Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
137 Cards in this Set
- Front
- Back
|
Hematocrit |
Females: 36%-48% Males: 42%-52% |
|
|
Hemoglobin |
Females: 12-16 g/dL Males: 14-17.4 g/dL |
|
|
White Blood Count |
4,000-10,000/mcL |
|
|
Red Blood Cells |
Females: 4-5 Million RBC/ml Males: 4.5-5.5 Million RBC/ml
|
|
|
Complete Blood Count Tests for What? |
Hematocrit, Hemoglobin, WBC, and RBC |
|
|
Basic Metabolic Panel tests for what? |
Sodium, Potassium, Calcium, BUN, and Creatnine. |
|
|
Sodium |
Adults and Children: 135-145 mEq/L |
|
|
Potassium |
3.5-5 mEq/L |
|
|
Calcium (Ca) |
Adults: 8.2-10.2 mg/dL |
|
|
BUN |
8-20 mg/dL |
|
|
Creatnine |
Females: 0.6-0.9 mg/dL Males: 0.8-1.2 mg/dL |
|
|
Prothrombin Time |
10-14 Seconds |
|
|
Prothrombin Time (Patients taking Coumadin) |
1-2.5 times the normal limit |
|
|
Partial Thromboplastin Time |
21-35 Seconds |
|
|
Partial Thromboplastin Time (Patients taking Heparin) |
2-2.5 times the normal limit |
|
|
International Normalized Ratio (INR) |
Coumadin Therapy - A. Fib: 2.0-3.0 Mechanical Prosthetic Heart Valve: 3.0-4.5 |
|
|
Why would Hematocrit and Hemoglobin be high? |
High H+H could indicate polycythemia, |
|
|
Why would Hematocrit and Hemoglobin be Low? |
Low H+H would indicate anemia. |
|
|
What does and elevated WBC count indicate? |
Infection |
|
|
Why could RBC's be low? |
Hemorrhage |
|
|
Why could Potassium be high? |
This would indicate hyperkalemia - and shows that your kidneys are not working properly. |
|
|
Why could Potassium be low? |
Potassium could be too low because of loss of electrolytes through diarrhea and vomiting. Also through too much antibiotics. |
|
|
What medications does the INR monitor? |
Coumadin |
|
|
What could happen to the patient if the INR is too high? |
Excessive bleeding anywhere in the body. |
|
|
Platelet Count |
Adults: 140,000-400,000/uL |
|
|
What does BMP measure? |
BUN, creatnine, glucose, Serum Chloride, Serum Potassium, Serum Sodium, Carbon dioxide. |
|
|
What drugs require drug monitoring? |
Dilantin, Digoxin, Vancomycin, Gentamycin, Heparin, Coumadin, and Depakote. |
|
|
Patient Safety (Diagnostic tests) |
Identify the patient using two identifiers (Name, and DOB) |
|
|
Acute Pain |
Short term, unrelieved can cause chronic pain and other problems |
|
|
Chronic Pain |
More than 6 months, symptoms other than pain, may have "break through pain" or acute pain. |
|
|
Cancer Pain |
Seen in advanced cancer patients, related to tumor progression, infections, or treatments, referred pain. |
|
|
Pathological Process Pain |
Somatic, Visceral, Neuropathic |
|
|
Somatic Pain |
Dull, ache, musculoskeletal |
|
|
Visceral Pain |
Cramp, internal organs |
|
|
Neuropathic |
Burning or sharp, Damage to nerves |
|
|
Idiopathic Pain |
WE JUST DON'T KNOW WHY |
|
|
Factors that influence pain |
Age, Fatigue, Genetics, Previous experience, Family and social support, Anxiety and coping, Culture. |
|
|
Cultural Differences |
Expression of pain varies: May or may not be vocal about it.
Acceptable levels of pain
May be related to spiritual beliefs: you must suffer to enter heaven.
