Unit 1 Exam Flashcards
Why is documentation so important?
- vital component of safe, ethical and effective nursing practice
- it provides RNs with guidelines for professional accountability in documentation and to describe the expectations for nursing documentation in all practice settings, regardless of the method or storage of that documentation
- meet standards of practice related to the documentation
What is documentation?
anything written or electronically generated that describes the status of a client or the care or services given to that client
What are the different documentation methods?
- open format vs closed formal
- charting by exception
- electronic vs. paper
- electronic medical records
- required for reimbursement from federal agencies (medicare or medicaid)
What is HIPPA?
- Health insurance portability and accountability act
april 2003 federal guidelines
$25k penality
What is subjective data?
What pt says about himself/herself during history taking
What is objective data?
observed when inspecting, percussing, palpating, ausculating pt during exam
EX: vital signs
What occurs during the assessment?
- Review of clinical records
- interview
- Health history
- physical exam
- functional assessment
- cultural and spiritual assessment
- consultation
- review of the literature
What are the steps of the nursing process?
AD - PIE
Assessment: ask questions Diagnosis: identify a problem Planning: hypothesis implantation: experiment Evaluation: analyze / conclusion
What are the priority problem levels?
- First level priority
- emergent, life threatening, and immediate EX: No pulse/not breathing
- Second level priority
- Next in urgency, requiring attention so as to avoid further deterioriation EX: O2 level at 85%
- Third level priority
- Important to pt’s health but can be addressed after more urgent problems are addressed EX: client needs pain medication
- Collaborative problems
- Approach to treatment involves multiple disciplines. RT, PT, OT, SW
What are the different categories of physical appearance?
- Age
- Sex
- LOC: awake and alert, drowsy, etc
- Skin color
- Facial features
What are the different categories of body structure?
- Stature
- Nutrition
- Symmetry
- Position
- Body build
What is gait?
base as wide as shoulder, accurate foot placement, smooth, even walk
What are the different assessment techniques?
- inspection
- auscultation: listen to sounds produced by the body, w/ a stethescope
- palpation: use touch to assess
- percussion
What is resonance?
low, clear, over normal lung tissue sounds
What is hyper-resonance sounds?
lower, booming, over lungs with increased air EX: emphysema
What is tympany?
high, drum-like - over air filled viscus
What is dull sounds?
high, muffled thud, over dense organ/fluid where air containing lung tissue should be
What are flat sounds?
high, short sound, over thigh muscles, bone, tumor
What is the BMI calculation?
weight in pounds / height in inches x 703
weight in kilograms / height in meters
What is the temp range?
36-38 C
96.9 - 100.4 F
What is the average oral / tympanic temp?
37 C
98.6 F
What is the average rectal temp?
- 5 C
99. 5 F
What is the average axillary temp?
- 5 C
97. 7 F
Where is the apical pulse?
4th - 5th intercostal space at left (MCL)
under the left nipple
Where are all the places you can take your pulse?
- temporal
- carotid
- apical
- brachial
- radial
- popliteral
- posterior tibial
- dorsalis pedis
What is the normal pulse rate for adults?
60-100
What is bradycardia?
pulse below 60
What is tachycardia?
pulse above 100
What are the different pulse characteristics?
0 = absent \+ 1 = weak, thready, diminshed \+2 = normal/expected 3+ = full, increased 4+ bounding
Normal respirations for adolescents?
adults?
adolescents: 16-19
Adult 12-20
- **bradypnea = too low RR
- **tachypnea = too high RR
What is pulse pressure?
difference between systolic and diastolic BP
What is mean arterial pressure?
pressure forcing blood into tissues
Too narrow cuff gives:
Too large cuff gives:
Too narrow cuff gives: false high
Too large cuff gives: false low
What effects BP readings?
- anxiety
- anger
- activity
- leg position (legs crossed)
- inaccurate cuff size
- examiner error
- deflating too quickly or too slowly
What is a healthy persons O2?
97-98
What is acute pain?
- short term and self-limiting
- resolves and injury heals
What is referred pain?
pain in places where they shouldn’t have pain
EX: they are having arm pain while having a heart attack
What are the different pain scales?
- hospice pain scale
- pain assessment in in advanced dementia
- numeric pain scale
- verbal pain scale
- Wong-baker faces pain rating scale
- face pain scale
What are standard precautions?
- minimum infection prevention practices that apply to all pt care, regardless of suspected or confirmed infection status of the pt
What is the diaphragm used for?
better for listening to high-pitched sounds, such as heart, lung, or bowel sounds.
What is the bell used for?
used for hearing low-pitched sounds, such as heart murmurs and vascular bruits
What is the tuning fork used for?
- High frequency forks (500 to 1,000) are often used to test hearing
- Low frequency forks (100 to 400) are used to test vibration
What is a 10-gram monofilament?
