Exam 1

VS, History, Nursing process, Technique, Respiratory

what is the first step in the nursing process

assessment

describe what assessment means in the nursing process

collecting data and information pertinent to cline and or situation

what is the second step in the nursing process

daignosis

describe diagnosis in the nursing process

analyze data to determine what the problem is

what is the third step in the nursing process

outcome identification

describe outcome identification in the nursing process

the RN identifies expected outcomes for a plan individualized to the health care consumer or situation (what is the goal?)

what is the fourth step in the nursing process

planning

describe planning in the nursing process

how you obtain the outcome/goal; what you will do

what is the fifth step in the nursing process

implementation

describe implementation in the nursing process

coordinate care and implement the plan

what is the sixth step in the nursing process

evaluation

describe evaluation in the nursing process

reassess. collect data and determine if the goal was met (i.e. did the plan work?)

what is health history

subjective date that the PT tells you

what is the physical exam

objective data that the RN sees, hears, or feels

what does a health history consist of

subjective data collected during an interview that includes PT’s current state of health, current meds, previous illness and surgeries, family hx, personal and psychosocial hx, and review of systems

describe PRIMARY health promotion

preventing problems and is good for everyone

give examples of primary health promotion

immunizations, healthy diet, sleep, exercise

what is SECONDARY health promotion

early detection before a possible or expected problems occur; screening at risk groups

give an example of secondary health promotion

screening exams

what is TERTIARY health promotion

treating and/or preventing complications from disease

give examples of tertiary health promotion

maintaining insulin and diet for diabetes management, cardiac rehabilitation, hypertension management

what is subjective data

information that the patient TELLS you or SAYS

what is objective data

information that is seen, gathered, measured, or heard

what is biographic data

data used to identify the PT and make the PT a unique indivudual

what is another way of saying “reason for seeking care”

chief complaint

which type of history would be asked about if the RN wanted more information about the chief complaint

history of present illness

how far back would the RN ask about for family history

at least 2 generations

mental health and who PT lives with falls under which history category

personal and psychosocial history

what is a review of systems

an assessment broken down into each body system to inquire about past and present health

what is a comprehensive assessment and when is it done

detailed history at onset of care in primary care setting and is done if PT is newly admitted to hospital or long term care facility

what is a problem/focused assessment and when is it done

history and exam are limited to specific problem and is done in walk in clinics and ER

what is a shift assessment and when is it done

head-to-toe assessment at routine times during a shift or based on changes and is done at shift changes or if baseline has changed

what is a screening assessment

short, focused on a specific potential problems

what is an episodic/follow up assessment

follow up for previously identified problem and is done

how do you record/document the chief complaint

in PT stated quotes (i.e. “here for routine exam”)

when is OLDCARTS used

for pain assessments and history of present illness

describe the meaning of OLDCARS

O- onset, L- location, D- duration, C- characteristics, A- aggravating/alleviating factors, R- relative/related symptoms, T- treatment, S- severity

what should the RN ask after being told the PT has an allergy to a specific medication or treatment

what is the reaction/what happens

what should the RN facilitate in the interview discussion

the RN should facilitate patient centered discussion

what should happen during the summary part of the interview

allow PT to clarify data and validate PT that the RN understands problems

what are some techniques that DIMINISH data collection

using medical terminology, expressing value judgements, interrupting PT, being authoritarian or paternalistic, and using why questions

what are techniques that enhance data collection (study chapter 2 vocab for definitions)

active listening, facilitation, clarification, restatement, reflection, confrontation, interpretation, summary

what are standard precautions

measures used to reduce the risk of transmitting infection from bodily fluids and non-intact skin. Used on EVERYONE!

