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NURS2500 Patho/Pharma > week 2 : Clinical Judgment & Vital Signs > Flashcards

week 2 : Clinical Judgment & Vital Signs Flashcards

1
Q

Nurses treat disease at different levels of care
1) Primary
2) Secondary
3) Tertiary
4) Quaternary

A

1) ever to go to physician, entry or access to healthcare example : primary physician
2) access through primary care
example to a doctor for a dermatologist
3) a bunch of different services, coordinate effort
example : hospital
4) outside of normal rounds, randomize control trials
example : private care

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2
Q

making sense of a patient (what you should be thinking about)

A

clinical judgment

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3
Q

What does AAPIE stand for in clinical judgment ?

A

assessment
analysis
planning
implementation
evaluation

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4
Q

how to think like a nurse? the usual answer…..

A

clinical judgment

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5
Q

clinical judgment ….

A

the observed outcome of critical thinking and decision making.

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6
Q

this uses nursing knowledge to observe and assess presenting situations, prioritize patient concerns

A

clinical judgment

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7
Q

Nursing Process Assessment (Recognize Cues; Noticing)

A

1) deliberate and systematic collection of data to determine the patient past and present coping patterns
2) data collection/verification
3) subjective/objective data
4) primary vs secondary vs tertiary

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8
Q

from the nursing process : assessment (recognize cues; noticing) this comes directly from the patient

A

primary

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9
Q

from the nursing process: assessment (recognize cues; noticing) the source, someone else telling their condition (family member, etc)

A

secondary

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10
Q

from the nursing process: assessment (recognize cues; noticing)
from data related to how we make sense of it (in terms of prior knowledge)/past experience whats actually going on with the patient (from generic) textbooks, or manuals

A

tertiary

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11
Q

Assessment Techniques-What is the patient’s baseline?

A

Client Health History (Verbal)
Review of Systems
Head-to-Toe Assessment (physical assessment and observations)

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12
Q

Client Health History
what does
S
A
M
P
L
E
stand for

A

signs and symptoms
allergies
medications
past medical/history
last eat or drink
events leading up (what happened to you)

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13
Q

what are the vital signs?

A

1) blood pressure 120/80 mmhg
2) heart rate 60-100 bpm
3) respiratory rate (rr) in an adult 10-20 full inspiration and expiration
4) temperature 35.8 degrees- 37.3
5) oxygen saturation SPO2 97-99%
if its under 90= dangerous

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14
Q

what are the different level of care?

A

primary
secondary
quaternary
tertiary

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15
Q

what is ROS

A

review of systems = collect data on all body systems (use as a guide) but u can ask more details questions if its needed

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16
Q

In london engand Dr.pepper came in and weight himself to be 272 lbs , what would be the conversion be in kg?

A

123.6 kg

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17
Q

what is body mass index and waist-to-hip ratio used for ?

A

body mass index= fat, health risk
waist-to-Hip Ratio= risk for disease if they are under or over weight

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18
Q

what is general survey?

A

changes, signs of clinical distress such as physical appearance, body stricture, behaviour, mobility

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19
Q

what is subjective investigation?

A

pain, dizziness, nauseau

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20
Q

what is objective investigation , give examples?

A

fever, broken leg, high blood pressure, skin rash, etc.. u know the vibes

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21
Q

Subjective Investigation
Health Assessment Questions
O
P
Q
R
S
T
U

A

onset (first question u should ask)
precipitation (the cause )or palliation (what makes it better)
Quality (description of the pain)
Region or Radiation (referred to as pain)–> where in terms of the body
severity
time or timing ( pattern or duration)
understanding( the issue)

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22
Q

Physical of Assessment
I
P
P
A
O
what do they stand for?

A

inspection
palpation
percussion
auscultation
olfaction

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23
Q

what is the instruments used for inspection?

A

penlight
otoscope
ophthalmoscope
specula : vaginal, nasal

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24
Q

give examples of palpation

A

touch-can conform what you saw during inspection

palpating your abdomen

palpating thyroid gland

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25
Q

what is generally used when it comes to palpation, light palpation & deep palpation?

A

light palpation

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26
Q

what motions do you use when it comes to palpation ?

