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Nursing Process > Over all notes > Flashcards

Over all notes Flashcards

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1
Q

Pre-hypertension

A

Systolic: 120-139
Diastolic: 80-89

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2
Q

Respiration (Cheyne-Stokes)

A

Before death

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3
Q

Where is the body temperature relatively constant

A

Core

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4
Q

Checking vital signs for an adult: pulse rate of 120

A

tachycardia (tachy: fast, cardia: heart beat)

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5
Q

Bradycardia

A

slow pulse rate (below 60)

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6
Q

Pulse location for emergency

A

carotid artery

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7
Q

BP of 140/90

A

hypertension

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8
Q

Normal temp

A

97°F-99.6°F

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9
Q

Average heart rate

A

60-100

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10
Q

When do you check the brachial artery

A

When doing blood pressure

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11
Q

Reached above temp

A

hyperthermia → damaged body cells

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12
Q

What does a temp below 93.3°F indicate

A

Death can occur

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13
Q

Tympanic thermometer

A

Ear

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14
Q

How do you do a adult tympanic reading

A

Adult: up & back

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15
Q

How do you do a child’s Tympanic reading

A

Child: down & back

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16
Q

Dyspnea

A

Difficulty breathing

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17
Q

conditions to bring dyspnea

A

The amount and type of activity

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18
Q

Respiration is controlled by

A

medulla oblongata

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19
Q

Hypothalamus

A

Controls body temperature

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20
Q

Incident report

A

Incident events

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21
Q

How long do you check client vital signs

A

60 seconds

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22
Q

OBRA

A

Regulation of standard

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23
Q

Institution

A

Owner of patients medical records

24
Q

Subjective

A

symptoms (what the patient feels & says)

25
Q

Narrative charting

A

Describes occurrences in chronological order w/ subjective & objective

26
Q

How to fix Error

A

cross off, mark error, & initial name

27
Q

When do you chart

A

ASAP as often as possible

28
Q

Kardex

A

concise, centralized source of info. of client or treatment

29
Q

Additional treatments that were done

A

Charting by exception

30
Q

Traditional block

A

organize of scientific problems

utilizes narrative charting for nurse’s notes

31
Q

HIPPA

A

Confidentiality and privacy of patient information

32
Q

H&P:

A

history and physical

33
Q

I & O:

A

I & O: intake and output

34
Q

DNR:

A

do not resuscitate

35
Q

NPO:

A

nothing by mouth

36
Q

STAT:

A

immediately

37
Q

Patient’s access to charts/info

A

not right away, follow established procedures of facility or institution

38
Q

How do you document right and wrong

A 
Do not erase (use correction fluid)
Only chart for yourself
Title, date, time, name, signature
cannot use own words when documenting
use approved medical terms can be used
39
Q

Joint Commission

A

accredited agency that specifies guidelines for charting

40
Q

Nursing diagnosis

A

ADPIE

Initial step of nursing process: assessment/gathering info. (nursing health history)

41
Q

Newly admitted patien

A

Star with assessment

42
Q

Family

A

Secondary source of patient information

43
Q

Head to toe assessment

A

Organized approach

44
Q

Evaluation

A

identify outcome (did plan work or not work)

45
Q

Found patient on floor

A

first initial response → assess for any injuries

46
Q

Fever

A

Objective

47
Q

Postoperative

A

reassess the client again for expected outcome
Revision of care plan
Client expected outcome vs. evaluation

48
Q

Assessing eyes for pupil reflex

A

Penlight

49
Q

To use penlight

A

Darken the room

Shine the light in one pupil

50
Q

SOAPE

A

Problem oriented medical records

51
Q

QRSTUV

A 
R = region of the body affected
Q = quality/quantity
52
Q

Palpation

A

To identify tenderness

53
Q

Nursing diagnosis

A

Focuses on health problems

54
Q

Medical diagnosis

A

Is only for physicians

55
Q

Evaluation

A

Modification of plan of care

56
Q

Implementation/intervention

A

process of carrying out the plan

consider etiology, patient centered goal & desired outcome, risk factors when doing nursing diagnosis

57
Q

Normal blood pressure

A

120/80 mm Hg

Nursing Process (1 decks)

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