Term
| What are the 3 aspects of critical thinking? |
|
Definition
| knowledge, experience, and common sense |
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|
Term
| Define the "nursing process" |
|
Definition
| ensuring safe nursing practice and quality care |
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Term
| What are two other name for the nursing process? |
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Definition
| problem solving process and scientific method |
|
|
Term
| What are the 5 stages of the nursing process? |
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Definition
Assessment
Diagnosis/Analysis
Planning
Implementation and Documentation
Evaluation |
|
|
Term
| What does the nursing process always begin with? |
|
Definition
|
|
Term
|
Definition
| ongoing process of gathering, analyzing and reflecting on evidence to make informed judgements |
|
|
Term
| What are the four concepts of health? |
|
Definition
| biomedical model, wellness, holistic health, health promotion and disease prevention |
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|
Term
ID:
Focus is curing disease;traditional view of W. medicine; health is absence of disease, health and disease are opposites |
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Definition
|
|
Term
| What was Dunn's contribution to medicine? |
|
Definition
| The idea of wellness; different levels exist; dynamic process moving toward optimum functioning |
|
|
Term
| Describe the concept of holistic health |
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Definition
| Health is dependent on the state of the mind, body and spirit. Health functions as a whole within the environment |
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Term
| What is the focus of health promotion and disease prevention? |
|
Definition
| the link between health and personal behavior |
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|
Term
ID:
data collection about an individual's health |
|
Definition
|
|
Term
| Describe the diagnosis/analysis portion of problem solving |
|
Definition
| interpret data for clusters of cues, make and validate inferences, document |
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|
Term
| What are the two components of the planning aspect of problem solving? |
|
Definition
| develop goals/outcomes; ID interventions |
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|
Term
| Planning goal/outcome is always focused on who? |
|
Definition
|
|
Term
| Define interventions; who is this focused on? |
|
Definition
| actions that nurses do that enable client to achieve set goal; nurse focused |
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|
Term
| Describe the evaluation portion of problem solving |
|
Definition
| data that indicates if goal was achieved. Leads to re-assessment |
|
|
Term
| Describe General Systems Theory |
|
Definition
| basis of our approach to nursing; explains breaking whole into parts and their working together into a system |
|
|
Term
|
Definition
| a set of interacting parts |
|
|
Term
| Nursing problem solving process is a ___ system |
|
Definition
|
|
Term
| What are the 4 aspects of the general system theory? |
|
Definition
| input, throughout, output, feedback |
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|
Term
| Align the aspects of the general systems theory with the aspects of nursing problem solving |
|
Definition
input=assessment
throughput=analysis/diagnosis
output=planning
feedback=reassessment |
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|
Term
| What are the 5 goals of a system? |
|
Definition
| equilibrium, balance, homeostasis, steady state, health |
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|
Term
| What are the 4 types of data collection? |
|
Definition
| complete, episodic, follow-up and emergency databases |
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|
Term
| Describe the complete data base |
|
Definition
| complete health history; full physical exam |
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|
Term
| Describe the episodic data base |
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Definition
| mini database, problem-centered, exam follows chief complaint |
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|
Term
| Describe the follow-up data base |
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Definition
| focus on one area to determine improvement, status of ID'd problems are evaluated at regular intervals |
|
|
Term
| Describe the emergency data base |
|
Definition
| rapid data collection concurrent with life-saving measures; focuses on ABCs |
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|