A

circular motions

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27
Q

what are the characteristics of palpation?

A

texture, temperature, moisture ( diaphoresis)

swelling, thickness, (^ density ), lumps or masses

presence of tenderness or pain

vibration or pulsation

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28
Q

what is percussion ?

A

tapping skin with short, sharp strokes to assess underlying structures
direct
indirect
produce vibration –> sounds

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29
Q

what is an artifacts?

A

hearing sounds, coming through (not from the patient)

for example : extra room noise, keep patient warm-prevent shivering etc.

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30
Q

What is Data Verification?

A

making sure the information you’re collecting is accurate

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31
Q

A nurse takes a patient’s radial pulse. They count 40 beats in one minute. What should the nurse do next, in terms of data verification?

A

Abnormal is it really accurate? to make sure check the other arm.

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32
Q

Laboratory values provide key in formation about….

A

homeostasis in your body

33
Q

TRUE OR FALSE. laboratory values are important piece of evidence to inform out clinical judgment

A

true

34
Q

what is the suggested prioritization framework for planning nursing care

A
  1. Life-threatening situations
    2.Safety issues
    3.Client priorities
    4.Nurse priorities
35
Q

List in order of priority :

A patient requires a bed bed bath per their nursing care plan

A patient has no pulse and is unresponsive

A patient asks to mobilize to the wheelchair to visit family

A patient has the side rails down on their bed

A

A patient requires a bed bed bath per their nursing care plan (4)

A patient has no pulse and is unresponsive (1)

A patient asks to mobilize to the wheelchair to visit family (3)

A patient has the side rails down on their bed (2)

36
Q

name the implementation process

A

1) re-assess the patient
2) reviewing the existing nursing care plan
3) organizing resources and care delivery
4) anticipating and preventing complications

37
Q

The Evaluation process, which determines the effectiveness of nursing care, consists of five elements

A

1) identifying evaluative criteria and standards
2) collecting data to determine whether the criteria or standards are met
3)interpreting and summarizing findings
4) documenting findings and any clinical judgment
5) terminating, continuing or revising the care plan

37
Q

Application Exercise:
_______ are techniques a nurse uses to gather data about the patient’s current condition

The nurse uses their _______ to provide safe care.

______ provides the health care team with an overview of clinical manifestations the patient is experiencing

____ is when the nurse performs additional assessments

_______ is a technique/tool used to assess a specific clinical manifestations (e.g pain)

A
  1. IPPA
    2.Clinical judgment
    3.ROS
    4.OPQRSTU
    5.Data Verification
37
Q

Put the statements in the right category
- collect data
-organize data
- validate data
- document data
-analyze data, identify health problems ,risks, and strengths
-formulate diagnostic statements
-collect data related to outcomes
-complete data with outcomes
-relate nursing actions to patient goals/outcomes
-draw conclusions about problems status
-continue, modify, or end the patient’s care plan
-reassess the patient
-determine the nurse’s need for assistance
-implement nursing interventions
-supervise delegated care
-document nursing activities
-prioritize problems and diagnoses
formulate goals and designed health outcomes
-identify nursing interventations

A

assessment
- collect data
- organize data
- validate data
- document data

Nursing diagnosis/analysis
- analyze data
- identify health problems, risks , and strengths
- formulate diagnostic statements

Planning
-prioritize problems and diagnoses
-formulate goals and designed health outcomes
- identify nursing interventions

Implementation
- reassess the patient
- determine the nurse’s need for assistance
- implement nursing interventions
- supervise delegated care
- document nursing activities

Evaluation
- collect data related to outcomes
- complete data with outcomes
- relate nursing actions to patient goals/outcomes
- draw conclusions about problem status
- continue, modify, or end the patient’s care plan

37
Q

What are the five vital signs?

A

Blood pressure
Respiration rate
temperature
oxygen saturation
pulse

38
Q

Thermoregulation & Interrelated concepts (list the categories)

A

infection
intracranial regulation
nutrition
fluid and electrolytes
tissue integrity
perfusion

39
Q

pulse reflects what?

A

systole, contractility, and stroke volume

39
Q

where on the body can you take temperature?

