Nursing 204: Exam 1

clinical judgement: definition

an interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response

clinical judgement attributes

notice, interpret, respond, reflect

assessment definition

health assessment is a systematic method of collecting data about a patient for the purpose of determining the patient’s current and ongoing health status, predicting risks to health, and identifying health promoting activities

tanner’s model for clinical judgement

reflect on things after the fact, reflection-in-action

assessment attributes

subjective and objective, holistic assessment, evidence based screenings

ADPIE

assessment

diagnosis

planning

implementation

evaluation

objective data

can be detected by an observer or can be measured or tested again

objective data example

physical exam: vital signs

subjective data

symptoms, feelings or perceptions that can be described or verified only by the patient (you can’t see it, observe it, or prove it)

subjective data example

pain scale

nursing diagnosis

describe the human response or a patient’s physical, sociocultural, psychologic, and spiritual responses to an illness or a health condition

angina

a type of chest pain caused by reduced blood flow to the heart;

medical diagnoses

made by a licensed provider such as a physician, advanced practice nurse, or PA

PES format

Problem (what are the approved nursing diagnoses? what is the human response to illness?)

Etiology (what caused the problem? why is this response occurring?)

Signs/Symptoms (what are they? how does the nurse know? how might a nurse now?)

arm fracture medical diagnosis

simple, closed, radial ulnar fracture of the right arm

arm fracture nursing diagnosis

pain related to injury as evidenced by crying, risk for self care deficit

SMART goals

specific

measurable

attainable

relevant

time based

UAP

unlicensed assistive personnel

(CNA’s, technicians)

temperature normal range

98\.6 (37)

97-99 (36.1=37.5)

what affects temperature

environment, time of day, health, activity levels, periods

what helps maintain a balance between heat lost and heat produced by the body

hypothalamus

areas to take temperature

sublingual (mouth/oral)

rectum (usually higher than oral)

axilla (armpit, usually lower than oral)

temporal artery (forehead)

tympanic membrane (eardrum, least accurate)

bladder (if a tube is already there)

esophagus (if a tube is already there)

hypothermia

less than 36.5

normothermia

36\.5-37.3

hyperthermia

more than 37.3

fever

more than 38

shunting means what

flushing

places to take a pulse

temporal artery (temple)

facial artery (jaw)

common carotid artery

brachial artery

radial artery

femoral artery

popliteal artery (inside knee)

posterior tibial artery (ankle)

dorsalis pedis artery (top of foot)

pulse scale

3+ = bounding

2+ = normal

1+ weak

0 = none

brachycardia

less than 60 bpm

hypoxia

low oxygen in body tissues

normal pulse

60-100 bpm

younger/smaller children have faster resting HR

newborn normal pulse

110-160 bpm

tachycardia

more than 100 bpm

inhalation

diaphragm moves down

exhalation

diaphragm moves up

apnea

no breathing

inspiration

inhaling air with oxygen into the lungs

\

diaphragm is attached to what nerve

T5

expiration

exhaling air with CO2 out of lungs

bradypnea

less than 12 breaths per min

eupnea

12-18 breaths per min

tachypnea

more than 18 breaths per min

blood pressure

pressure exerted by the circulating volume of blood on the arterial walls, veins, and chambers of the heart

systolic

represents ventricles contracting

diastolic

represents the pressure within the artery between beats

pulse pressure

difference between systolic and diastolic

too small of a blood pressure cuff causes

a false high

too large of a blood pressure cuff causes

false low

orthostatic hypotension

from going to laying down to standing

* heart rate increases 30
* systolic drop of 20
* diastolic drop of 10
* cause: fluid volume deficit

fluid volume deficit

dehydration

hypotension

BP less than 90/60

normotension

BP of 90/60-120/80

* young children have lower

hypertension

more than BP of 120/80

why does BP increase with age

vessels become less elastic

normal adult BP

less than 120 and less than 80

elevated adult BP

120-129 / less than 80

high BP stage 1 for adults

130-139 / 80-89

high BP stage 2 for adults

140+ / 90+

hypertensive crisis for adults

higher than 180 / higher than 120

hemorrhage increases or decreases BP

decrease

increased intercranial pressure increases or decreases BP

increases

acute pain increases or decreases BP

increases

end-stage renal disease increases or decreases BP

increase

general anesthesia increases or decreases BP

decrease

exercise postural change increases or decreases BP

decrease

smoking increases or decreases BP

increases

oxygen saturation

percentage of blood hemoglobin that is filled or saturated with oxygen

SpO2

saturation, peripheral of oxygen

desaturation

less than 95% on room air

normal saturation

95-100% on room air

high oxgen saturation

100% for patients on supplemental oxygen

in comparison to adults, children should have

* the same temperature
* higher HR
* higher RR
* lower BP
* same oxygen saturation

cardiac output

the amount of blood pumped by the heart in one minute

CO (ml/min) = HR (bmp) x SV (ml/beat)

heart exam physical assessment

inspect appearance, color, scars, neck veins

pallor

pale

cyanosis

blueish color

* tells u oxygen levels have been low

murmers

sound of turbulent blood flow in the heart

* blood reverberates or bounces off the walls of the atrium or ventricles

bruits

sound of turbulent blood flow in the artery

thrills

the feeling of turbulent blood flow in the heart or arteries

extra heart sound S3 causes

* congestive heart failure
* left ventricular hypertrophy
* pulmonary edema
* heart attack
* sounds like Kentucky

extra heart sound S4 causes

\

* ventricular hypertrophy
* long term hypertension
* sounds like tennessee

skin turgor explained

tight = more fluid under

normal

loose = tenting, less fluid underneath

edema

swelling due to fluid accumulation

peripheral temperature

warm if warm environment

capillary refill

should be 1-3 seconds

men heart attack symptoms

* nausea, vomiting
* jaw, neck, or back pain
* squeezing chest pressure or pain
* shortness of breath

women heart attack symptoms

* nausea, vomiting
* jaw, neck, or back pain
* chest pain but not always
* pain or pressure in lower chest or upper abdomen
* shortness of breath
* fainting
* indigestion
* extreme fatigue

syncope

fainting

NANDA diagnosis

* activity intolerance/risk for activity intolerance
* decreased CO/risk for decreased CO
* risk for unstable BP
* risk for decreased cardiac tissue perfusion
* risk for ineffective cerebral tissue perfusion
* ineffective peripheral tissue perfusion/risk for it

clubbing

tells oxygen levels have been low for a really long time

cadexia

extreme thinness

eupnea

normal breathing

dyspnea

difficulty brething

kussmaul

very shallow then fast

cheyne-stokes

no breathing, then deeper and deeper, then no breathing

vesicular lung sounds

normal

bronchovesicular lung sounds

normal

inspiratory stridor lung sounds

top, trachea, epiglottis

* obstruction in the airway

wheezes

high pitch bottom of chest