Exam 1 NUR-202 Flashcards
What is the nursing process
(ADOPIE)
Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
What is the first step in the nursing process?
Assessment
What is Assessment?
Collection of Data that is both Subjective and Objective.
How do you implement Diagnosis?
Comparing clinical findings with normal findings.
Interpreting data
Validating
Documenting
(CIVD)
How do you implement outcome identification?
Identify expected outcomes
Individualize to the person.
culturally appropriate
realistic and measurable
include a timeline
How do you implement Planning?
Establish priorities
develop outcomes
Set timelines for outcomes
identify interventions
integrate EBP
Document plan of care
How do you implement Implementation?
Implement in a safe and timely manner.
use EBP interventions
Collaborate with colleagues
Use community resources
Coordinate care delivery
health teaching
document
how do you implement Evaluation?
progress towards outcomes
Conduct systematic, ongoing criterion-based evaluation.
Include patients and significant others.
Use ongoing assessment to revise diagnoses, outcomes, and plans.
Disseminate results to patient and family
First level priorities are?
ABC
Airway
Breathing
Circulation
Second level priorities are?
ACI
Acute pain
Change in mental status
Infection
Third-level priorities are?
LFAR
Lack of knowledge
Family coping
Activity
Rest
Types of data?
Complete
Episodic
Follow-up
Emergency
What is a complete data base
describes current and past health state and forms a baseline.
What is episodic database
it is a mini database smaller in scope and more focused.
Follow up data base?
identified problems should be evaluated at regular intervals
Emergency database?
rapid collection of data often compiled concurrently with life saving measures.
What is EBP?
use of best evidence when practicing care.
5 steps to EBP?
ask the clinical questions
acquire sources of evidence
appraise and synthesize evidence
apply relevant evidence in practice
assess the outcomes
Dysarthria
Disorder of articulation: Distorted speech sounds; may sound unintelligible
Dysphonia
Disorder of voice: Difficulty or discomfort talking. With abnormal pitch or volume cause by laryngeal disease. Sounds hoarse or whispered, articulation and language are intact
Aphasia
Language comprehension and production secondary to brain damage: True language disturbance; a defect in word choice and grammar or comprehension. Language processing is disrupted.
Dysphagia
Dysphasia
Global aphasia
The most common and severe form of a large lesion of language areas
Expressive aphasia
Can understand language but can’t use language effectively
Receptive aphasia
can use language but cannot understand it very well.
What are the 4 components of general survey
- Physical appearance
- body structure
- Mobility
- Behavior
(PDMB)
Physical appearance?
Age, Sex, LOC, Skin color, facial features, overall appearance
Body structure?
Stature, Nutrition, Symmetry, posture, and position.
Mobility?
Gait and ROM
Behavior?
Facial expression, Mood and affect, speech, speech pattern, dress.
Abnormalities in Body Height and Proportion?
Dwarfism (Hypopituitary dwarfism, Achondroplastic dwarfism), Gigantism, acromegaly, anorexia, bulimia, Cushing’s Syndrome, Marfan Syndrome.
Hypopituitary dwarfism?
Lack of GH in childhood results in growth below the 3rd percentile (hypothyroidism and adrenal insufficiency. Infantile facial features and chubbiness.
Achondroplastic dwarfism?
normal trunk size, short arms and legs, and short stature. Large head with frontal bossing: midface hypoplasia (small) and thoracic kyphosis… ect.
Gigantism
Excessive secretion of GH delayed sexual development.
acromegaly
excessive secretion of GH in adulthood
bulimia nervosa
the Person has mental disorder where the person self purges. (dental issues)
Anorexia nervosa
Mental disorder where the person does not eat fanatic concern with weight.
Cushing’s Syndrome
Moon face, buffalo hump, weight gain, edema, excessive production of ACTH
Marfan syndrome
tall thin stature >95th percentile long thin fingers.
Vital signs
Temperature, Pulse, RR, BP
What type of data are vital signs
Objective data
what is normal temperature
35.8 to 37 degrees C
What is normal pulse
60-100 and 2+ normal force
what is normal respirations
12-20
what is normal BP
120/80
Force of pulse grading
0-3
0+ weak
1+ thready
2. normal
3+ bounding
bradycardia
<50 Beats/min
Tachycardia
> 95-100 beats/min
What may be affecting the pulse?