Term
|
Definition
| airway, breathing, cardiovascular |
|
|
Term
| What are the 3 levels of assessment priorities? |
|
Definition
1st: ABCs, vital signs
2nd: mental status changes, acute pain, risks of infection
3rd: lack of knowledge, rest, family |
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|
Term
| What are 3 components of an inference? |
|
Definition
| conclusion, reasoning process, implication |
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|
Term
| What is the easiest way to come up with an overall goal for the patient? |
|
Definition
| turn the diagnosing upside down |
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|
Term
| Interventions include what 3 components? |
|
Definition
| What the nurse will assess, do and teach |
|
|
Term
| What are 5 types of assessment categories? |
|
Definition
| inspection, palpation, percussion, auscultation, instrumentation |
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|
Term
| What do you look for during inspection? |
|
Definition
|
|
Term
| What terms should be used in place of "normal"? |
|
Definition
| symmetrical; within normal limits |
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|
Term
| What is the purpose of palpation? |
|
Definition
| assess texture, temp, location size, vibrations and pain |
|
|
Term
| What 3 areas of your body are used for palpation? |
|
Definition
| grasping of fingers and thumb, dorsum of hands/fingers, ulnar surface (base) of fingers |
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|
Term
| What does percussion give you? |
|
Definition
| palpable vibration, characteristic sound, location, size density of organ |
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|
Term
| What are the two methods of percussion? |
|
Definition
| direct/immediate and indirect |
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|
Term
| Name and describe the four percussion note characteristics. |
|
Definition
amplitude=intensity
pitch=frequency
quality=timbre
duration |
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|
Term
ID the percussion sound:
clear hollow, medium loud, moderate duration, over normal lung tissue |
|
Definition
|
|
Term
ID the percussion sound:
booming, louder, long duration, over lungs with increased air |
|
Definition
|
|
Term
ID the percussion sound:
musical, drumlike, loud, longest duration, over an air filled structure |
|
Definition
|
|
Term
ID the percussion sound:
muffled thud, soft, short duration, over relatively dense organ |
|
Definition
|
|
Term
ID the percussion sound:
dead stop sound, very soft, very short duration, when no air is present |
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Definition
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|
Term
| the ____ on a stethoscope is for high pitched sounds and the ____ is for low pitched sounds |
|
Definition
| Diaphragm (high); bell (low) |
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|
Term
| What accommodations should be made for geriatrics during physical assessment? |
|
Definition
| positioned sitting or lying down, minimize position changes, give breaks |
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|
Term
|
Definition
| study of the whole person covering the general health state, obvious physical characteristics, overall impression of the person |
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|
Term
| What are the 4 areas of general survey? |
|
Definition
| physical appearance, body structure, mobility, and behavior |
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|
Term
| What 4 aspects of physical appearance are first looked at in a general assessment? |
|
Definition
| ABCs, neurostatus, pain and acute distress |
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|
Term
| In charting a general survey, what 5 areas should be covered? |
|
Definition
| age, symmetry, nutrition, position and physical deformities |
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|
Term
| Acute weight changes are likely related to what? |
|
Definition
| acute fluid status changes |
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|
Term
| What are the 5 vital signs? |
|
Definition
| temp., pulse, respiration, BP, pain (sometimes O2 sat) |
|
|
Term
| What is the least accurate and most accurate forms of taking temperature? |
|
Definition
| axillary (least) rectal/tympanic (most) |
|
|
Term
| What is the normal range for a pulse? |
|
Definition
|
|
Term
| What are the 4 levels of force regarding pulse? |
|
Definition
| bounding 3+, WNL 2+, weak/thread 1+, non palpable =0 |
|
|
Term
| Breathing should be ____ and ____ |
|
Definition
|
|
Term
|
Definition