- Using standardized monofilaments to test for sensation has become common in recent years, especially for examining the feet of clients who have diabetes.
What does a BMI over 25 mean? over 30? 18.5 or less?
25+ = overweight
30+ = obese
18.5 or less = underweight
What is a pulse deficit?
- Pulse deficit: difference between the rate of the apical pulse (left center of your chest below the nipple) and the rate of the radial pulse (wrist)
What is erythema?
redness of the skin caused by dilation of the superficial capillaries
What is cyanosis?
bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood
What is vitiligo?
condition in which the skin loses its pigment cells (melanocytes).
EX: The black model on Americas next top model
What is pallor?
paleness; a decrease or absence of skin coloration
How can you check skin turgor?
gently pinch a skin fold over the client’s clavicle or sternum. Watch to determine if the skin fold returns quickly. Well-hydrated skin in this area is resilient and returns quickly to its original position within several seconds
What is clubbing?
classic indicator of long-term oxygen deprivation. It is enlargement of the fingertips and flattening of the angle between the fingernail and the nail bed, which results in an angle gerater than 180 degrees.
How can you check capillary refill?
press on the nail to cause blanching. The color should return within 2-3 seconds. If it doesn’t it indicates decreased tissue perfusion.
Right lung has ____ lobes and the left lung has ____ lobes
Right lung = three lobes
left lung = two lobes
What are bronchial breath sounds suppose to sound like?
heard anteriorly over the trachea. You should hear a loud, high-pitched, hollow sound. It is abnormal to hear this sound over peripheral lung tissue.
What are bronchovesicular breath sounds suppose to sound like?
heard over mainstream bronchi, which are relatively large-diameter airways. You should hear medium-pitched and quitter sounds.
What are vesicular breath sounds suppose to sound like?
heard over most of the lung tissue. You should hear soft, fine, breezy, low-pitched sounds.
What is pneumothorax?
accumulation of air or gas in the pleural space causing the lung to collapse.
What is atelectasis?
absence of breath sounds in the bases of the lower lobes of the lung due to collapse alveoli.
What are crackles?
aka rales – wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration.
What are wheezes?
continuous sounds caused by air moving through constricted airways.
What are Rhonchi sounds?
low-pitched wheeze that may clear with coughing.
What are stridor sounds?
high pitched crowing sound that is usually heard without a stethoscope. It occurs when a larger airway is blocked by a foreign body, severe inflammation, or a mass.
What is a friction rub?
result when the pleural membranes are covering the lungs and lining the thoracic cavity and are inflamed.
How are murmurs graded?
- Grade 1: difficult to hear, even in a quit room
- Grade 2: clearly audible but quit
- Grade 3: moderately loud
- Grade 4: loud and associated with a thrill
- Grade 5: very loud, easy to palpate thrill
- Grade 6: very loud, may be audible without touching the client’s chest, associated with a palpable and visible thrill
What are the different identification levels of edema?
- 1+ edema = 2 mm indentation
- 2+ edema = 4 mm indentation
- 3+ edema = 6 mm indentation
- 4+ edema = 8 mm indentation
What is bruit? How do you listen to a bruit?
abnormal sound heard through a stethoscope
**Use the bell of the stethoscope to listen to bruits
What is scoliosis?
Mild scoliosis?
severe scoliosis?
lateral curvature of the spine
- Mild scoliosis: a curve less than 20 to 30 degrees
- Severe scoliosis: a curve greater than 60 degrees
What is crepitus?
clicking or crunching within the joint
What is the most common test for balance?
Romberg test
What is Glasgow Coma scale?
uses a point system based on the client’s responsiveness as indicated by eye opening, as well as verbal and motor responses to stimulation
What is the AVPU scale?
What do the letters stand for?
- AVPU Scale: assigns points according to the clients degree of alertness and response to verbal and painful stimulation. The letters stand for: o Alert o Verbal stimulus response o Pain stimulus response o Unresponsive
What are the four types of data bases?
- complete total health database
- episodic or problem-centered database
- Follow up data base
- Emergency database
What is the complete total database?
Admission
- includes complete health history and physical exam
- describes current and past health state and forms baseline to measure all future changes
- yields first diagnosis
pg 49
What is episodic or problem-centered database?
EMERGENCY ROOM VISIT
- for limited or short-term problems
- collect mini database
- concerns mainly one problem
what is follow up database?
- *care plan, daily assessment**
- status of all identified problems should be evaluated at regular and appropriate intervals
- note changes have occurred
- determine if condition is getting better or worse
what is emergency database?
- rapid response
- code blue
rapid collection of data, often compiled concurrently with lifesaving measures
What are the appropriate ways to communicate with your patient?