Asking for help may be viewed as weakness or lack of respect. |
|
|
Factors that alter Sleep and Rest |
Environment, Medication use, Exercises and fatigue, Lifestyle, Food and calorie intake, Sleep patterns, Emotional Stress, Sleep disorders |
|
|
What steps do you use in Pain Assessment? |
PQRST |
|
|
What does the P stand for in "PQRST" |
Provocation (What caused the pain, or provoked it?) |
|
|
What does the Q stand for in "PQRST" |
Quality and Quantity (What does it feel like?) |
|
|
What does the R stand for in "PQRST"? |
Region/Radiation (where is it? Does it move?) |
|
|
What does the S stand for in "PQRST" |
Severity (for this use the scales) |
|
|
What does the T stand for in "PQRST" |
Timing (is the pain worse at any specific time of the day? When does it start? When does it stop?) |
|
|
Numeric Rating Scale |
Rate your pain from 0-10 (zero being no pain, and 10 being the worst possible pain) |
|
|
Wong-Baker Faces Scale |
Goes from 0-2-4-6-8-10 (showing smiley-crying face) use mostly for children. |
|
|
OUCHER pain scale |
Goes from 0-100 on the pain level, and shows pictures of children (different ethnicities and genders) |
|
|
Flacc Pain Scale |
Vocalizations of pain, facial expressions, body movements, and social interactions. Add the points up at the end. |
|
|
What are some barriers to pain assessment? |
Non verbal status, non English speaking, culture, bias, unclear assessment questions, and incorrect use of tools. |
|
|
What are skills for physical assessment? |
Inspection, palpation, percussion, auscultation. |
|
|
Inspection |
You're looking for symmetry, any skin discoloration, breaks in the skin, swelling/edema, and the appearance of the skin (shiny, dry and flakey, or distention) |
|
|
Palpation |
Uses the sense of touch as part of the assessment |
|
|
What are you assessing for when you use palpation? |
Swelling, vibration or pulsation, rigidity or spasticity, crepitation, lumps or masses, and the presence of pain or tenderness. |
|
|
What are you looking for when using the dorsa of your hand? |
Temperature (thinnest skin) |
|
|
What are you looking for when you use your fingertips? |
Moisture, texture, pulsations, edema... |
|
|
What do the base of your fingers feel? |
vibration |
|
|
What are you looking for when you're using the grasping action of your fingers and thumb? |
Size, shape, and consistency of a mass. |
|
|
Percussion |
Elecits a characteristic sound or vibration, and assists with determining location, size, and density of an organ. |
|
|
Percussion Sounds |
Resonant, Hyperresonant, Tympanic, Flat, and Dull |
|
|
Resonant |
Medium amplitude, Low pitch, and hollow quality. |
|
|
Hyperresonant |
Loud amplitude, Booming quality |
|
|
Flat |
Soft amplitude, high pitch, dead stop (thigh muscle, or tumor) |
|
|
Dull |
Soft amplitude, high pitch, muffled quality, (masses and organs) |
|
|
Tympany |
Loud amplitude, high pitch, (over air filled masses) |
|
|
Auscultation |
Listening to body sounds using a stethoscope. |
|
|
Bell |
Soft, low pitched sounds like heart sounds (press lightly when using) |
|
|
Diaphragm |
High pitched sounds, like lung and bowel sounds. (press firmly when using, should leave a little bit of a red ring when you let up) |
|
|
How can you be successful in using Auscultation? |
Avoid extra noise in the room, keep the PT warm (warm your stethoscope before using it on the PT), be aware of hairy surfaces, always auscultate on skin (not through clothing), avoid adding your own noise (like bumping or rubbing the tube while listening) |
|
|
SOAP |
S: Subjective O: Objective A: Assessment P: Plan |
|
|
SOAPIE |
S: Subjective O: Objective A: Assessment P: Plan I: Implementation E: Evaluation
|
|
|
APIE |
A: Assessment P: Plan I: Implementation E: Evaluation |
|
|
PIE |
P: Plan I: Implementation E: Evaluation |
|
|
What is the purpose of interview and history? |
To collect and gather physical data, obtain baseline data about the patient, gather data to begin your nursing process, identify the patients needs. |
|
|
Who are your sources of information during an interview? |
Patient, family members, observers, caretakers, and the patients EMR. |
|
|
What is Subjective informtation? |
What the patient says. When charting subjective information, you must ALWAYS use quotations and write down exactly the patients words. |
|
|
What is objective information? |
Your observations. They are all measureable. Ex: vital signs. |
|
|
Setting the stage of an interview |
Introduce yourself, and your role (if you are a nursing student, you must say so), provide privacy (private rooms are preferred, but simply closing a shade can provide psychological privacy for the PT), and explain why it is that you're doing this interview. |
|
|
Set An Agenda |
Start with the patients chief complaint, or reason for being in the hospital. Always be focused on the patient, their concerns, and their wants/needs. Always allow the patient to become an active partner in their own care plan. |
|
|
Techniques of the interview |
Asking open ended questions, back channeling, probing, and the use of close ended questions. |
|
|
Open Ended Questions |
Require the patient to elaborate on previous statements, cannot be answered with just a yes or a no. |
|
|
Back Channeling |
Keeps the patient talking, and makes the patient feel as if you are engaged in the conversations, using terms like, "Uh-huh", "Go on"... |
|
|
Probing |
Asking questions to make the patient explain themselves until they have nothing left to say. |
|
|
Close ended Questions |
Questions that only require a yes or no answer. |
|
|
When collecting a health hx, what are you going to ask about? |
Reason for seeking care, patient expectations, current illness, home life, monetary concerns, and biographical data. |
|
|
What type of past events will you ask the patient about? |
