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Foundations of Nursing Assessment > Module 2 > Flashcards

Module 2 Flashcards

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1
Q

Writing a diagnosis

A

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

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2
Q

ADPIE (nursing process)

A

Assessment
Diagnosis
Planning
Implementation
Evaluation

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3
Q

SMART (planning goals for patients)

A

Specific - contains behavioral verb
Measurable
Attainable
Realistic
Timebound (short, long term)

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4
Q

General Adaptation Syndrome

A

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

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5
Q

Defense mechanisms

A

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

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6
Q

Requirements of EBP

A

Research and critical thinking
One’s own clinical expertise
Client preferences and values

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7
Q

PICO format

A

Patient, population, problem of interest
Intervention of interest
Comparison of interest
Outcome of interest

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8
Q

PICO example

A

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

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9
Q

3 questions for critical thinking

A

What do I know?
How do I know it?
What options are available to me?

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10
Q

Health definition

A

State of complete physical, mental, and social well being

An active state, includes 6 dimensions of self (emotional, physical, social, environmental, spiritual, mental)

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11
Q

Morbidity vs Mortality

A

Morbidity - frequency of a disease

Mortality - number of deaths from a disease

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12
Q

Illness

A

The response of the person to a disease, how their level of functioning changes, may be a pathologic change in structure or function

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13
Q

Illness stages

A
  1. experiencing symptoms
  2. assuming the sick role
  3. Assuming the dependent role (accepts treatment)
  4. Achieving recovery and rehabilitation
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14
Q

Health promotion

A

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

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15
Q

We use 24-hour clock for documenting.

A

True

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16
Q

Specifics for charting

A

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

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17
Q

What to chart

A

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

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18
Q

SOAPIE (documentation)

A

Subjective info
Objective info
Assessment
Plan
Implementation
Evaluation

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19
Q

ISBARR

A

Identity/introduction
Situation
Background
Assessment - what you think problem is
Recommendation
Read back (restate your orders)

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20
Q

Cranial nerve I

A

Olfactory - smell

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21
Q

Cranial nerve II

A

Optic - vision

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22
Q

Cranial nerve III

A

Oculomotor - pupil constriction

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23
Q

Cranial nerve IV

A

Trochlear - downward and inward eye movement

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24
Q

Cranial nerve V

A

Trigeminal - jaw clenching, chewing, neck sensation

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25
Q

Cranial nerve VI

A

Abducens - lateral eye movement

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26
Q

Cranial nerve VII

A

Facial - taste on front of tongue, facial muscles

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27
Q

Cranial nerve VIII

A

Vestibulocochlear - hearing

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28
Q

Cranial nerve XI

A

Accessory - movement of neck and shoulders

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28
Q

Cranial nerve IX

A

Glossopharyngeal - taste on back of tongue, swallowing and pharyngeal movements

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28
Q

Cranial nerve X

A

Vagus - talking and swallowing

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28
Q

Weber test

A

Hearing test used to determine cause of hearing loss in one ear

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28
Q

Cranial nerve XII

A

Hypoglossal - tongue movement

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28
Q

Presbyopia

A

Rigidity of eye lens due to age

28
Q

Retinopathy

A

Damaged blood vessels in eye

28
Q

Glaucoma

A

Increase in intraocular pressure

29
Q

Ototoxicity

A

Injury to auditory nerve, ototoxic drugs may cause tinnitus

29
Q

Sensorineural hearing loss

A

Sounds heard in good ear

29
Q

Conductive hearing loss

A

Sounds heard in poor ear

30
Q

Romberg test

A

Balance test, patient stands with feet together, eyes open then closed

31
Q

Pallor of lips indicates what?

A

anemia

32
Q

sweet, fruity breath indicates what?

A

diabetic ketoacidosis

33
Q

Ammonia odor in breath indicates what?

A

kidney failure

34
Q

Glasgow coma scale - min and max score

A

3 - 15

35
Q

What does each section of GCS measure and what is the max?

A

Eye opening - 4
Verbal response - 5
Motor function - 6

36
Q

Aphasia

A

Sensory - cannot understand written or verbal speech
Motor - cannot speak or write

37
Q

Kyphosis

A

Exaggerated thoracic spine (upper)

38
Q

Lordosis

A

increased lumbar curvature

39
Q

Scoliosis

A

Lateral curvature of the spine

40
Q

Internal rotation

A

Move joint inward

41
Q

External rotation

A

Move joint outward

42
Q

Dorsiflexion

A

Flex toes upward

43
Q

Plantar flexion

A

Point toes downward

44
Q

Prone position

A

Used for assessing coccyx or dressing back, ICU

45
Q

Supine

A

Laying on back face up

46
Q

Side lying

A

alternate between lying on back

47
Q

Sims position

A

Left side lying for suppositories and enema

48
Q

Fowlers position

A

HOB 90+ degrees

49
Q

Semi-fowlers position

A

HOB 40-89 degrees

50
Q

Dorsal recumbent position

A

Supine with knees slightly flexed

51
Q

Lithotomy position

A

for rectal and vaginal exams, supine with feet elevated

52
Q

Knee-chest position

A

Prone with knees and buttock elevated, for rectal examination

53
Q

Trendelenburg position

A

Head on a decline, for dizziness and increase blood pressure. Do not use on stroke or dyspneic patients

54
Q

Diffusion

A

O2 and CO2 movement between alveoli and blood

55
Q

What decreases drive to breathe?

A

Opioids, oxygen on COPD patients

56
Q

Lobes in right lung

A

3

57
Q

Lobes in left lung

A

2

58
Q

Hemoptysis

A

blood in sputum

59
Q

Orthopnea

A

Trouble breathing lying down

60
Q

Barrel chest cause

A

COPD or other chronic pulmonary issue

61
Q

Normal pulse ox for COPD

A

88-90%

62
Q

oxygen %s

A

Mask - 80-90%
Nasal cannula - 24-44%
room air 21%

63
Q

Which side of stethoscope when listening to breath?

A

Diaphragm

64
Q

Four types of breath sounds

A

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

65
Q

Crackles

A

Bubbling popping sound, often at end of inspiration

Due to fluid in lungs

66
Q

Rhonchi

A

Snoring sounds, low pitched, rumbling throughout breathing cycle

Mucus in larger airways

67
Q

Wheezes

A

High pitched, continuous

High velocity air traveling through constricted airways

68
Q

Stridor

A

High pitched on inspiration
Harsh honking noise

Air passing through a very constricted upper airway

69
Q

Atelectasis

A

Sticky lungs caused by fluid buildup, leads to collapse

70
Q

Kussmaul respirations

A

Exaggerated deep, rapid, labored breaths consistent with metabolic acidosis and kidney failure

71
Q

Cheyne-Stokes respirations

A

Deep, rapid breathing followed by periods of apnea
associated with end of life

72
Q

Biot’s respirations

A

Varying shallow respiration followed by apnea
Associated with respiratory compromise

Foundations of Nursing Assessment (7 decks)

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