Module 2 Flashcards
Writing a diagnosis
Actual:
Diagnostic label
R/T (etiology or cause)
As evidenced by (defining characteristics)
Risk for:
Diagnostic label
R/T (etiology or cause)
Wellness/health promotion:
Diagnostic label
use Maslow’s for order, even a risk of respiratory events is higher priority than acute pain
ADPIE (nursing process)
Assessment
Diagnosis
Planning
Implementation
Evaluation
SMART (planning goals for patients)
Specific - contains behavioral verb
Measurable
Attainable
Realistic
Timebound (short, long term)
General Adaptation Syndrome
Alarm Reaction - release of hormones, fight or flight, increase of vital signs
Stage of Resistance - Body attempts to resist or adapt to stressor
Stage of Exhaustion - body has depleted energy, immune system weakens
Defense mechanisms
Compensation - overachievement in one area to offset deficiencies in another area
Denial - refusing to admit reality
Displacement - Transfers an emotional reaction from one source of stress to an unrelated person
Projection - Attributing undesirable feelings to another person
Rationalization - a person tries to give a logical or socially acceptable explanation for behavior
Reaction formation - conscious attitude & behaviors that are opposite of their true feelings
Regression - reverting to behaviors consistent with earlier stages of development
Repression - storing painful feelings in unconscious
Sublimation - Transformation of unwanted impulses into something less harmful
Undoing - using an act to negate a previous unacceptable act
Requirements of EBP
Research and critical thinking
One’s own clinical expertise
Client preferences and values
PICO format
Patient, population, problem of interest
Intervention of interest
Comparison of interest
Outcome of interest
PICO example
P - adult patients
I - when measuring B/P with patient’s legs crossed
C - versus patient’s feet flat on floor
O - have a more accurate B/P
3 questions for critical thinking
What do I know?
How do I know it?
What options are available to me?
Health definition
State of complete physical, mental, and social well being
An active state, includes 6 dimensions of self (emotional, physical, social, environmental, spiritual, mental)
Morbidity vs Mortality
Morbidity - frequency of a disease
Mortality - number of deaths from a disease
Illness
The response of the person to a disease, how their level of functioning changes, may be a pathologic change in structure or function
Illness stages
- experiencing symptoms
- assuming the sick role
- Assuming the dependent role (accepts treatment)
- Achieving recovery and rehabilitation
Health promotion
Primary - prevent condition from ever happening, promoting health
Secondary - identifying high risk individuals and screening for illness, catch early
Tertiary - after an illness diagnosed, goal is to improve maximum function of individual
We use 24-hour clock for documenting.
True
Specifics for charting
Complete, current, organized
Use black ball point pen
Correct errors by drawing a single line through the error, then sign with your initials
No white out or erasers
Use a horizontal line to fill up a partial line
Date each entry and time
What to chart
Assessment at start of shift
Changes in mental, psychological, physiological conditions
Reactions to medications or procedures
Left and returned from unit
Teaching
Physician visits
Time client left and returned including transportation and destination
Medications: dose, route, site, pain, side effects
Late entry
SOAPIE (documentation)
Subjective info
Objective info
Assessment
Plan
Implementation
Evaluation
ISBARR
Identity/introduction
Situation
Background
Assessment - what you think problem is
Recommendation
Read back (restate your orders)
Cranial nerve I
Olfactory - smell
Cranial nerve II
Optic - vision
Cranial nerve III
Oculomotor - pupil constriction
Cranial nerve IV
Trochlear - downward and inward eye movement
Cranial nerve V
Trigeminal - jaw clenching, chewing, neck sensation
Cranial nerve VI
Abducens - lateral eye movement
Cranial nerve VII
Facial - taste on front of tongue, facial muscles
Cranial nerve VIII
Vestibulocochlear - hearing
Cranial nerve XI
Accessory - movement of neck and shoulders
Cranial nerve IX
Glossopharyngeal - taste on back of tongue, swallowing and pharyngeal movements
Cranial nerve X
Vagus - talking and swallowing
Weber test
Hearing test used to determine cause of hearing loss in one ear
Cranial nerve XII
Hypoglossal - tongue movement
Presbyopia
Rigidity of eye lens due to age
Retinopathy
Damaged blood vessels in eye
Glaucoma
Increase in intraocular pressure
Ototoxicity
Injury to auditory nerve, ototoxic drugs may cause tinnitus
Sensorineural hearing loss
Sounds heard in good ear
Conductive hearing loss
Sounds heard in poor ear
Romberg test
Balance test, patient stands with feet together, eyes open then closed
Pallor of lips indicates what?
anemia
sweet, fruity breath indicates what?
diabetic ketoacidosis
Ammonia odor in breath indicates what?
kidney failure
Glasgow coma scale - min and max score
3 - 15
What does each section of GCS measure and what is the max?
Eye opening - 4
Verbal response - 5
Motor function - 6
Aphasia
Sensory - cannot understand written or verbal speech
Motor - cannot speak or write
Kyphosis
Exaggerated thoracic spine (upper)
Lordosis
increased lumbar curvature
Scoliosis
Lateral curvature of the spine
Internal rotation
Move joint inward
External rotation
Move joint outward
Dorsiflexion
Flex toes upward
Plantar flexion
Point toes downward
Prone position
Used for assessing coccyx or dressing back, ICU
Supine
Laying on back face up
Side lying
alternate between lying on back
Sims position
Left side lying for suppositories and enema
Fowlers position
HOB 90+ degrees
Semi-fowlers position
HOB 40-89 degrees
Dorsal recumbent position
Supine with knees slightly flexed
Lithotomy position
for rectal and vaginal exams, supine with feet elevated
Knee-chest position
Prone with knees and buttock elevated, for rectal examination
Trendelenburg position
Head on a decline, for dizziness and increase blood pressure. Do not use on stroke or dyspneic patients
Diffusion
O2 and CO2 movement between alveoli and blood
What decreases drive to breathe?
Opioids, oxygen on COPD patients
Lobes in right lung
3
Lobes in left lung
2
Hemoptysis
blood in sputum
Orthopnea
Trouble breathing lying down
Barrel chest cause
COPD or other chronic pulmonary issue
Normal pulse ox for COPD
88-90%
oxygen %s
Mask - 80-90%
Nasal cannula - 24-44%
room air 21%
Which side of stethoscope when listening to breath?
Diaphragm
Four types of breath sounds
Bronchial - normal, loud, blowing, hollow over larynx and trachea
Bronchovesicular - normal, medium pitched over 1-3rd intercostal spaces
Vesicular - normal, soft, low pitched, breezy, whispering sounds over the whole lung field
Adventitious - abnormal
Crackles
Bubbling popping sound, often at end of inspiration
Due to fluid in lungs
Rhonchi
Snoring sounds, low pitched, rumbling throughout breathing cycle
Mucus in larger airways
Wheezes
High pitched, continuous
High velocity air traveling through constricted airways
Stridor
High pitched on inspiration
Harsh honking noise
Air passing through a very constricted upper airway
Atelectasis
Sticky lungs caused by fluid buildup, leads to collapse
Kussmaul respirations
Exaggerated deep, rapid, labored breaths consistent with metabolic acidosis and kidney failure
Cheyne-Stokes respirations
Deep, rapid breathing followed by periods of apnea
associated with end of life
Biot’s respirations
Varying shallow respiration followed by apnea
Associated with respiratory compromise
