Exam Flashcards
Subjective data
Data collected from patient or family members during interview process
Objective data
observed through senses - hearing, sight, smell and touch
Pulse deficit
apical pulse rate 90bpm, radial pulse 79 - pulse deficit - 11
Bounding
Dorsal Pedis pulse +3
Steps in accessing abdomen
inspect, auscultate, palpate, percuss
assessment
step of nursing process done when nurse collects data
steps of nursing process in order
assess, diagnose, plan, implement, evaluate
measurable and timeline
when a nurse makes a goal, it must contain these characteristics
implementation
step of nursing process when nurse puts plan into action
evaluation
step of nursing process where nurse reflects on patient and if they have or have not resolved problem
EHR
hospitals required to have this charting system
narrative charting
tells story of patient
charting by exception
done in hospitals, least amount of charting info
J Baker SPN
correct initials to sign following documented nurses note
SOAPIER
S - subjective assessment
O - objective assessment
A - nursing assessment
P - planning
I - implementation
E - evaluation
R - revision
Radial
pulse found in wrists
bilaterally
when palpating pulses, you should check them
Dorsalis Pedis
pulse checked following knee surgery
Palpate irregular pulse for
1 minute
pulses from head to toe
temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
Normal heart rate for adult
60-100 per minute
reverse Trendelenburg
when a patient experiences hypotension put them in
hypoxemia
low oxygen in the blood
Reye’s syndrome
aspirin given to children under 15 can experience this acute fatal syndrome that affects CNS and liver
incident report
form filled out when an abnormal incident occurs to staff, patients or visitors in health care facility
crackles
when assessing patient’s lungs, they cough, and you hear rice crispy sounds, sounds wet. Ineffective airway clearance.
walked to patients’ room, patient found face down on floor, assessed for injuries, no obvious injuries, patient put back to bed
when you hear loud thud from nurses’ station, enter patients’ room, find patient lying face down on hardwood floor with no obvious injuries, help them back in bed and document
anxiety and fear affect
HR, RR, BP
3-part nursing diagnosis
impaired gas exchange R/T Decreased lung capacity AEB OX Sat of 82% - 3 uses evidence, 2 does not
Nursing Process
decision making framework used by all nurses to determine needs of their patients and decide how to care for them
inspection
visual examination of patient’s body for rashes, breaks in skin, appearance of nose, eyes, ears, etc
Palpation
touching or feeling torso, limbs for pulses, abnormal lumps, temp, moisture, vibrations
Auscultation
listening for abnormal sounds in lungs, heart, bowels
Percussion
tapping movements to detect abnormalities of internal organs
ecchymosis
caused by bruising of skin - air on side of caution for abuse
edematous
condition of being swollen due to excess accumulation of fluid in body’s tissues
Stridor
life threatening upper airway obstruction caused by foreign body tumor, swelling, bronchial spasms. shrill high pitched harsh crowing sound heard upon inspection.
wheezing
continuous melodious, musical, whistling sounds. Constriction of airway during inspiratory or expiratory. During asthma attack.
pleural friction
grating, creaking sound caused by inflamed, edematous pleural surfaces rubbing together during breathing.
pulmonic valve
second intercostal space left of sternum - left base heart sound
tricuspid valve
edge of sternum, fourth intercostal space, left of sternum, left lateral sternal border
mitral
heard at PMI
aortic valve
second intercostal space just right of sternum, known as right base heart sound
central cyanosis
blue discoloration around lips, tongue and chest - low oxygen levels in blood due to lung/heart issues
peripheral cyanosis
blue discoloration in fingers, toes, nails - poor blood circulation, cold temps, normal oxygen levels in blood
documentation
remember rules
narrative charting
tells story in chronological order, admission to discharge, condition, complaints, problems, assessment findings activities, treatments, care provided, effectiveness of interventions
Maslow’s
physiological, safety and security, love and belonging, self-esteem, cognitive, aesthetic, self-actualization transcendence
indirect vs direct interventions
direct - interactions with patient (bathing)
indirect - assistance without patient present (documenting)
when to document
directly after care, so details are not forgotten
aphasia vs dysphagia
aphasia - inability to speak or understand language.
dysphagia - difficulty coordinating/organizing words correctly in a sentence
temperatures
oral, axillary, tympanic, skin, rectal, temporal
most accurate rectal
avoid rectal for cancer or diarrhea
capillary refill check
gently squeeze nailbed of extremity to empty capillaries of blood, nailbed will turn pale until pressure is removed, should take less than 3 seconds to turn pink again
delegating vital signs
do not delegate if something feels off or if patient is in distress
ABC’s
Airway, breathing, circulation
