Nursing Process

Question 1

What is ADPIE

Answer 1

Assessment
Diagnosis
Planning
Implementation
Evaluation

Question 2

What are Gordon’s 11 functional health patterns

Answer 2

Health perception/management
nutrition/metabolic
Elimination
activity/exercise
sleep/rest
cognitive/perceptual
Self perception
roles/relationships
sexuality/reproductive
coping/stress tolerance
values/beliefs

Question 3

What are the 13 domains for nursing diagnosis

Answer 3

Health Promotion
Nutrition
Elimination and Exchange
Activity/Rest
Perception/Cognition
Self Perception
Role Relationships
Sexuality
Coping/Stress Tolerance
Life Principles
Safety /Protection
Comfort
Growth/Development

Question 4

what are the 3 portions to a nursing diagnosis statement

Answer 4

Diagnostic statement
–Names the problem: “Impaired tissue perfusion”
Etiology of problem
–Origin of problem: related to (r/t): traumatic arm injury
Defining characteristics
–Signs/symptoms: as manifested by (a/m/b): lack of pulse distal to the injury, pale hand, profuse bleeding

Question 5

What is and how to write a 2 part statement for nursing diagnosis?

Answer 5

“risk for” statement

“Risk for…[diagnosis]”
--Potential problem only, suspected
--No manifestation portion
Diagnostic statement
--Names the problem: “Risk for Falls”
Etiology of SUSPECTED problem
--Suspected probelm related to (r/t): impaired mobility

Question 6

during the planning stage of the nursing process, what are you doing as the nurse?

Answer 6

writing a goal for the patient and what the expected outcome is
Ex:
1. GOAL: “The client will have clear lungs throughout the day”
2. EXPECTED OUTCOME: “Client will achieve incentive spirometer goal of 90% every 2 hours”

Question 7

what is SBAR?

Answer 7

For reporting to providers, other nursing etc

​​Situation – what is occurring (why is this communication taking place)
Background – What has led up to the current situation at hand
Assessment – your impression of the problem(s)
Recommendation – explain what you would do to correct the problem (your suggestion)

Question 8

what are normal temperatures? where does regulation of temp come from?

Answer 8

36.1-37.6° C
97-99.6° F
F= (9/5 x C°) + 32

–regulation by hypothalmus in brain stem

Question 9

what are influences to temp?

Answer 9

Biorhythms
Environment
Exercise
Eating
Age--younger and older have harder time regulating temp
Meds--antipyretics

Question 10

what are the 5 ways to take temps?

Answer 10

oral, rectal, tympanic, axillary, temporal

Question 11

what 3 things should you assess when taking a pulse or assessing respiratory rate?

Answer 11

rate, rhythm and quality

Question 12

what is the grading scale for grading a pulse? (0-3)

Answer 12

0 (Absent)
1+ (Weak/Thready)
2+ (Normal/Brisk)
3+ (Bounding)

Question 13

name 8 pulse points on the body:

Answer 13

temporal, carotid, apical, brachial, radial, ulnar

Question 14

what is apnea vs eupnea vs orthopnea?

Answer 14

apnea–absense of breathing
eupnea–normal breathing
orthopnea–sensation of breathlessness in recumbent but relieved by sitting/standing

Question 15

what is systolic vs diastolic in terms of force on ventricles?

Answer 15

systolic–force of ventricles contracting

diastolic–force of ventricles relaxing

Question 16

what is pulse pressure?

Answer 16

difference of systolic and diastolic mmHg

Question 17

What node regulates pulse?

What are the difference sounds you hear in S1 and S2?

Answer 17

Pulse regulation thru ANS thru cardiac sino-atrial node
S1 & S2 = lub dub
S1 = AV valves/end diastole
S2 = semilunar valves, end systole

Question 18

what are influences on BP?

Answer 18

Cardiac output
Peripheral vascular disease
Artery elasticity
Blood volume
Blood viscosity (higher viscosity = slower blood flow)
Heart rate
Age
Exercise--higher in overweight ppl
Emotions
Increases after eating

Question 19

what are normal BP?

Answer 19

Ranges: 100-140/60-90

Question 20

what is orthostatic hypotension?

Answer 20

–a drop of at least 20mmHg systolic or 10mmHg diastolic within 3 minutes of quiet standing after being supine

–norm is to drop 20 SBP or 10 DBP when standing up

Question 21

what kind of method(s) should you use to take BP if a patient has an arrhythmia?

Answer 21

use automatic AND manual

Question 22

What are Korotkoff sounds? What are the phases?

Answer 22

Phase I: First sound heard (systolic)
Phase II: Murmur like sound
Phase III: Clear tapping sounds
Phase IV: Sounds changed from tapping to muffled (first diastolic sound)
Phase V: Sounds can no longer be heard (second diastolic sound)
For adults: record I and V

Question 23

What should you look for/ask about when assessing pain?

Answer 23

Assessment characteristics:
Location
Duration
Periodicity–at times or chronic
Quantity–using scale 1-10, emotions displayed, smileys
Quality–sharp pain, ache, throbbing etc.
Chronicity–when did it start, progress, how long
Aggravating Factors
Alleviating Factors
Associated Phenomena
Physical and Behavioral Assessment

Question 24

Why should you be careful with O2 admin for COPD patients?

Answer 24

• -normally, CO2 levels drive breathing, however in COPD patients, the stimulus to breath is low O2
• -if you give a COPD patient too much O2, their stimulus to breathe gets wiped out

Question 25

what is the percent O2 that a nasal cannula delivers?

Answer 25

Delivers 24-44% FiO2 at 1-6 L/min

room air is 21% O2

Question 26

what is the percent O2 that a simple face mask delivers? What potential for injury should you be aware of?

Answer 26

FiO2 40-60% at 5+ L/min (if less L/min than 5, CO2 buildup in mask)

Question 27

what are signs of respiratory distress?

Answer 27

Agitation, increased pulse, cyanosis, dyspnea, paleness, shortness of breath

Question 28

what is the purpose and goal of incentive spirometry?

Answer 28

• -See if patient is improving with deep breathing
• -Goal–patient should be able to do ¾ of pre-operative level
• -Provide pain intervention if needed