Test 1 Ch 1-11 Flashcards
Nursing role that encompasses keeping patients safe, communicating their needs, identifying side effects of treatment and finding better options and helping them understand their diseases and treatments to they can optimize their self care
Advocacy
An umbrella term given to an RN whose achieved a bachelor’s degree in nursing science (BSN) which includes educational and clinical practice requirements as well as minimum of a master’s degree
Advanced practice registered nurse (APRN)
Gathering information about the health status of the patient, analyzing and synthesizing those data, making judgements about nursing interventions based on findings, and evaluating patient care outcomes
Assessment
Assessment method in which a nurse examines the patient focused on a single system or clusters data related to that system together to identify issues
Body systems assessment
CNM
Certified nurse midwife
CNS
Clinical nurse specialist
An assessment that includes a complete health history and physical assessment (like a physical for school) done annually on an outpatient basis, following admission to a hospital or long term care facility or every 8 hours for patients in intensive care.
Comprehensive assessment
CRNA
Certified nurse registered anesthetist
An assessment that involves a life threatening or unstable situation and that focuses on A-airway (with cervical spine protected if injury suspected), B-breathing (rate and depth, use of accessory muscles), C-circulation (pulse rate and rhythm, skin color), D-disability (level of consciousness, pupils; movement)
Emergency assessment
Judgement of the effectiveness of nursing care in meeting the patient’s goals and outcomes based upon the patient’s responses to the interventions
Evaluation
This is an assessment based on the patient’s issues that can occur in all health care settings; it usually involves one or 2 body systems and is smaller in scope than the comprehensive assessment
Focused assessment
Type of assessment that focuses on functional patterns all humans share: health perception and health management, activity and exercise, nutrition, elimination, sleep and rest, cognition and perception
Functional assessment
Assessment that organizes collection of comprehensive physical data by proceeding through entire body from head to toe
Head to toe assessment
The National model for health promotion and risk education developed by the US dept of health and human services
Healthy People
NP
Nurse practitioner
Measurable findings from the health assessment, usually gathered in the physical examination
Objective data
Strategies aimed at PREVENTING health problems
Primary prevention
The early diagnosis of health problems and provision of treatment to prevent complications
Secondary prevention
Prevention of complications from an existing disease and promoting health to the highest level
Tertiary prevention
A-P
Anterior-posterior
BP
Blood pressure
CC
Chief complaint
C/o
Complains of
DOE
Dyspnea on the exertion
DTR
Deep tendon reflexes
HEENT
Head eyes, ears, nose , throat
HOH
Hard of hearing
ICS
Intercostal space
LMP
Last menstrual period
NSR
Normal sinus rhythm
P
Pulse
PERRLA
Pupils equal, round, reactive to light and accomodstio
PMH
Past medical history
PMI
Point of maximal impulse (apical heart)
PND
Paroxysmal nocturnal dyspnea
PPD
Packs per day
S, M, W, D
Single, married, widowed, divorced
TPR
Temperature, pulse, respiration
Who prescribes the frequency of assessing patients?
The facility
What are a complex combination of knowledge and skills that a health care provider uses to deliver care that considers the situation?
Cultural competence
These are anything patient reports
Subjective cues
This involves data where the nurse observes general appearance, assess vital signs, listen to heart, lungs; abdomen, assess circulation
Objective data
What are the differences between comprehensive, focused, and emergency assessments?
Comprehensive is like a physical for school and includes complete health history and physical assessment. Done annually on outpatient basis, following admission to hospital within 8 hours or long term care facility, or every 8 hours in intensive care
Focused assessment is based on the patient’s issues. Usually involves 1/2 body systems, more in depth to specific issues
Emergency assessment focuses on the ABCDs and an emergency situation
On NCLEX, if question is asking what will you DO first, if answers are about assess, diagnosis, plan, evaluate (think ADPIE) it’s talking about what?
The nursing framework
What is a therapeutic response to someone who received grave news like a terminal illness?
Ask open ended questions about what they’re feeling
What are the 4 phases of the therapeutic interview process?
Preninteraction ohase (reviewing records), adjust environment, etc
Beginning phase: introduce yourself, explain purpose of interview, ask patient’s name/birthdate
Working phase: ask patient questions and get them to share story, negotiate a plan
Closing phase: summarize interview and state 2-3 problems/patterns
Talk with patient about next steps
What are primary communication techniques for patients with primary language different from yours?
use simple and clear language, but do not raise your voice. Instead of using complete sentences, you might speak in one or two words, such as “Pain?” Insert pauses in the conversation to allow patients an opportunity to speak; such pauses facilitate trust, respect, and sharing. A pause of 5 to 10 seconds gives the patient the opportunity to consider the questions being asked. It seems like a long time at first, but will become more comfortable as you practice waiting for the patient to answer.