A

rectum, tympanic (ear), temporal (forehead), oral (mouth), axilla

39
Q

what is a normal temperature?
Hypothermia
Normal temperature
Hyperthermia

A

Hypothermia- <35.8
Normal temperature- 35.8-37.3
Hyperthermia - >38.5

39
Q

What is the normal pulse rate for ..
- adult
- newborn
- infant

A

normal adult- 60-100 bpm
newborn - 70-190
infant - 80- 160

40
Q

bradycardia bpm

A

<60 (less than 60)

41
Q

tachycardia

A

> 100 ( more than 100)

42
Q

what is conditioned athlete bpm

A

50-100 bpm

43
Q

pulse strength scale
4+
3+
2+
1
0

A

full, bounding
strong
weak
thready
absent

44
Q

what is the basic documentation when getting the pulse of the patient?

what is additional document when getting the pulse of the patient

A

rate + location

additional document: regularity (rhythm) + strength (force)

45
Q

name the following :
normal sinus rhythm
regularly irregular
irregular

A

60-100 bpm
30 sec P
60sec P/HR
60sec HR

46
Q

what is pulse deficit ?

A

pulse deficit is when the heart rate is higher than the pulse rate

47
Q

how long do you count a pulse for ?

A

30 seconds regular
60 seconds irregular

48
Q

what do you think could be the cause of the following?

an absent pulse
a week pulse
a strong, bounding pulse
a thready pulse

A

an absent pulse can indicate the heart stopped
a weak pulse - not strong, consistency there, poor percfussion (can cause by dehydration)
a strong bounding pulse can indicate someone running on a treadmill and exercising
a thready pulse - u can feel it but not consistent, coming in and out

49
Q

formula for blood pressure:

A

CO x SV

50
Q

When to take a blood pressure?

A

5 min rest, 3 measures 2 min apart, discard first and average second and third measure

51
Q

true or false.
Measure in both arms ( may be 5-10 mmHg diff) take higher reading

A

true

52
Q

True or false.
When taking a blood pressure if arms differ more than 20mmHg may need to continue to do both

A

true

53
Q

What does auscultatory gap mean?

A

abnormal, more common with hypertension

54
Q

the first sound you hear when taking a blood pressure manually is…?

A

systolic pressure

55
Q

the silence you hear when taking a blood pressure manually is ….?

A

diastolic pressure

56
Q

are any of these common error in blood pressure measurement ?

waiting 1-2 min between measures with cuff fully deflated

halting during inflation

A

the first one is not an error but accurate, you should wait 1-2 min

this is a common error

57
Q

true or false. Electronic accurate “ 2’ mmHg (132/42) while manual only accurate to every “1” mmHg (131/43)

A

false, it is the other way around electronic is accurate “1” mmHg (131/43) while manual only accurate to every “2” mmHg (132/42).

58
Q

hypotension: low BP

A

typically it is less than 95/60

59
Q

hypertension ranges from …?

A

> 140/90

60
Q

4:1 ratio pulse respiratory rate, what does that mean?

A

for every 4 heartbeats, there should be 1 breath

61
Q

What is bradypnea? what is tachypnea?

A

bradypnea -less then 10 per min, slow
tachypnea - more then 20 per min, fast

62
Q

what is the effort or depth of breathing? what is the rhythm of breathing?

A

decreased: ex. hypoventilation
normal: easy chest rise and fall
increase: for ex. hyperventilation

rhythm:
normal, even and regular
irregular

63
Q

how do you count respirations?

A

watch of feel the patient’s chest rise and fall

64
Q

Oxygen Saturation

A

normal range: 97-99%
critical: less then 90%
measured by pulse oximetry, O2 Sats SpO2

65
Q

In Client Health History , can SAMPLE be approach?

A

yes it can be approach

66
Q

Pallor

A

unhealthy pale colour

67
Q

hypercapnia

A

high level of carbon dioxide

68
Q

diaphoresis

A

sweating

69
Q

diurnal cycle

A

variations in the day/night cycle, affects temperature

70
Q

pyrexia

A

essentially fever

71
Q

febrile

A

showing the symptoms of fever

72
Q

hypoxia

A

not enough oxygen levels in the tissue level to maintain homeostasis

NURS2500 Patho/Pharma (16 decks)

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