Interactions & Vital Signs Flashcards

1
Q

temperature: expected value

A

98.6F / 37C (adult)

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2
Q

pulse: expected value

A

60 - 100 bpm (adult)

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3
Q

pulse: character

A
0+ absent
1+ diminished/barely palpable
2+ expected
3+ full/strong
4+ bounding
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4
Q

respiratory rate: expected

A

12 - 20 respirations per minute (resting)

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5
Q

BP - cuff too wide

A

false low

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6
Q

BP - cuff too narrow

A

false high

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7
Q

BP - deflate cuff too quickly

A

false low systolic, false high diastolic

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8
Q

BP - arm below heart level

A

false high reading

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9
Q

BP - arm above heart level

A

false low

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10
Q

BP - cuff or stethoscope placed over clothing

A

false high

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11
Q

History of Present Illness: 7 dimensions

A
1 location
2 quality
3 quantity (pain, use scale)
4 timing/setting
5 aggravating factors
6 alleviating factors
7 associated data
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12
Q

physiologic indicator of pain (mnemonic!)

A
FLACC
Facial expression
Leg movement
Activity (other body movement)
Crying (or other vocalization)
Consolability
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13
Q

When do you use FLACC?

A

cognitive disability, unconscious, head trauma, children

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14
Q

BMI

A

weight / height^2

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15
Q

AIDET

A
A cknowledge
I ntroduce
D uration
E xpectation
T hank you
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16
Q

SOAPIE (assessment in action)

A
S ubjective
O bjective
A nalysis
P lan (goal + Expected Client Outcomes)
I mplement interventions
E valuation
17
Q

physical exam: assessment techniques

A

I nspection
P ercussion
P alpation
A uscultation

18
Q

stethoscope diagphragm

A

high pitch sounds (ex: lungs, bowels)

19
Q

stethoscope bell

A

low pitch sounds (ex: some heart, vascular)

20
Q

SOAP (documentation)

A

S ubjective
O bjective
A nalysis
P lan

21
Q

percussion character of sound

A

tympany: air or fluid
dull: solid tissue

22
Q

ECO + SMART

A

Expected Client Outcome

specific, measurable, attainable, realistic, timely

23
Q

Hi 5s - P H I V ES

A
P rocedure
H ands
ID/V erify
E quipment
S afety
24
Q

Bye 5s

A
  1. Wash hands
  2. Equipment
  3. Safety
  4. Teach
  5. Chart
25
Q

SBAR

A

S ituation
B ackground
A ssessment
R ecommendations

26
Q

The Nursing Process (5)

A
Assessment >
Nursing Diagnosis >
Planning >
Implementation >
Evaluation >

So what? Was it effective?
Always analysis.