Nursing Process/ Lab Values Flashcards
Why is the nursing process is important?
- Problem solving approach
- Identifies and manages patient problems
- Provides an organizing framework for the practice of professional nursing
- Provides the foundation for nursing knowledge, judgement and actions.
- Requires reasoning, analysis, synthesis as well as psychomotor and affective skills.
List the nursing process.
- ) Assessment
- ) Diagnosis
- ) Planning
- ) Implementation
- ) Evaluation
During assessment, the RN collects subjective and objective patient data… which includes what?
- From the admitting history and physical, obtain the history, duration and symptoms of current illness. Be sure to understand what problems started this hospitalization.
- Note history of previous illnesses
- Significant illnesses that can affect current problems that should be particularly noted include diabetes, CV disease, chronic pulmonary disease, chronic renal disease.
- Any symptoms that you observe and any that patient reports should be included in the assessment.
- Gather lab data
- Examine the most recent values as well as the trends.
Complete blood count (CBC) includes ______ and _______, RBC, WBC and ______
hemoglobin, hematocrit, platelets
Normal hemoglobin level?
12-14
Normal hematocrit level?
40-54%
In what scenarios are CBCs most commonly decreased?
- Protein malnutrition
- Acute or chronic blood loss
- Drug toxicities
- Diseases such as anemia, leukemia, chronic renal failure.
In what scenarios are CBCs most commonly increased?
- High altitudes
- Dehydration
- Late stage emphysema
- Polycythemia vera (bleeding out of every orifice)
Normal Red blood cell (RBC) count?
4.5-5.9
Decreased RBCs are most often associated with ______, excessive intravascular fluid, chronic renal failure, _______ and radiation, and anemia.
leukemia, chemotherapy
Increased RBCs are most often associated with Polycythemia vera, ______, high altitude, and _________ disease.
dehydration, cardiovascular
What are RBCs indices used for?
Useful in differentiating various types of anemias.
*include MCV, MCH, and MCHC
MCV is the average ____ of red blood cells.
size
MCH is the ____ of the hemoglobin (hemoglobin amount per RBC).
weight
MCHC indicates the hemoglobin _______ per unit volume of RBC.
concentration
What is the reticulocyte count?
Immature red blood cells
Normal range of Platelets?
150,000-400,000
- Critical values: 1,000,000
- Platelets provide info about clotting factors
Normal range of WBC count (respond immediately to foreign invaders) and differential?
Total: 4,500-10,000
_______-identifies numbers of specific white blood cells
Differential
Elevated values of WBC (_______) - common with acute inflammation/ infection, tissue necrosis, leukemia, collagen diseases
leukocytosis
Decreased values of WBC include certain ______, viral infections, and drug influences.
anemias
What are two other diagnostic tests elevated during inflammatory process?
- ) C-reactive protein
2. ) Erythrocyte sedimentation rate (ESR)
What is included in the white blood cell differential?
Neutrophils, Eosinophils, Basophils, Monocytes, Lymphocytes
______: first line of defense against acute infections (segments are mature and bands are immature)
Neutrophils
_______: increase during allergic or parasitic conditions.
Eosinophils
*increased steroid levels produced my meds or stress can cause decrease in eosinophils.
______: increase during healing
Basophils
______: second line of defense against bacterial infections and foreign substances-respond late during acute phase of infection or inflammation.
Monocytes
______: occur in chronic and viral infections- often seen in chronic lymphocytic leukemia. May be decreased during excessive adrenocortical hormone secretion or steroid therapy.
Lymphocytes
What is a basic metabolic profile (BMP) ?
A group of blood tests that determine metabolism- Chemistry 7
BMP includes _____ level, BUN and _______, glomerular filtration rate, and ______ (sodium, potassium, chloride, and bicarbonate)
glucose, creatinine, electrolytes
Normal glucose level?
70-110
Normal BUN?
5-25
Normal creatinine?
0.5-1.5
BUN and creatinine give an overview of _____ function. Most often elevated with _______ or a renal damage/ disorder with creatinine being more sensitive to kidney disease.
renal, dehydration
Glomerular Filtration Rate…decreased renal reserve level: ___-___. Renal insufficiency: ___-___. Renal Failure: ___-___. End stage renal disease (ESRD): ____
40-60, 20-40, 10-20, <10
Normal sodium level?
135-145
Normal Potassium level?
3.5-5.0
Normal chloride level?
95-105
For coagulation, what do you assess for?
- Platelets
- Prothrombin time (PT)
- International normed ratio (INR)
- Partial Thromboplastin time (PTT)
- Look for elevations in patients on anticoagulants, liver disease.
What four things do you assess for liver function studies?
- ) Bilirubin
- ) AST/SGOT
- ) ALT/SGPT
- ) Alkaline Phosphatase
Normal Bilirubin level?
- 1-1.0
* elevations can occur in autoimmune or hemolytic induced reactions, liver damage congestive heart failure.
* significant elevations can cause jaundice
Normal AST/SGOT?
8-38
- Enzyme normally found in heart and liver muscles.
- Level increase with acute MI, and liver damage.
Normal ALT/SGPT?
10-35
*Enzyme found primarily in liver cells-used to diagnose liver disorders- Used to differentiate jaundice caused by liver disease and hemolytic disorders.
Alkaline Phosphatase has ___ _____ indicator of liver and bone disease.
non specific
To assess pancreatic studies, what is labs are used?
Amylase and Lipase
Normal amylase levels?
60-160
- Enzyme that changes starch to sugar.
- Rises significantly with damage to pancreas such as pancreatitis- causes severe inflam. and pain. Also with abdominal surgery involving the gallbladder and stomach.
Normal Lipase levels?
20-80
- Enzyme secreted by pancreas aids in digesting fats
- Lipase increases in the blood stream when there is damage to pancreas such as pancreatitis, cancer, hepatitis.
When evaluating a patients nutrition status, how do you assess?
- Ht/weight
* BMI: weight in lbs x 703, divided by heigh in inches squared
What are the BMI levels? Underweight: \_\_\_\_\_ Healthy:\_\_\_\_\_ Overweight:\_\_\_\_\_ Obese: \_\_\_\_\_ Morbid Obesity: \_\_\_\_\_
30, >40
When evaluating labs for nutrition status, Pre-albumin, _____, and transferrin may be low during inflammatory metabolic response b/c the liver _____ production of these labs.
albumin, decreases
- Differentiation between that and poor nutritional status are important.
- Note any significant weight loss, history of nausea, vomiting, anorexia, dysphagia, which may contribute to nutritional intake.
During analysis and synthesis, take each piece of collected abnormal data and begin to group it, patterns will emerge that will indicate your patients problems also known as the nursing ________.
diagnoses
Name some nursing diagnosis
- activity intolerance
- airway clearance, ineffective
- anxiety
- altered nutrition less than body requirement
- altered skin integrity
- impaired mobility
- breathing pattern ineffective
- risk for infection
- altered circulation (peripheral, cerebral)
- altered cardiac output
- altered comfort (acute or chronic pain)
- altered fluid and electrolytes
- impaired gas exchange.
An _____ is defined as the result of achievable nursing interventions and pt responses.
outcome
- specific
- measurable
- consider pt’s desires and resources
- created by listing items and behaviors that can be observed or heared.
- definitie time frame for achievement–Example: Pt will ambulate in hall 15 mins four times per day within 24 hours, WBC count will return to normal within 48 hrs.—> outcome documentation and measurement provide the direction for planning and validating nursing interventions!
During _______, reassess, and determine if outcomes have been met, revise interventions according to the pt’s desires or resources.
evaluation