what is the single most important action to reduce infection transmission

hand hygiene

what should you never do with a needle once it has been used on a patient

recap it

how should you move through an assessment

from less personal to more personal

where should a pediatric exam occur if the PT is less than 6 months old

on the exam table

where should the pediatric exam occur if PT is older than 6 months

usually in the caregiver’s lap to decrease fear and distress

which part of the exam should you do first on a pediatric assessment

the less distressing part (auscultate heart and lungs, palpate fontanels, pulses and abdomen)

which part of the pediatric exam should be done last

the more distressing parts (musculoskeletal exam, ear and oral exam)

what is inspection

visual exam including body movement, posture, and smell

what is palpation

touching PT to determine texture, size, shape, consistency, pulsations, locations

what part of your body should RN use to determine position, texture, size, consistency, masses, fluid or crepitus

palmar surface of finger pads

which part of body should RN use to feel vibrations

ulnar surface

which part of body should RN use to determine temperature

dorsal surface

which stage of palpation do RN’s use

light palpation (1st)

what is percussion

an advanced practice used to detect tenderness, ddetermines extent of fluid in body cavity

what is direct percussion

striking finger or hand directly on/against patient body

what is indirect percussion

the use of both hands; distal aspect of middle finger of non-dominant hand is against skin, other hand is tapping hand that is against PT body

what is auscultation

listening to sounds in the body

true or false: it is okay if the stethescope is not directly on PT skin

false

true or false: you should not take your personal stethoscope into an isolation room

true

what is the diaphragm on the stethoscope

the flat surface with rubber ring on edge and is used for high-pitch sounds

what is the bell of the stethoscope

concave/cup part used to hear soft, low-pitched sounds

how should the bell be used when listening

it should be pressed very lightly to be used accurately

what is the general inspection

the observation of physical appearance and hygiene, body structure and position, body movement, emotional and mental status

what three types of temperature methods should you do on newborns-5 years of age

axillary, temporal, and tympanic

what is the most common peds temp method

axillary

axillary temps are 1 degree ____ than oral temps

lower

if the axillary temp is 98.5 what is the oral temp

99.5

tympanic temp is what part of the body

the ear

how should you position the ear on a pediatric tympanic temp

tug helix down and back

how should the ear be positioned for an adult tympanic temp

tug helix upward

what does the tympanic temp measure

measures tympanic membrane temp

oral temp is acceptable for what ages

5 years and up

what can affect oral temp in adults

smoking, eating, and drinking can impact for 10 mins

where should the probe be placed for oral temp

posterior sublingual pocket

which type of temp do you need a doctor’s order

rectal

how far should the probe be inserted for rectal temp

maximum of 2.5 cm (less for newborns and young infants)

what is the expected range of temperature and the average

96.4 F- 99.1 F (average of 98.6F/37 C)

when is temperature expected to be the lowest

early in the morning by 1-1.5 F degree

what are some reasons for hyperthermia (fever) in newborns

viral/bacterial infections, dehydration, exposure to heat

what are some reasons for hypothermia in newborns

environmental exposure

what is the average temperature for older adults

97.2 F

why do older adults have a lower temp average

decreased metabolism and less physical activity

what does the pulse oximeter do

estimates the oxygen saturation of hemoglobin in the blood

what is considered abnormal for oxygen saturation

less than 90%

a nurse is preparing to measure joe’s level of oxygen saturation and observes edema of both hands and thickened toenails. the nurse should apply the pulse oximeter probe to which of the following locations? (finger, toe, skin fold, or ear lobe?)

ear lobe

qhwn rhw O2 sat probe is initially palced, it reads 60%. Joe does no appear to be in distress and his RR is 14BPM. What should the nurse do first? (document the O2 sat of 60%, wait about 10-20 seconds for probe to properly work, call rapid, move probe to different location)

wait about 10-20 seconds for probe to properly work

what is the most common palpation sight of HR in adults

radial artery

apical pusle=?

auscultation of heart

apical pulse is typically done on?

infants

where does the stethoscope need to be placed on adults

5th intercostal space mid clavicular line

what is rhythm

interval or spacing between heart beats and can only be documented as regular or irregular

what is rate

number of pulsations per minute and can only be documented as a number

what should you do if the HR is irregular

palpate for 1 full minute

how long should you auscultate the apical HR of infants or children

listen for one full minute

what is the HR range for infants/newborns

100-160bpm

what is the HR range for toddlers

98-140 bpm

what is HR range for school age children

75-118bpm