Fever, meds, anxiety, cardiac history, athlete, activity, ect.
when you cant palpate the pulse what do you use?
doppler
What situations can affect respirations?
Narcotics, head injury, HF, activity intolerance, Anesthesia, exercise, sleep.
Note the position of the patient when they are breathing what are some positions that patients take to facilitate breathing
Orthopnea (breathing becomes better when sitting up), tripod, nocturnal dyspnea (labored breathing while asleep.
SpO2 what should you know?
Typical range is 97-99%, should be taken. Every shift assessment. If abnormal have the patient cough/deep breath. check if it is a machine issue, if results are abnormal put on O2, it can also be monitored continuously or intermittently
What situations could affect O2 saturation?
Anemia, Lung disease, Heart disease, Inadequate O2 given or method of delivery.
what is the difference between systolic and diastolic
Systolic pressure: max pressure felt on artery during left ventricular contraction or systole.
Diastolic pressure: elastic recoil, or resting, pressure that blood exerts constantly between each contraction.
Mean arterial pressure (MAP)
It is the pressure of blood forcing into tissue, averaged over the cardiac cycle. if less than 60 mmHg blood is shunted to major organs.
What is the definition of orthostatic hypotension
Drop in the systolic BP > 20 mmHg and/or Drop in the diastolic BP > 10 mmHg
What are some common causes of orthostatic changes in BP?
Fluid loss, aging and related vascular changes, bedrest, changes in BP meds.
Korotkoff 1
(Systolic number) Is the first audible tapping sound
Korotkoff 5
Is silence, diastolic pressure is the number which the last audible sound is heard before silence.
transduction
Pain is felt in the periphery. (Distal)
Transmission
Pain moves away from the spinal cord to the brain (moves toward the middle)
it is also important for a quick reaction
Perception (pain)
becomes aware of the pain (me)
Modulation
body tries to modify the pain through endogenous hormones (mod-ify)
PQRST
Provocation: What causes the pain
Quality: what does the pain feel like
Radiates: where does the pain go
Severity: the pain on a scale from 1-10
Time: when did the pain start
Visceral Pain
Pain that originates from the larger internal organs
(e.g., stomach, intestine, gallbladder, pancreas) symptoms of this pain are nausea, sweating, tachycardia, and hypertension.
Somatic Pain
Originates from musculoskeletal tissues or the body surface. Symptoms of this pain are sharp or dull.
Deep Somatic Pain
Pain that originates from sources such as the blood vessels, joints, tendons, muscles, and bones. Symptoms of this pain are aching and throbbing
Cutaneous Pain
Pain that is derived from the skin’s surface as well as the Sub Q tissue. Symptoms of this pain are sharp and burning.
Acute pain
Is pain that is new in onset. It is short-term and self-limiting and often follows a predictable trajectory. It is a protective measure.
Chronic Pain
Which is pain that has lasted longer than expected or continues for six months or longer. This pain can be divided into malignant and nonmalignant. (malignant pain often parallels the pathology created by the tumor cells, i.e., organ stretching and necrosis.) and (nonmalignant pain is often associated with deep somatic pain like arthritis, fibromyalgia, and low back pain.
Breakthrough Pain
In an otherwise controlled pain syndrome, it is a transient spike in pain level, moderate to severe intensity. It often results in end-of-dose failure or episodic pain.
What are the pain scales
Numerical PS (0-10)
FLACC PS (infants/toddlers)
PAINAD (advanced dementia)
CRIES (neonatal postop care)
Nociceptive Pain
Pain that is Somatic or Visceral
Neuropathic Pain
HIV/AIDS, diabetes, and Herpes zoster.
Cancer Pain
Bone metastases neuropathy
Pressure Ulcers Stages
Stage 1: Intact non-blanchable (no capillary refill)
Stage 2: Shallow, Red wound (partial thickness)
Stage 3: Full thickness, no bone, tendon, or muscle
Stage 4: Full thickness, with bone, tendon, or muscle & slough/necrosis (debreeding and cleaning)
Unstageable: you can’t see red covered in eschar and slough.