What mneumonic is useful in collecting information related to the patients HPI? What are examples of questions that you ask to collect each piece of information?
OLDCARTS or COLDSPA
Onset: when did you first have the pain?
Durstion:how long does it last?
Location: show me where it hurts. Where does it hurt?
Character
Aggravating factors: what makes it worse or go away?
Intensity: 0-10 scale how bad does it hurt?
Pattern
What information should you collect when discussing patient allergies?
to note the type of response, such as rash, throat swelling, difficulty breathing, or anaphylactic shock. Note what they were allergic to and if it was an adverse event or an allergy. Throat swelling and difficulty breathing are allergic reactions.
Rashes and nausea from medications can be adverse effect
What is a functional assessment? How do you collect one?
Asking about quality of life (sexual, relationships, spiritual beliefs, physical activity, nutrition, etc, health knowledge) usually asking toward end due to more personal questions.
What is the difference between primary and secondary sources of information?
Primary is the patient and secondary is a from charts, others, etc
What are the broad goals of nursing?
Promote health through care, prevent illness by promotion and prevention, treat responses to illness, advocating for patients, families, communities for knowledge promotion
How is a chief complaint recorded?
Ask patient what problem they’re having, ask open-ended questions and use mneumonic COLDSPAR to help it getting more information.
What is the purpose of a health assessment?
Get a baseline recorded for future health findings, evaluate and come to a plan and diagnosis.
What are the 4 techniques used to collect a physical assessment? In which order?
IPPA unless it’s abdominal. Inspect, palpate, percussion, auscultation
Tone that is loud, high pitched, drum like sound, moderate duration
Tympanic
Tone of sound during physical assessment that is very loud, hollow and heard in healthy lungs
Resonant
Tone of sound that is described as high in pitch, sounds dull and is heard over bone
Flat
Tone of sound heard over liver, high in pitch and sounds like a thud
Dull
What sounds is the bell of the stethoscope best used for? What about the diaphragm?
Bell is used for low frequency sounds like a heart murmur, vascular sounds
Diaphragm for lung sounds, heart, bowel
What is a soap note and the components of it?
Subjective, objective, assessment, plan
What is the SBARR? When does it occur and what’s it include?
Situation, background, assessment, recommendation, request during handoffs of a patient
What are the ABCDEs of melanoma detection?
Asymmetry, border, color, diameter (more than 6mm about size of pencil eraser), evolution of lesion over time
What are the signs/symptoms of hirutism?
Excessive androgenic hormones in a female patient can cause masculinization changes, including hair in male distribution patterns (i.e., beard, chest, back, upper thighs).
What education is important for patients regarding the integumentary system?
Excessive UV radiation is the most important focus area for the integumentary system because exposure to it has been shown to cause skin cancers, particularly melanoma. Wear 30spf, apply 15-30 min before and frequently, avoid sun in afternoon hours
What are the 3 common integumentary symptoms?
Pruritus (itching)
Rash
Single lesion or wound
Where should the nurse assess skin color changes in the dark-skinned patient?
Oral mucosa or conjunctiva (eye). Should be pink and moist
What are expected breast changes in pregnancy?
Nipple size and color will change. Breast size changes and will be nodular, veins noted
33) What is Peau d’ orange? What does it look like? What is the cause?
Advanced breast cancer. From blocked lymph drainage (orange peel)
What breast changes are concerning for malignancy? What are normal variances in breast?
Breast changes: inverted nipple, change in color of breast especially if only one side changes color or contour or nipple characteristics change, discharge when not breastfeeding,
Normal: crackling or crust or normal is breastfeeding, some have an extra nipple, may be inverted/everted, mostly symmetrical and contour, one slightly bigger than other
Where is the most common site for breast masses?
Upper outer quadrant because this is where most glandular tissue lies
What is the proper sequence of exam for patient reporting a new abnormal breast finding?
Seated arms at side, arms against waste, on hips, overhead, leaning forward, standing and in supine. Vertical palpating for 4 quadrants, look at color, size, symmetry, look at nipple next for changes, the palpate in different positions