Past hospitalizations, past surgeries, and past illnesses. |
|
|
What type of medications are you going to ask the patient about? |
You're not only going to ask the patient if they're on any current medications from their doctor, but you're also going to ask if they are taking any over the counter, vitamin supplements, or herbal supplements, for these may effect your plan of care. |
|
|
Allergies |
Ask the patient if they have any allergies, (NOT ADVERSE REACTIONS) to ANYTHING. This includes but it not limited to any medications, food, or anything in the environment. |
|
|
Habits |
You're going to ask the patient if they engage in any habitual behavior such as smoking, alcohol consumption, and recreational drug usage. |
|
|
What environmental concerns might you have about a patient? |
Their work situation. Are they around any harmful chemicals or pollutants in the workplace? Do they have any barriers in their home that might be a risk for injury? |
|
|
Psychosocial |
Does the patient have any hx or mental illness such as depression, or anxiety? What are their coping mechanisms? Are they healthy coping mechanisms? |
|
|
Spiritual |
Do they practice any religion? If so, how involved are they? Do they practice any rituals? |
|
|
What are you looking for when assessing a patients physical appearance? |
Age (Do they seem to look they age they say they are?) Sexual development (are they at the stage they should be for their age?) Level of conciousness (are they alert? Skin color (Are they of even tone? Any lesions?) Facial Features (Are they symmetrical?) Making sure there are no signs of acute distress. |
|
|
What are we observing when it comes to the patients behavior? |
Facial expressions (are they appropriate for the conversation?), mood and affect, speech (are they speaking properly?), dress (Are they dressed appropriately for the weather?), and personal hygiene (do they appear to have showered? Brushed hair? Brushed teeth?). |
|
|
What do you document? |
WHAT YOU OBSERVE You are not to document you opinion, just gather data. |
|
|
Call lights (and Potential Problems) |
Must always be within the patients reach. If one thing does not work , then there is a potential for all of them to be malfunctioning. May control multiple things in the room. Safety sticker needs to be within the proper date. |
|
|
Common Patient Equipment |
IV pumps, poles, and bags. Portable O2, Oxygen flow meters attached to the wall, call lights, beds, side rails, bed side tables, catheter bags, chest tube collection chamber, sequential compression devices, compression stockings, wall suction. |
|
|
IV (and potential problems) |
Pump not on (not getting prescribed meds or fluids) Pump not connected to pt (liquid on flood can cause falls) Pump at wrong rate (can cause multiple types of pt harm) Machine safety date expired, open wires, alarms (fire hazard, risk for machine malfuntions) Tubing impending pt movement or ambulation (safety risk) |
|
|
Oxygen (and potential problems) |
Flow meter correct Based on MD order Correctly applied to the patient |
|
|
Beds (and potential problems) |
Should always be in the lowest position when pt is not attended. Side rails. X1, X2, X3, X4 Check hospital policies. Side Rails X4 is a RESTRAINT - not used unless you have MD orders. What is safe depends on the pt X2 is the most common (Upper 2) |
|
|
Alarms |
Some beds have alarms that can be set based on patient need. Can be attached to a pt and to bed or chair. |
|
|
Bedside tables (and potential problems) |
Not to be used as a bed side rail because they MOVE and do not have LOCKS Check to be sure the table is w/in the patients reach. Ensure wheels are free from clutter (this means no linens, or catheters near it) |
|
|
Catheter bags (and potential problems) |
Hung on NON MOVEABLE PART OF THE BED (this means not on siderails or bed joints)
Leaking bags (fall risk) Bags not closed correctly |
|
|
Chest tubes (and potential problems) |
Collection containers always need to be UPRIGHT They should never fall over May be connected to suction Make sure they are not under the bed but bedside the bed Never raised above the lung Do NOT tug or pull on the actual tube inserted into the pt's body. |
|
|
Sequential Compression Device (SCD) (and potential problems) |
Only on in bed or in a chair Staff should place and remove Be aware of the bed/base unit and cords |
|
|
Compression Stockings (TEDS) (and potential problems) |
Must wear foot wear with stockings ID if the are knee or thigh stockings, worn correctly Fit correctly |
|
|
Nasogastric Tubes (and potential problems) |
Pinned to the patients gown Taped to patients nose |
|
|
Suction Set Up |
Used for many reasons Calibration of suction based upon pt need at the time and MD's orders. Suction should not be on full vac continuously Used suction catheters are discarded after use Suction containers are emptied as needed and or when full |
|
|
Physical Deformities |
Does the patient have any obvious physical deformities? |
|
|
Posture |
Is the patient standing or sitting up straight? |
|
|
Body Build |
Is the patients weight appropriate for their height, and build? |
|
|
Gait and ROM |
Are they walking with a proper gait? And do they have full range of motion? |
|
|
Nutrition |
Do they appear to be healthy? Is their body weight distributed properly? |
|
|
Symmetry |
Does their right and left side of the body seem to be even? |
|
|
Young Adults (Late Teens to Late 30's) |
Accounts for about 1/3 of the population Risks? Family hx, person hygiene, violent death and injury, substance abuse, STD's, and other environments/occupational factors. |
|
|
Middle Age Adults (35-64) |
Accounts for about 40% of the population They are called the sandwich generation because they are caring for children as well as caring for their elderly parents. Health concerns? Obesity, anxiety, depression, stress.
