Exam 1 Flashcards
Chapters 1-6
1oz to ml
30ml
1tbs (T) to ml and tsp
15 ml = 3tsp
1oz to tbs
2tbs
1 cup to ml and oz
240 ml = 8oz
1 pint (pt) to ml and oz
500ml = 16oz
1 quart (qt) to ml and oz
1000ml = 32oz
1 pound (lbs) to oz
16oz
1kg to lbs
2.2lbs
1 inch to cm
2.5cm
how to calculate F
1.8*C + 32
how to calculate C
5/9 * (F - 32)
1 pint to cups
2c
1 quart to pints and cups
2 pints = 4 cups
1 gallon to quarts and pints
4 quarts = 8 pints
1 ton to lbs
2000lbs
1foot to inches
12 inches
1 yard to feet and inches
3 feet = 36 inches
6 Standards of Nursing Practice
- Assessment
- Diagnosis
- Outcome Identification
- Planning
- Implementation
6.Evaluation
1st step of nursing practice - assessment
RN collects data and information
2nd step of nursing practice - diagnosis
RN analyzes assessment data to determine actual or potential diagnoses
3rd step of nursing practice - outcome identification
RN identifies expected outcomes for a plan of care
4th step of nursing practice - planning
RN develops a plan to attain expected outcome
5th step of nursing practice - implementation
implementation of the plan of care
6th step of nursing practice - evaluation
evaluation of the progress
5 types of health assessment
- comprehensive
- problem-based/focused
- episodic/follow-up
- shift assessment
- screening assessment
screening assessment
focused on disease detection
4 components of health assessment are
- health history
- physical examination
- reviewing other data from health records
- documenting the findings
Subjective data
symptoms, family history - data collected during an interview
objective data
signs - data collected during physical examination
Palpation
method of feeling with the fingers or hands during a physical examination
Inspection
Visually assess patient
Percussion
tapping body parts with fingers, hands, or small instruments
Auscultation
listening to the sounds of the body
what is EHR
digital version of personal health information
when should the documentation occur
at the time of the health care encounter
define clinical judgement
interpretation or conclusion about patient’s needs, concerns, or health problems
what 4 components are involved in clinical judgement
- nurse’s knowledge
- experience
- ethical perspective
- knowing the patient
Clinical manifestations
signs and symptoms associated with a specific disease
what is client’s problem list
key component of data analysis - summary of health problems
3 levels of health promotion
- primary prevention
- secondary prevention
- tertiary prevention
primary prevention
protection to prevent occurrence of disease
secondary prevention
early identification of disease
tertiary prevention
minimizes severity and disability from disease
3 phases of an interview
- introduction phase
- discussion phase
- summary phase
purpose of open-ended questions
encourage free flowing, open response
directive questions are also called
close-ended questions
facilitation
uses phrases to encourage patients to continue talking
clarification
used to obtain more information about statements
reflection
used to gain clarification by restating a phrase used by the patient
why should “why questions” be avoided
they may make patients defensive
why nurses may need to use silence as an interview technique
to give patients time to reflect or gather courage
another term for chief concern
presenting problem
what is a chief concern
the reason for seeking care
symptom analysis (old carts)
- Onset - when did symptoms begin
- Location - where is the symptom
- Duration - how long does it last
- Characteristics - describe the symptom
- Aggravating factors - what makes symptom worse
- Related symptoms - are other symptoms present
- Treatment - what factors alleviate it
- Severity - describe intensity
past health history is significant because
it may have some effect on patient’s current health needs
family history is significant because
to identify genetic or familial illnesses
personal and psychosocial history explores what
variety of topics including any information that reflects patient’s mental and physical health
where are standard precautions applied
in all aspects of patient care and in all health settings
what is single most important action to reduce the transmission of infection
hand hygiene
6 primary elements of standard precautions are
- hand hygiene
- PPE
- respiratory hygiene
- appropriate patient placement
- managing contaminated equipment
- environmental infection control
sequence of putting on PPE
gown, mask, goggles/face shield, gloves
what do transmission-based precautions involve
1) contact precautions
2) droplet precautions
3) airborne precautions
what are transmission-based precautions designed for
