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14 Cards in this Set
- Front
- Back
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Write an example of objective writing
Write an example of subjective writing. |
A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement such as “respiratory rate 20 and unlabored.” Avoid terms such as appears, seems, or apparently, which are often subject to interpretation. For example, the description “the patient seems to be in pain” does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts. Objective documentation needs to include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, or guarding a body part. (Perry 50)
The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient's exact words whenever possible. For example, you record, “Patients states, ‘My stomach hurts.’” You also include complementary objective findings so the database is descriptive. (Perry 50)
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Nursing documentation; describe graphic record and progress record. |
Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. They are especially useful for the documentation of routine observations or repeated specific measurements for a patient such as vital signs , intake and output, hygiene measures, medication administration, and pain assessment. (Perry 53)
Progress notes provide a format for documenting a patient's health status and progress. You can use a variety of formats when writing notes, including SBAR, SOAP, SOAPIE, PIE, and DAR. All caregivers need to be able to read the progress note and have a clear picture of the problem, level of care required, and results of interventions. The nurse caring for the patient is responsible for writing and signing each progress note, which includes full name and title. (Perry 61)
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What is a core temperature?
When is it expected to be at its highest and lowest?
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Core temperature, or temperature of the deep body tissues, is under control of the hypothalamus and remains within a narrow range. Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically. (Perry 67)
Temperature is lowest during early morning. Most patients have maximum temperature elevation between 5 pm and 7 pm (Perry 70)
Core Sites • Rectum • Tympanic membrane • Temporal artery • Esophagus • Pulmonary artery • Urinary bladder (Perry 68)
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Describe the correct procedure for obtaining an adult tympanic membrane temperature. |
Pull ear pinna backward, up, and out for an adult (Perry 75)
Move thermometer in a figure-eight pattern. (Perry 75)
Fit speculum tip snug in canal, pointing toward the nose. (Perry 75)
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Explain Orthostatic hypotension |
Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., light-headedness or dizziness) and low blood pressure when rising to an upright position. (Perry 91)
Orthostatic hypotension or postural hypotension is a drop in blood pressure that occurs when a patient changes from a horizontal to a vertical position. A drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with symptoms of dizziness, light-headedness, nausea, tachycardia, pallor, and fainting indicates orthostatic hypotension (Perry 236) |
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Define: Hemiparesis, ROM, TEDS |
Hemiparesis: Muscular weakness of one half of the body. (Perry 1160)
ROM: the extent of movement of a joint, measured in degrees of a circle. (Mosby 1518)
Range-of-motion (ROM) exercises may be active, passive, or active assisted. They are active if a patient is able to perform the exercise independently and passive if the exercises are performed for a patient by the caregiver. (Perry 222)
TEDS: elasticized stockings worn to prevent the formation of emboli and thrombi, especially in patients who have had surgery or who have been restricted to bed. Return flow of the venous circulation is promoted, preventing venous stasis and dilation of the veins, conditions that predispose individuals to varicosities and thromboembolic disorders. (Mosby 111) |
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Demonstrate the correct use of a cane |
(1) Begin by having patient place cane on side of strong leg.
(2) Place cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs.
(3) Have patient stand straight, look straight ahead, and move involved leg forward, even with cane.
(4) Advance strong leg past cane.
(5) Move involved leg forward, even with strong leg.
(6) Repeat these steps. (Perry 246)
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(1) What supportive surface would be most beneficial for a patient with a stage 3 pressure ulcer?
(2) Are there any contraindications for its use?
(3) What are some of the problems associated with this bed? |
(1) If a patient has large stage III or IV pressure ulcers on multiple turning surfaces of the skin, a low-air-loss bed or air-fluidized bed may be indicated (Perry 283)
Patients with stage III or IV pressure ulcers on multiple turning surfaces often benefit from an air-fluidized bed. (Perry 278)
Air-fluidized bed is a special bed designed to distribute weight evenly over its support surface. (Perry 1157)
(2) Do not use this surface with a patient who has an unstable spine or who is in traction (Perry 283)
(3) a Dehydration Patients may become dehydrated with use of this bed because of insensible fluid loss.
b Aspiration Inability to elevate head of bed is limited to placing foam wedges under patient's head and shoulders.
c Difficulty with patient positioning Repositioning is limited to use of foam wedges.
d Assess level of orientation Patients may be at risk for developing delirium from dehydration and floating sensation with air-fluidized bed. (Perry 285)
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Explain how a nurse would implement a restraint free environment. |
A restraint-free environment is the first goal of care for all patients. (Perry 304)
Using specific diversional or activity measures for making the environment safe.
Applying appropriate alarm devices.
