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65 Cards in this Set

  • Front
  • Back
what are the essential components of the nursing assessment?
health history, physical and psychosocial assessment, analysis of laboratory and diagnostic tests
what are the aspects of critical thinking?
control and purpose
what is critical judgement?
nursing opinion made about a pat, family, etc at a certain point in time
what is the difference between novice thinking and expert thinking?
Novice- relies on literature and fact, etc

Expert- have vast array of knowledge in head
what are the five steps of the nursing process?
assessment, diagnosis, planning, implementation and evaluation
define implementation
carrying out the interventions, putting them into action
what is the purpose of the nursing assessment?
nursing care is based on the results of the assessment
what is the average rate for a pulse over 1 minute?
60 to 100 bpm 80bpm average
what is the normal temperature for:
oral and tympanic:
oral/tympanic = 98.6
axillary = 97.7
rectal = 99.5
what are the functions of the following parts of the hand?

dorsal surface
finger tips
palmer surface
dorsal surface = temperature
finger tips = texture, size, pulse, forms, etc
palmar surface = vibrations
what do bronchovesicular breath sounds sound like?
medium pitched with an equal inspiratory and expiratory phase
what is critical thinking+
a combination of reasoned thinking, openness to alternatives, an ability to reflect, and a desire to seek truth
what do the vesicular breath sounds sound like?
soft, low pitched breezy sound with a lengthy inspiration phase and a short expiration
what do bronchial breath sounds sound like?
loud, high pitched tubular sounds. inspiration is of longer duration then exhalation
what is stereognisis?
the ability to recognize the form of a silid object by touch
what is graphesthesia?
the ability to recogize outlines, numbers or symbols written on the skin
what is an adverse event?
an injury caused by medical management rather than by the underlying disease or condition of the pt
what is a sentinel event?
an unexpected occurance involving death or serious physical or psychological injury
where would you listen to the mitral valve?

How does it sound?
at the apex, 5th ICS in the mid clavicular line

s1 is louder than s2
where would you listen to the tricuspid valve?

How does it sound?
left lateral sternal border - from the apex move finer up to the 4th ICS, then move close to the sternum

s1 is louder than or equal to s2
where would you listen to the aortic valve?

How does it sound?
base right - 2nd ICS

s2 is louder than s1
where would you listen to the pulmonic valve?

How does it sound?
base left - 2nd ICS

s2 is louder than s1
where is s1 (lub) heard the loudest?
at the apex (mitral and tricuspid)
what part of the steth. do you listen for murmurs with?
the bell
what is the active stage of the heart called?
what are the semilunar valves?
pulmonic and aortic
what are the atrioventricular valves?
tricuspid and mitral
what is the resting stage of the heart called?
what is bradypnea?
slow respirations
what is tachypnea?
rapid respirations
what is some objective ata collected when doing a chest/lung assessment?
shortness of breath
decreased mental alertness
nasal flaring
what is some of the subjective data collected when oding a chest/lung assessment?
any cough?
chest pain?
Hx of respiratory infections
Hx of smoking
environmental exposure
self care behavior
where is s2 hear the loudest?
at the base (pulmonic and aortic)
how many different areas should you listen to when auscultating the lungs?
at least 6
what are adventitious reath sounds?
additional sounds other ehan the normal breath sounds
If breath sounds are absent what could this mean?
a pneumothorax, a collapsed lung or a portion or all of the lung has been removed
what is a pneumothorax?
a punctured lung
what is cheyne-stokes respirations?
periods of apnea (not breathing)
what is the difference between hyperventilation and hypoventilation?
hyper= deep, RAPID, breathing

hypo = deep, SLOW, breathing
what are some adventitous breath sounds?
crackles, rhonchi, wheezes, stridor
what is the prehypertensive blood pressure range?
systolic = 120 - 130

diastolic = 80 - 89
what is the normal frequence of bowel sound?

How long do you listen if you do not hear them?
5- 35 is normal

if absent, listen for 5 minutes
If a bluish color occurs around the umbilicus, what could be occurring?
intra-abdominal bleeding
what is the normal range fo the heart rate?
60 to 100 bpm
what is the average pulse rate per minute?
80 bpm
what is the ideal rectal temperature?
what are the five steps of the nursing process?
assessment, diagnosis, planning, implementation and evaluation
how do you take a tympanic temp in an infant?

in an adult?
infant: raise the ear up and back

adult: pull the ear back
what does PERRLA stand for?
pupils, equal, round, and reactive to light and accommodation
what is the normal range for blood pressure?
systolic = 100 - 120
diastolic = 60 - 80
what is the ideal axillary temperature?
what is the ideal oral or tympanic temperature?
what is the normal range for a respiratory cycle?
12 - 20
what is a fully alert, normal persons glascow coma scale score?
what objective data would you look for durin a neuro assessment?
glascow coma scale
are they oriented to time, place, person
level of consciousness
memory lapses
list some subjective data that you would collect when dong a neurologic assessment?
headache, head injury, dixxiness, seizures, tremors, numbness;tingling, difficulty swallowing
how can the nursing plan change throughout the patients hospitalization?
it is constantly being revised and updated as more data is collected on the patient
what kind of data is being collected during an assessment?
objective and subjective
what does it mean to view a patient "Holistically"?
to assess the:

physical, developmental, cognitive, psychsocial and spiritual

aspects of the patient
what are some ways of collecting data?
what are some sources for collectin data?
the patient
diagnostic test
previous records
what are the levels of maslows heirarchy?
1. physiological - basic needs
2. safety and security - both physical and psychological
3. love and belonging - relationships, the need to give and receive affection
4. self-esteem
5. self-actualization
a nursing diagnosis IS:
a statement of the clients problem
actual or potential
w/in the scope of nursing practice
directive of nursing intervention
a nursing diagnosis IS NOT:
a medical diagnosis
a nursing action
a physicians order
a therapeutic treatment
what is the difference between an actual and a potential nursing diagnosis?
actual: the problem exists

potential: the problem will occur if no nursing intervention