Nursing Process Flashcards
What is ADPIE
Assessment Diagnosis Planning Implementation Evaluation
What are Gordon’s 11 functional health patterns
Health perception/management nutrition/metabolic Elimination activity/exercise sleep/rest cognitive/perceptual Self perception roles/relationships sexuality/reproductive coping/stress tolerance values/beliefs
What are the 13 domains for nursing diagnosis
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
what are the 3 portions to a nursing diagnosis statement
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
What is and how to write a 2 part statement for nursing diagnosis?
“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
during the planning stage of the nursing process, what are you doing as the nurse?
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”
what is SBAR?
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)
what are normal temperatures? where does regulation of temp come from?
36.1-37.6° C
97-99.6° F
F= (9/5 x C°) + 32
–regulation by hypothalmus in brain stem
what are influences to temp?
Biorhythms Environment Exercise Eating Age--younger and older have harder time regulating temp Meds--antipyretics
what are the 5 ways to take temps?
oral, rectal, tympanic, axillary, temporal
what 3 things should you assess when taking a pulse or assessing respiratory rate?
rate, rhythm and quality
what is the grading scale for grading a pulse? (0-3)
0 (Absent)
1+ (Weak/Thready)
2+ (Normal/Brisk)
3+ (Bounding)
name 8 pulse points on the body:
temporal, carotid, apical, brachial, radial, ulnar
what is apnea vs eupnea vs orthopnea?
apnea–absense of breathing
eupnea–normal breathing
orthopnea–sensation of breathlessness in recumbent but relieved by sitting/standing
what is systolic vs diastolic in terms of force on ventricles?
systolic–force of ventricles contracting
diastolic–force of ventricles relaxing
what is pulse pressure?
difference of systolic and diastolic mmHg
What node regulates pulse?
What are the difference sounds you hear in S1 and S2?
Pulse regulation thru ANS thru cardiac sino-atrial node
S1 & S2 = lub dub
S1 = AV valves/end diastole
S2 = semilunar valves, end systole
what are influences on BP?
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
what are normal BP?
Ranges: 100-140/60-90
what is orthostatic hypotension?
–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
what kind of method(s) should you use to take BP if a patient has an arrhythmia?
use automatic AND manual
What are Korotkoff sounds? What are the phases?
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
What should you look for/ask about when assessing pain?
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
Why should you be careful with O2 admin for COPD patients?
- -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
what is the percent O2 that a nasal cannula delivers?
Delivers 24-44% FiO2 at 1-6 L/min
room air is 21% O2
what is the percent O2 that a simple face mask delivers? What potential for injury should you be aware of?
FiO2 40-60% at 5+ L/min (if less L/min than 5, CO2 buildup in mask)
what are signs of respiratory distress?
Agitation, increased pulse, cyanosis, dyspnea, paleness, shortness of breath
what is the purpose and goal of incentive spirometry?
- -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
