Exam 1 Concepts Flashcards
nursing process
A ssessment "D elicious" iagnosis P lanning I mplementation E valuation
ethnocentrism
tendency to view our own way of life as most acceptable
non-verbal behaviors
eye contact, personal space, touch, facial expressions, gestures
rules of etiquette - physically
ensure privacy, minimize interruptions, decrease noise, maintain 4-5 ft distance, equal status seating
rules of etiquette - nonverbal (respecting values of others)
appearance, posture, gestures, facial expressions, eye contact, voice, touch
communication pitfalls
AVOID: false reassurance, unwanted advice, using authority, avoidance language, distancing language
communication pitfalls cont’d
AVOID: professional jargon, leading questions, talking too much, interrupting, why questions
communication tools
open ended questions, reflecting, summarizing, SILENCE
language barriers
use trained interpreter, speak directly to pt, document use of interpreter
H and P parts
chief complaint, history of present illness, review of systems
assessment of the mind
A ppearance S peech L evel of consc.
B ehavior T hought I nsight/judgement
C ooperation A ffect C ognition
M ood Knowledge
P erception E ndings (life)
R eliability
echolalia
repetition of words/phrases
clanging
rhyming w/o reason
delusion
false fixed belief
hallucination
complete fabrication of the mind
auditory, visual, tactile, olfactory
illusion
misinterpretation of existing objects/ideas
loose associations
words loosely connected
neologism
creation of new words
CAGE questionnaire
substance abuse assessment; may need to ask family member to step out of room C utting down A nnoyed others G uilty E ye opener
signs of intoxication
ataxia, slurred speech, dulled concentration
usually oppose withdrawal symptoms
NAT
nonaccidental trauma
red flags for violence
physical findings inconsistent w/pt, family, or caregiver story
bruising in atypical places
patterned injuries
physical assessment order
Inspection Palpation Percussion Auscultation *unless assessing abdomen, then auscultate 1st
palpation (parts of hand)
fingertips: texture, moisture, swelling, masses
dorsa of hand/fingers: temperature
ulnar surface hand/fingers: vibration (d/t turbulent blood flow)
temperature measurement
blue tips for oral/axillary
red for rectal
document route used in celcius
37 degrees is nml; 38.5 degrees celcius fever
HR measurement
rate, rhythm, force
50-95 bpm nml
respiratory rate measurement
noble lie
10-20 breaths/min nml
NML vital signs
T 37c
HR 50-95bpm
RR 10-20 breath/min
BP <120/<80 mmHg
nociceptive pain
pain related to tissue damage
neuropathic pain
pain related to nerve damage
ex. shingles
phantom limb pain
nerves w/o input d/t amputation still firing signals
PQRST questions
P rovocation, palliation Q uality R egion, radiation S everity T iming
FLACC scale
pain scale typically used for children under 7yrs F ace L egs A ctivity C ry C onsolability
nutritional assessments
calorie count
24-hour recall
body mass index
30-<35 obese
25-<30 overweight
19-<25 normal