If it is Red (protect) proliferative stage and requires moist dressings.
If it is Yellow (clean), drainage and slough
If it’s black (debride), remove eschar (necrotic tissue) with mechanical or chemical debridement.
ABCDE Moles and freckles
Asymmetry
Border
Color
Diameter
Elevation/enlargement
Macule/Patch
freckle, flat nevi, petechiae, measles, scarlet fever
Nodule
Solid, elevated, hard, or soft, larger than 1cm
Vesicle
Fluid-filled (blister) i.e., herpes simplex, zoster, varicella.
Wheal
welts/hives, i.e., allergic reaction, mosquito bite, TB skin test.
Cyst
An encapsulated fluid-filled cavity in the dermis of the subq layer, tensely elevating skin. I.e., subq cyst and wen.
Pustule
A pus-filled cavity that is elevated. I.e., impetigo and acne.
Annular/Circular
begins in the center and spreads
Confluent
circles that runs together
Discrete
separate i.e., acne
Grouped
It looks like bubble wrap i.e., vesicles, contact dermatitis
Gyrate
snake-like, twisted, coil
Target
Looks like a bullseye
Linear
straight like a scratch
Polycyclic
annular growing together many circles getting closer
(beehive)
Zosteriform
follows nerve path (herpes zoster)
What factors contribute to pressure injury development
Compression of blood vessels, friction, and shear (that tear and injure blood vessels and damage the top layer of the skin.), Bony prominences, and moisture.
What is assessed in the BRADEN SCALE
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
Bruising
ecchymosis
Pallor
cyanosis (blue/purple)
Diaphoresis
sweating
dehydration not definition what can happen to the skin.
increase in turgor (tenting)
What to do if patient is Jaundiced
assess the sclera and mucous membrane
What to do if patient presents with Inflammation
Palpate for edema and warmth.
When gathering OBJECTIVE DATA on the skin what should be gathered?
Texture- is the skin smooth and firm
Thickness- observe for thickened areas
Edema- assess for fluid accumulation in the interstitial spaces using the rating scale of 0-4
Mobility and turgor- is the patient’s skin elastic
Vascularity and bruising (ecchymosis)
Assessing hair
The patient’s hair is blonde, thin, full, with no lesions or inhabitants.
Capillary refill
should be under 3 seconds if over 3 it is considered sluggish.
Malignant Skin conditions
Basal cell carcinoma- pearly translucent top and overlying telangiectasia (broken blood vessel). Round pearly borders with central red ulcer.
Squamous cell carcinoma
Arise from actinic keratoses or de novo—erythematous scaly patch with sharp margins, 1cm or more. de
Malignant melanoma
Transformation of melanocytes is often cutaneous. 80% of cutaneous melanomas arise in sun/artificial UV-exposed areas: irregular borders, mixed pigmentation, flaking/oozing texture.
Kaposi Sarcoma
Aids/HIV
mental status assessment
ABCT
Appearance
Behavior
Cognition
Thought Process
(Person, Place, Time) ANOS X 4
LOC
Awake, Alert, responds appropriately
Facial Expressions
Appropriate to situation
Speech
quality of speech, effortless, and appropriate
Mood and affect
Body language, facial expression, and cooperative
Orientation
Person, place, time
Attention Span
Ability to concentrate
recent memory
diet recall
remote memory
ask about historical events
new learning
4 unrelated words test at intervals of 5, 10, and 30 mins.
PHQ-2
Asks 2 questions about depressed mood used as a screening tool for PHQ-9
PHQ-9
Series of 9 questions requiring adding column totals that relate frequency of occurrence of symptoms.
The higher the score, the greater the likelihood of functional impairment or clinical diagnosis.
High score (bad)
What is the difference between dementia and delirium?
Dementia is a chronic disturbance of consciousness and cognition. Long-term and short-term memory loss is more pronounced. (irreversible), Delirium is an acute disturbance of consciousness and cognition that develops over a short period of time. No history of dementia and may develop in addition to dementia during hospitalization. UTI is another example, and it is usually reversible.
What is the difference between cognitive function and consciousness?
LOC is the patient’s level of awareness, which is determined by. We are starting with awake, Lethargic, Stuporous, Obtunded, and comatose.
