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97 Cards in this Set
- Front
- Back
- 3rd side (hint)
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GOALS OF NURSING |
1. promote 2. prevent 3. treat 4. advocate |
TAPP |
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5 rights of patients |
1. altruism 2. human dignity 3. autonomy 4. integrity 5. social justice |
HIS AA |
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a systematic method of collecting data about a client for the purpose of determining the client's current and ongoing health status, predicting risks to health, and identifying health promoting activities. Also, to establish baseline for the patient, in which all other data collected can be compared |
health assessment |
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a systematic, problem-solving approach to identifying and treating human responces to actual or potential health difficulties |
the nursing process |
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The Nursing Process |
Assessment Diagnosis Planning Implementation Evaluation
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ADPIE |
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patient centered, focused on solving problems, enhancing strengths. The essence and method of nurses critical thinking and diagnostic reasoning |
the nursing process |
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knowledge, role, evidence-based practice, ethics |
critical thinking
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REEK |
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NDx |
nursing diagnosis |
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verbal expression of nurses critical thinking and diagnostic reasoning |
NDx |
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AAOx3 |
awake, alert and oriented to person, place, time |
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Maslow's Hierarchy of needs |
physicological --> saftey --> belongingness and love --> esteem needs --> self actualization |
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components of health assessment |
1. health interview 2. physical exam |
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types of health assessment |
1. initial 2. problem-focused 3. emergency 4. ongoing |
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stages of interview |
1. preinteraction/introduction 2. working/body 3. closing |
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SBAR |
situation background assessment recommendation |
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primary information |
from client |
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secondary information |
from family/friends |
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skin, hair, nails |
integumentary system |
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techniques for integumentary assessment |
palpation, observation, odor |
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assess nails |
determine curvature and angle; texture; tissue surronding nails, clubbing |
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natural covering of an organism |
integument |
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3 skin layers |
epidermis, dermis, subcutaneous |
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what is hair composed of? |
keratin rooted in the dermis |
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where does hair get its blood supply? |
the dermis |
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made of slow growing, hardened keritin |
nails |
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function of skin |
structure, protection, thermoregulation role in immune response |
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Skin reflects the status of your... |
nutrition, hydration, medication, perfusion, endocrine, digestion |
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in assessment, skin should be... |
clean, dry, intact |
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document normal skins as |
C/D/I |
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if an IV is in, is skin CDI? |
no, it is not intact |
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Braden Scale is for... |
predicting pressure sore risk
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nomocephalic |
normal shaped head |
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it it normal to blink involuntarily ________ per minute |
15-20 times |
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pupils should be ___________ mm in diameter |
3-7 |
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Pain assessment |
Provocation (what) Quality/Quantity (use descriptive words) Region/Radiation (where) Severity (1-10) Timing (when did it start, how long does it last, how often does it occur) |
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Folstein Test or MMSE |
Mini Mental State Exam |
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LOC |
level of conciousness |
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immediate recall assessment |
repeat 3 #s in a row. gradually increase #s. Start again with same 3 #s but ask to repeat backwards |
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recent memory assessment |
recall the days events (those which can be validated) |
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remotememory assessment |
ask about birthday or anniversary |
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Romberg Test assesses |
equillibrium |
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Self Skin Assessment |
Asymmetrical Borders are uneven Color Diameter (larger than pencil eraser) Evolving (change) |
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BP normal |
90/50 120/80 130/90 |
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Normal HR |
60-100 bpm |
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Normal temperature |
96.8-99.5 |
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Normal RR |
12-20 |
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Normal pulse ox |
95-100% |
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UAP |
unlicensed assistive personnel |
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R/T |
related to |
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AEB |
as evidenced by |
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GCS |
Glascow Coma Scale |
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Cluster and organize data of patient to draw inference and propose NDx |
Diagnostic reasoning |
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Verbal expression of nurses critical thinking and diagnostic reasoning |
NDx |
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Components of health assessment |
Interview, physical exam |
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Types of health assessment |
Initial, problem-focused, emergency, ongoing |
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Pain assessment |
Provocation Quality/Quantity Region/Radiation Timing |
PQRST |
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observation of breasts |
size, symmetry, shape, countour |
SSSC |
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localized hypervascular areas |
large veins |
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how to emphasize retraction in breasts |
raise arms above head; push hands together, elbows flexed |
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it is most important to palpate______ during a breast exam |
axillary, subclavicular, supraclavicular lymph nodes |
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indication of abdominal aortic aneryism |
pulsing in abdomon |
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breast growth in men |
gynecomastia |
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quadrants of abdomen |
RLQ, RUQ, LUQ, LLQ |
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normoactive bowel sounds |
gurgling every 5-20 seconds |
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hypoactive bowel sounds |
soft/infrequent 2-3 per minute |
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hyperactive bowel sounds |
high pitched, loud rushing sounds, every 3 seconds |
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abnormal sound generated by a turbulent flow of blood in an artery due to either an area of partial obstruction; or a localized high right of blood flow through an obstructed artery |
bruit |
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a normal bladder should____during palpation |
not be felt |
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where to palpate to palpate bladder |
area above pubic symphysis |
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ileus |
bowel blockage |
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5 P's of Sex History |
Partners Practices Protection Past history Prevention of pregnancy |
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Slight pitting, no visable distortion, disappears rapidly 2mn or less |
1+ edema |
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Somewhat deeper pit, no readily detectable distortion, disappears 10-15 sec. 2-4mm indent |
2+ edema |
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Pit noticeably deep, last more than 1 minute, dependent extremity looks fuller 4-6mm |
3+ edema |
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Pit very deep, last 2-5 minutes, extremity grossly distorted 6-8mm |
4+ edema |
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nonblanchaeble erythema of intact skin or discoloration of skin, with warmth and edema |
stage 1 pressure ulcer |
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partial thickness of skin loss involving epidermis, dermis, or both |
stage 2 pressure ulcer |
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full thickness of skin involving damage of necrosis to subcutaneous tissue, a deep crater without any underlying tissue |
stage 3 pressure ulcer |
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full thickness skin loss with extensive destruction, tissue necrosis, and possible damage of muscle, bone, or supporting structures |
stage 4 pressure ulcer |
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measure the amount someone has smoked over a long period of time |
number of packs per day x number of years a person has been smoking, ppd or pack year |
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3+ measurements for metabolic symptom |
Fasting glucpse of 100mg/dl + Abdominal Obesity (40+ men, 35+ women) Sys. BP of 130+, Dys. 85+ Triglyceride of 150+ HDL less than 40 in men, 30 in women |
FATHS |
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HT/WT/BMI |
anthropometrics |
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normoactive bowel |
gurgling every 5-20 seconds |
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hypoactive bowel |
soft, infrequent, 2-3/minute |
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hyperactive bowel |
high pitch, loud rushing, every 3 seconds |
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absent bowel |
none for 3-5 minutes |
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hold breath, bear down as though have a bowel movement. What is it called? What does it do? |
Valsalva Maneuver reveal inguinal hernia |
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vibration felt through chest wall when patient speaks |
tactile fremitus |
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full and symmetric thorax expansion, thumbs should_____ |
move apart 1-2" |
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S1 is louder at the |
apical area |
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S2 is louder at the |
base of the heart |
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S1 sound |
LUB |
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S2 sound |
DUB |
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symptom: cyanosis, brown ankles |
venous insuffiency |
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symptom: dusky red pallor, cool skin, slow cap refill |
arterial insuffiency |
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edema, waxy shiny skin |
arterial or venous insuffiency |
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neurovascular status, 5 PS |
pain, pulse, pallor, paresthesia, paralysis |
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