5 Provide visual and auditory stimuli meaningful to patient (e.g., clock, calendar, radio/MP3 player [with patient's choice of music], television, and family pictures). Orients patient to day, time, and physical surroundings. You must individualize stimuli for this to be effective. (Perry 305)
6 Anticipate patient's basic needs (e.g., toileting, relief of pain, relief of hunger) as quickly as possible. Basic needs provided in timely fashion decreases patient discomfort, anxiety, and restlessness. (Perry 305)
7 Provide scheduled ambulation, chair activity, and toileting (e.g., ask patient every hour about toileting needs). Organize treatments so a patient has uninterrupted periods throughout the day. (Perry 305)
9 Decrease wandering by eliminating stressors from environment such as cold at night, changes in daily routines, and extra visitors (Perry 305)
11 Use diversional activities such as puzzles, games, music therapy, pet therapy, activity apron, performing purposeful activity (e.g., folding towels, drawing/coloring). Be sure that it is an activity in which patient has interest. Involve a family member in the activity. (Perry 305)
Meaningful diversional activities provide distraction, help to reduce boredom, and provide tactile stimulation. Minimize occurrences of wandering. (Perry 305)
13 Use pressure-sensitive bed or chair pad with alarms: (Perry 305)
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Demonstrate nursing interventions during a patient seizure. |
Seizure response: a Position patient safely (1) If standing or sitting, guide patient to floor and protect head in your lap or place pillow under head. Turn patient onto side with head tilted slightly forward. Do not lift patient from floor to bed during seizure. (2) If patient is in bed, turn him or her onto side and raise side rails. Position protects patient from aspiration and traumatic injury, especially head injury.
b Note time seizure began and call for help.
Track duration of seizure. Have health care provider notified immediately. Have staff member bring emergency cart to bedside and clear surrounding area of furniture. Reduces exposure to injury. Description of seizure may help in ultimate identification of type of seizure.
c Keep patient in side-lying position, supporting head and keeping it flexed slightly forward.
Position prevents tongue from blocking airway and promotes drainage of secretions, reducing risk of aspiration.
d If possible, provide privacy. Have staff control flow of visitors in area.
Embarrassment is common after a seizure, especially if others witnessed it.
e Do not restrain patient; if patient is flailing limbs, hold them loosely. Loosen restrictive clothing/gown.
Prevents musculoskeletal injury. Promotes free ventilatory movement of chest and abdomen.
f Never force any object into patient's mouth such as fingers, medicine, tongue depressor, or airway when teeth are clenched. (Perry 316)
g Maintain patient's airway; suction orally as needed. Check patient's level of consciousness and oxygen saturation. Provide oxygen by nasal cannula or mask if ordered. Use oral airway only if you can easily access oral cavity
Prevents hypoxia during seizure activity.
h Observe sequence and timing of seizure activity. Note type of seizure activity (tonic, clonic, staring, blinking); whether more than one type of seizure occurs; sequence of seizure progression; level of consciousness; character of breathing; presence of incontinence; presence of autonomic signs of lip smacking, mastication, or grimacing; rolling of eyes.
Continued observation helps to document, diagnose, and treat seizure disorder.
i As patient regains consciousness, assess vital signs and reorient and reassure him or her. Explain what happened and answer patient's questions. Stay with patient until fully awake. (Perry 316-317)
Informing patients of type of seizure activity experienced helps them to participate knowledgeably in their care. Some patients remain confused for a period of time after the seizure or become violent. (Perry 317)
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Explain the use of hot therapy vs cold therapy |
Hot therapy:
Pain ↓ Spasm ↓ Metabolism↑ Blood flow ↑ Inflammation↑ Edema ↑ Extensibility ↑ (Perry 977)
Conditions: Inflamed or edematous body part; new surgical wound; infected wound; arthritis; degenerative joint disease; localized joint pain, muscle strains; low back pain; menstrual cramping; hemorrhoidal, perianal, and vaginal inflammation; local abscess (Perry 977)
Cold therapy:
Pain ↓ Spasm ↓ Metabolism↓ Blood flow ↓ Inflammation ↓ Edema ↓ Extensibility ↓
he use of cryotherapy for various injuries has a positive effect on pain relief. First, cold vasoconstricts the vasculature in adjacent tissues and slows bleeding into damaged tissues. Second, cryotherapy decreases the release of inflammatory mediators from the damaged tissues, which hinders protein release from the vasculature and decreases edema. Last, cold has an analgesic effect, which is believed to be caused by slowing of nerve conduction. Cold in combination with compression reduces bleeding, edema, and muscle spasm. (Perry 977)
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Explain a double-voided urine specimen |
ask patient to void, discard, and then drink a glass of water, then wait 30 minutes.
Perform hand hygiene and apply clean gloves. Ask patient to collect a fresh, random urine specimen. (Perry 1060)
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What foods may produce false-positive results in a stool specimen obtained for occult blood? |
false-positive result may occur if a patient has ingested red meat within 3 days of testing or is taking certain medications (e.g., iron). (Perry 1061)
Specimens will be positive if contaminated by menstrual blood, hemorrhoid blood, or povidone-iodine. Diets rich in meats, green leafy vegetables, poultry, and fish may produce false-positive results. (Perry 1061)
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Explain/demonstrate the correct procedure for obtaining a sputum specimen |
You collect a specimen either by having a patient cough and expectorate into a sterile specimen container or by suctioning into a sterile sputum trap (Perry 1071)
Provide opportunity to clean or rinse mouth with water. Patient should not use mouthwash or toothpaste because the products may alter culture results. (Perry 1072)
Have the patient take three-to-four deep slow breaths with full exhalation. Then take full inhalation followed immediately by a forceful cough, expectorating sputum directly into specimen container. (Perry 1072)
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