Exam 2 Flashcards
How do we prioritize nursing care?
Prioritize what is high priority vs low priority
Example of high priority: someone having chest pain
Example of low priority: someone who is coming in for a check up
Nursing Process steps and examples
Assessment- collecting, organizing, documenting data (physical assessment, interviewing the patient and family)
Diagnosis- sorting and analyzing assessment data and potential health problems (risk for pressure ulcers)
Planning- setting goals to eliminate identified problems (goal is to be able get up and walk with no assistance)
Implementation- carrying out nursing interventions during the planning (process, can be delegated to other health care members (helping patient stand with a gait belt)
Evaluation- evaluating the patients response to the nursing interventions (look at the patients progress and how well they are doing)
Different types of charting, reasons and examples
**Source-oriented (narrative) charting- Documentation in chronological order
Problem-oriented medical record charting (POMR)- focuses on patient status rather than on medical or nursing care (five parts database, problem list, plan, progress notes and discharge summary)
Focus charting- directed at nursing diagnosis, patient problem, concern, sign, symptom, or event
Charting by exception- based on assumption that all standards of practice are done unless documented otherwise
Computer- assisted charting- documentation done as interventions are performed using bedside computers
Case management system charting- a method of organizing patient care through an illness so clinical outcomes are achieved within an expected time frame
Open ended communication
allows patient to elaborate on a subject or to choose aspects of the subject to be discussed
Closed ended communication
forces listener to stick directly to the topic and be concise
Semi fowlers position
an elevation of 30-45 degrees
High fowlers position
an elevation of 60-90 degrees
Supine
laying flat
Prone
laying face down
Subjective data
what the patient tells you (they have a headache, having pain somewhere)
Objective data
information you can visually see (O2 87%, BP 156/90)
Auscultation
listening
Percussion
use of instruments, hands and finger to tap as part of an exam
Observations
watching until symptoms arise
Palpitation
rapid pulse sensation
Assessing heart sounds
Have pt. sit upright or elevate hob 45-90 degrees
Place stethoscope on apex (left midclavicular, fifth intercostal space) and identify the “lub” and “dub” sound
Take bell of stethoscope and listen ti the four valve areas (aortic area, tricuspid area, pulmonic area and mitral area)
Dependent nursing action
Requires a providers order
Independent nursing action
Doesn’t require a providers order, but requires critical thinking and clinical judgement
How to obtain a blood pressure
Inflate cuff while having 2 fingers on radial pulse until pulse is absent (keep note on what number it stopped on)
Deflate cuff and inflate again but with stethoscope on brachial pulse
Deflate cuff slowly until you hear the first kortokoff sound (keep note on what number you hear it on!)
Keep deflating until you hear the kortokoff sound disappear (keep note)
Diastolic pressure
The bottom number on a blood pressure reading. The last beat you hear when taking a BP
Systolic pressure
The number on top of the blood pressure reading, the first sound you hear when taking a BP
