Test 1 Flashcards
What is clinical judgment?
taking into account all aspects of a patients information in order to make a decision
What is critical thinking?
Knowing that everyone has allergies but they will all react in a different way
Identify critical thinking indicators
evaluate the relationship between clinical judgement and nursing process
Discuss the 5 aspects of ADPIE
Assessment
Diagnosis
Planning
Implement
Evaluation
What is SMART
Specific
Measurable
Attainable
Realistic
Timely
How do you determine appropriate NANDA nursing diagnoses and prioritize them
What is the lowest level to the highest level of Maslow’s Hiearchy
physology needs
needs for saftey and security
needs for love and belonging
self-esteem needs
self actualization
Identify and discuss phases of patient interview
Orientation
Working
Termination
What is primary data?
Something directly from the pateint
What is secondary data?
A chart, lab result
What do you do during the inspection phase of an assessment?
Using vision to inspect the patient
What do you do during the palpation phase of an assessment?
use touch to acess the patient
What do you do during the ausculation phase of an assessment?
Listening to sounds using your stetoscope
What do you do during a skin assessment?
Check skin color
Skin integrity
What is primary lesions and their descriptions
A type of somehting on your skin that has formed
Normal vs abnormal nail assessment
Capillaries refill within 3 seconds
nail shape is normal
Review head,ears,eyes,nose & throat assessment
No lumps bumps on head
PERRLA eyes
No excess drainage ears
nose septum is midline
trachea is midlime
Identify adventitious breath sounds with the description and their location
Crackles-pneumonia
Rhonchi-harsh gurgling
Wheezing- high pitched whisteling
Stridor-high pitched musical sound on inspriation
Describe auscultation of the heart
heart sounds/rate/rhythm
pulse deficit
cardiac murmors
Where is Erb’s Point located?
third intercostal space left side of the sternal border
Where is the Tricuspid valve located?
fourth intercostal space left side of the sternal border
Where is the pulmonary valve located
second intercostal space left of the sternal border
Where is the aortic valve located?
second intercostal space right of the sternal border
Where is the Mitral valve located?
middle under the nipple
How do you preform a peripheral vascular assessment, and what are the locations?
Inspection and palpation of peripheral pulses.
Describe the abdominal assessment and what order.
- Inspection
- Ausculation
- Palpation
Explain EMR and HIPAA
EMR is a medical record and HIPAA ensures that you have privacy of your information
Describe how to properly document in a medical record
Be clear and specfic and write it like a narrative-like you are telling a story
Understand verbal and telephone orders
Usually only happens in an emergency
must be taken by an RN
Must put order in immediately
Must document it as a phone/verbal order
includes date, time, physicians name, and RN signature
What is SBAR?
Situation
Background
Assessment
Reccomendation
What should be included a flow sheet?
What should be included in a charting by exception?
Abnormal or exception to normal things
What is the normal heart rate range
60-100
Name situations that would require a vital sign assessment
all unless the doctor states otherwise
What are factors that can influence body temperature
What are different tools for assessing body temperature
S/S of a fever
Anorexia
increased heart rate
increased breathing
Headache
hot, dry skin
flushing
thirst
shivering
complaints of feeling cold
sweating
cyanotic nail beds
Where is the popiteal pulse located?
behind the knee
Where is the carotid pulse
neck
where is the brachial pulse
inner elbow
where is the radial pulse
wrist
Where is the femoral pulse
femor
Where is the posterior tibial pulse
ankle
Where is the dorsalis pulse
top of foot
Where is the apical pulse
5th intercostal space left midclavicular line below the nipple
Explain the physiology and regulation of breathing and ventilation
your brain tells you to breathe you do not have to think about it
What is tachypnea
fast breathing
What is eupnea
regular breathing
What is bradypnea
slow breathing
What is apnea
no breathing
What is hypertension vs hypotension
hyper- high
hypo-low
What factors contribute to blood pressure
Age, weight, gender
Droplet Precautions
Flu, Pneumonia
Contact Precautions
MRSA, C-Diff
Airbone Precautions
Chicken pox, TB
What is medical asepsis
freedom from and prevention of disease-causing
Example: washing hands before surgery
What is the ability to focus and filter clinical data and to recognize what is important or least important
clinical reasoning
What are types of formatted charting
PIE
ADPIE
SOAP
DAR
The ability to express ideas and concerns to other members of the team while respecting the thought of others
assertiveness
What does CUS communication stand for?
concern
uncomfortable
saftey
Where is the temporal pulse
head
What is normal SBP
100-120
What is normal DBP
60-80
What is normal temperature
97.6-99.5
What is normal oxygen saturation
95-100
How many respirations are normal
12-20
What is the pain scale
0-10
Why are vital signs taken
to monitoe the functioning of body systems
detect changes in health status of the patient
identity early warning signs
evaluate the effectiveness of interventions
What does EMR stand for
Electronic health record
What does CPOE stand for
computerized provider order entry
What happens during the S in SBAR
Situation
indetify yourself and the facility/site you are calling from, Name and DOB of patient symptm onset and severity
What happens during B in SBAR
Background
Date/time of admission, admitting diagnosis, relevent medical history, lab results,notible chnages
What happens during A in SBAR
Assessment
suspected underlying cause or concerns
What happens during R in SBAR
Reccomendations
reccomendation and expectation, be clear and specific about urgency of request and expected timeframe
What is chicken pox
vesicle
What is hives
wheal
