checking the 6 P's
NEUROVASCULAR STATUS: Checking the 6 P's

1. Pain
2. Pallor
3. Polar
4. Paresthesia
5. Paralysis
6. Pulse
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)
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
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
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%
ALBUMIN (Description)
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