- open-ended questions
- closed or direct questions
- facilitation
- silence
- reflection
- empathy
- clarification
- confrontation
- interpretation
- explanation
What is facilitation?
- encourage the pt to say more
- “mmmhmm, go on, uh-huh”
Why should you be quiet when talking to a pt sometimes?
- gives the pt time to think
- lets you observe them and their nonverbal cues
How can you use reflection with a pt?
- Echo client’s words by repeating part of what they said
- mirroring their words can help them elaborate on a problem
What is empathy?
- capacity to understand or feel what another person is experiencing from within their frame of reference, the capacity to place oneself in another’s position
What is confrontation?
- frame of reference shifts from pt’s perspective to yours
- you said you didn’t have heart problems but you just came from the cath lab???
What are some cultural issues that come up in the medical field?
- authority
- etiquette
- space and distance
- gender
- sexual orientation/sex reassignment
- communication barriers
- interpreter
How close is intimate space?
personal space?
social space?
intimate: 0 - 1.5 ft
personal: 1.5 - 4 ft
social: 4 - 12 ft
Health history is ______
subjective
What is the health history sequence?
- biographical data
- source of history
- reason for seeking care
- present health or history of present illness
- past health
- family history
- review of systems
- functional assessment including activities of daily living
What is biographical data?
- name address and phone number - age and birth date - birthplace - sex - marital status - race - ethnic origin - occupation
What is a symptom and give an example
- subjective sensation person feels for disorder
- what person says is reason for seeking care is recorded and enclosed in quotation marks ot indicate a person’s exact words
EX: pain of a headache (the nurse can’t feel this nor can “observe” the pain)
What is a sign and give an example
- OBJECTIVE abnormality that can be detected on physical examiniation or in lab reports
- fever
- vital signs
- nurse can see a fever, on a thermometer,,, sweating, etc
How can you determine a pt’s functional ability?
- do they have the ability to perform activities necessary to live modern society (ADL’s = brush teeth, go to bathroom
Also including driving, using phone) - individuals actual perfomance of activities and tasks associated with their current life roles
Functional assessment domains include:
- ADLs
- IADLs (independent activity of daily living)
What is the KATZ index of independence in ADL?
- measures physical function in older adults and chronically ill
- goes off a point scale
What is the lawton instrumental activities of daily living?
- addresses higher level components
- initially designed to determine suitable living arrangements
- Scale assesses a person’s ability to perform tasks such as using a telephone, doing laundry, and handling finances. Measuring eight domains, it can be administered in 10 to 15 minutes.
What should your final statement be in documentation?
person’s reason for seeking care, not your assumption of problem
What is health?
- balance of a person is complex, interrelated phenomenon
- within one’s being: physical, mental, spiritual
- in outside world: natural, communal, metaphysical
What is illness?
loss of a person’s balance
- within one being: physical, mental, spiritual
- in outside world: natural, communal, metaphysical
What is cultural sensitivity?
- basic knowledge of and constructive attitudes toward diverse cultural populations
- *know it**
What is culturally appropriate?
applying background knowledge necessary to provide the best health care
apply it
What is culturally competent?
understanding and attending to total contex of pts situations
- stress, immigration status, cultural similarities
- *rock it**
What are the steps to cultural competence?
- Understand: understand one’s own heritage-based values, beliefs, attitudes, and practice
- Identify: identify meaning of health to patient
- understand: understand how health care works
- Acquire: acquire knowledge about social backgrounds to patients
- Become: become familiar with langugaes, interpretive services, and community resources available to nurse and pts
What is religion?
- belief in divine or superhuman power, or powers to be obeyed and worshipped as creator/ruler of universe
What is spirituality?
a person’s personal effort to find purpose and meaning in life
What is socialization?
Process of being raised within a culture and acquiring characteristics of that group
What is acculturation?
process of adapting to and acquiring another culture
What is assimilation?
Cultural assimilation is the process in which a minority group or culture comes to resemble a society’s majority group or assume the values, behaviors, and beliefs of another group whether fully or partially.
What is Biculturalism
dual pattern of identification and often of divided loyalty
What is magico-religious theories?
- supernatural powers predominate in area of health and illness
- examples include voodoo, witchcraft, and faith healing
What is healing and culture theories?
- in addition to seeking help from health care providers, pts may also seek help from folk or religious healers
- hispanic or american indians may believe that cure is incomplete unless healing is carried out for the body, mind, and spirit
What are the steps to cultural competency?
- culturally sensitive: caregivers possess basic knowledge and understanding
- culturally appropriate: caregivers apply knowledge to improve health outcomes
- culturally competent: caregivers apply a universal concept of understanding to all contextual aspects of care
- cultural care: provision of health care across cultural boundaries in consideration of context
What is a necessary tool for building cultural competence?
heritage assessment tool