|
|
|
What is passive health promotion? |
Passive health promotion is something that is regulated amongst the government. Fluoride in water sources Seat belts IPV laws Hand washing signs OSHA laws |
|
|
What is active health promotion? (for young and middle age adults) |
Active health promotion is something that we ACTIVELY do to promote self health. Knowing our family hx Hand washing Oral Hygiene Wearing seatbelts No impaired driving No Drug use Minimal alcohol use No Smoking Condom use Not living near pollutants
|
|
|
What is active promotion for predominantly young adults? |
Mediation Laughter Having a normal BMI No STI's Diet Changes Daily Activity |
|
|
Older Adult (Over 65) |
Accounts for 13% of the population By 2030, 72.1 Million americans will be over 65 Health risks/concerns? Heart Disease Cancer CVA Smoking Alcohol Nutrition |
|
|
Concerns and Safety risks for the Older Adult |
Dental problems Lack of Exercise Chronic Pain Depression Changes in Memory Polypharmacy Sensory Impariments |
|
|
Health promotion for the older adult |
Regular Screening Regular Exercise Weight Reduction, low fat diet Moderate alcohol use Dental Health STOP SMOKING Immunizations Remove enviro. hazards related to falls Use assistive devices CORRECTLY Wear glasses, hearing aides Correct shoes Avoid Polypharmacy |
|
|
Physical Assessment activities for ALL AGES |
Weight and Height Food Diary Sensory Assessment ROM testing Oral Cavity Exam Question Relate to oral hygiene Interview related to family hx Med use/hx
|
|
|
Psychological Assessment Activities for All AGES |
"Has anyone hurt you?" Affect, overall appearance, eye contact Hx of mental illness or substance abuse S/S of anxiety Physical assessment r/t unknown injury or bruising PT statements of job or family related stressors |
|
|
Risk Factors for Acute Illness |
Hand washing Accidents Family hx |
|
|
Risk Factors for Chronic Illness |
Smoking Alcohol/RX use Poor Diet Family Hx |
|
|
WHO's factors of Wellness |
Physical Emotional Occupational Spiritual Social Intellectual |
|
|
Components of Health and Wellness |
The ability to perform at ones best. The ability to adapt. A reported feeling of "being well" A feeling that everything is together and harmonious. |
|
|
What is health promotion? |
Activities to move towards the wellness end of the wellness-illness continuum. Activities that encourage a high level of wellness and avoid preventable illnesses.
|
|
|
Components of Health Promotion |
Self responsibility Nutritional awareness Stress reduction and management Physical Fitness |
|
|
What influences Health belief and practices? |
Developmental stage Intellectual background Perception of function Emotions Spiritual Family practices Socioeconomic factors Culture |
|
|
Maslows Heirarchy of Needs |
Physiological (food, water, shelter, warmth) Safety (security, stability, freedom from fear) Beloning - Love (friends, spouse, lover, family) Self Esteem (achievement, mastery, recognition, respect) Self Actualization (pursue inner talent, creativity, fulfillment.) |
|
|
Primary care |
Preventative care
|
|
|
Secondary Care
|
Currently Experiencing a health issue. |
|
|
Tertiary |
treatments for short term problems, or assisting in the comfort of imminent death. |
|
|
Stages of Change |
Pre-contemplation, Contemplation, Preparation, Action, Maintenance. |
|
|
Allopathic Medicine |
A group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine. |