for the control of infections among patients with infections of epidemiological significance
4 measures to prevent latex allergy
- use non-latex gloves for activities that do not involve infectious material
- usage of powder-free (low allergen) gloves
- do not use oil-based hand lotions
- wash hands with soap immediately after removal
describe lung percussion sounds
resonant, loud, and hollow
describe bone and muscle percussion sounds
flat, soft, very dull
describe viscera and liver borders percussion sounds
dull, medium loud, thud like
describe stomach and gas percussion sounds
tympanic, loud, drumlike
describe air trapped in lung percussion sounds
hyper resonant, very loud, booming
7 heart sounds (locations)
thermometer function and normal parameters
measures body temperature - 96.24 to 99.1 (35.8 - 37.3 C), average is 37 (98.6)
stethoscope function
to auscultate sounds within the body
sphygmomanometer function and normal parameters
blood pressure device - less than 120/80
pulse oximeter function
oxygen saturation in arterial blood
skinfold caliper function
used to estimate body fat
wood lamp function
used to detect fungal infections of the skin or corneal abrasions of the eye
distance vision charts (names, for whom, how)
Snellen or Sloan chart - for english speaking adults and kids 6+ - 20ft away
near vision examination (name, how)
Rosenbaum chart - 14inch away
ophthalmoscope function
to inspect internal structures of the eye
otoscope function
to inspect external auditory canal and tympanic membrane
audio scope function
used to perform basic screening for hearing
2 purposes of tuning fork
auditory screening and assessment of vibration sensation
nasal speculum function
to inspect internal surfaces of the nose
doppler function
amplifies sounds that are difficult to hear with stethoscope
goniometer is used to measure flexion of what
flexion or extension of the joint
deep tendon reflexes are tested with
percussion hammer
monofilament is used to test sensation of
sensation on the lower extremities
vaginal speculum is used to
to spread the walls of vaginal canal
what is systolic blood pressure
maximum pressure exerted on arteries when ventricles contract
what is diastolic blood pressure
minimum amount of pressure exerted on vessels during ventricular relaxation
Korotkoff sound
blood flow sound
first Korotkoff sound
the initial sound of blood pulsating through artery when cuff relaxes
6 errors resulting in false high pressure
crossed legs, arm below level of the heart, cuff too narrow, deflating too slowly, reinflating before deflating, not waiting 1-2min between obtaining repeat measurement
5 errors resulting in false low pressure
arm above the level of heart, cuff too wide, not inflating cuff enough, deflating too rapidly, pressing too firmly
what does diversity refer to
differences in gender, age, culture, race, ethnicity, religion, etc.
knowledge, belief, art, morals, customs and habits acquired by person as member of society is
culture
characteristics that group may share in some combination is
ethnicity
race is
genetic in origin - skin color, blood type, eye color, hair color
spirituality is
search for the sacred, broad term
religion refers to
organized system of beliefs
sex refers to
person’s genetic composition
gender is
society’s perception of person’s sex
gender identity is
person’s internal sense of self
cultural desire
giving up prejudices and biases
cultural awareness
self-examination of own cultural background
learning about values, traditions, and religions of other cultures is
cultural knowledge
collecting cultural data about patient’s health problem is
cultural skill
opportunities for nurses to interact with patients from culturally diverse backgrounds is
cultural encounters
somatic pain
bone, joint, muscle, skin, connective tissue
visceral pain
thoracic, pelvic, abdominal viscera
reffered pain
refers to visceral pain, person feels pain away from the tissue
neuropathic pain
abnormal processing by nervous systems (such as phantom pain)
pain threshold
point at which a stimulus is perceived as pain
pain tolerance
duration of intensity person endures before reacting
pain assessment tools
NRS (numeric) and FPS-R (faces)
NRS will provide inaccurate data for people from these countries/cultures
China, Japan, some Native Americans
proxy reporting
used for patients who cannot communicate - gathering information from others who are knowledgeable about the patient
when a problem-based assessment should be used
should be only used in case of emergency
acute pain
lasts less than 6 months
chronic pain
more than 6 months
Normal heart rate, o2 stat, respiration rate
Heart Rate: 60 to 100bpm
oxygen: 95-100%
respiration- 12 - 20 breaths per minute