| systolic-diastolic pressure |
|
|
Term
|
Definition
| mean arterial pressure; critical care settings |
|
|
Term
| How do you calculate MAP? |
|
Definition
|
|
Term
| How do you calculate cardiac output? |
|
Definition
|
|
Term
| Stroke volume is the result of what 3 occurences? |
|
Definition
| preload, afterload, and contractility |
|
|
Term
| If a BP cuff is too large it will lead to a false ____ but if it is too small it will lead to a false ____ |
|
Definition
|
|
Term
| Describe orthostatic vital signs |
|
Definition
| postural vital signs; Take BP and pulse in lying position, sitting and standing with a 1 min break in between each |
|
|
Term
| What is considered a positive orthostatic change? |
|
Definition
| 10-20mmHg drop of BP and rise in pulse between any position change; due to vasodilation and dehydration |
|
|
Term
| How do you validate a pulse ox reading? |
|
Definition
| good pulsatile signal and HR on pulse oximeter matches palpated HR within 5 beats |
|
|
Term
| What changes occur in aging adults regarding pulse and respiration? |
|
Definition
| pulse is more bounding due to atherosclerosis; pulse is irregular (atrial fibrillation); respiration increases and is more shallow |
|
|
Term
| What is the mnemonic for pain assessment? |
|
Definition
S=severity
O=onset
L=location
D=duration
C=character
A=aggravating factors
R=relieving factors
T=treatment |
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|
Term
| What type of data is health history and why? |
|
Definition
| Subjective; it's what the patient says about their health |
|
|
Term
| What is another term for history of present health? |
|
Definition
| history of presenting illness |
|
|
Term
| What is the mnemonic used in gathering HPI? |
|
Definition
| PQRSTU: provocative or palliative, quality or quantity, region or radiation, severity scale, timing, understand patient's perspective |
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|
Term
| What are two other names for a family tree? |
|
Definition
|
|
Term
| What type of data is review of systems and why? |
|
Definition
| ROS is subjective; patient's perspective on their health status of each system |
|
|
Term
| What are the cardiac acute pain responses? |
|
Definition
| tachycardia, elevated BP, increased CO |
|
|
Term
| What are the pulmonary acute pain responses? |
|
Definition
| hypoventilation, hypoxia, atelectasis |
|
|
Term
| What are the GI acute pain responses? |
|
Definition
|
|
Term
| What are the endocrine acute pain responses? |
|
Definition
| increased adrenergic activity |
|
|
Term
| How often is the epidermis completely replaced? |
|
Definition
|
|
Term
| What are the two layers of the epidermis? |
|
Definition
| stratum corneum and stratum germinativum |
|
|
Term
| What are the 3 layers of skin? |
|
Definition
| epidermis, dermis, subcutaneous |
|
|
Term
| What is the term for skin shedding? |
|
Definition
|
|
Term
| What is the condition where people shed epidermic layers quickly? |
|
Definition
|
|
Term
|
Definition
| baby hair once the baby is born; fine, faint peach fuzz |
|
|
Term
|
Definition
| lipid oil lubricates skin/hair; slows water loss |
|
|
Term
| What are the two different kinds of sweat glands? |
|
Definition
| eccrine (whole body); apocrine (axillae, nipples, anogenital) |
|
|
Term
| What 3 things do you inspect with skin? palpate? |
|
Definition
| color, odor, integrity; temp, turgor, texture |
|
|
Term
| What are the 6 color changes associated with skin? |
|
Definition
| pallor; erythema (red); plethora (rudy); cyanosis; jaundice; mottling (splotchy) |
|
|
Term
|
Definition
|
|
Term
| What is an underlying cause of palor? |
|
Definition
|
|
Term
| erythema is one of the classic signs of___ |
|
Definition
|
|
Term
| What is the name for increased blood cells? |
|
Definition
|
|
Term
| What is another name for cyanosis? |
|
Definition
|
|
Term
|
Definition
| normal newborns have cyanotic distal limbs as they adjust to life outside the womb |
|
|
Term
| What are 3 types of common pigmented areas for skin? |
|
Definition
| freckles (flat macules), moles/nevi (flat or raised), birthmarks |
|
|
Term
| What are the danger signs of skin inspection? |
|
Definition
Assymetry
Border irregularity
Color variation
diameter greater than pencil eraser
elevation and enlargement |
|
|
Term
ID Skin lesion:
<1cm, flat, circumscribed |
|
Definition
|
|
Term
ID Skin lesion:
>1cm, flat, circumscribed |
|
Definition
|
|
Term
ID Skin lesion:
<1cm, solid, elevated, circumscribed |
|
Definition
|
|
Term
ID Skin lesion:
>1cm, solid, elevated, circumscribed |
|
Definition
|
|
Term
ID Skin lesion:
>1cm, solid, elevated, circumscribed, extends deeper into dermis |
|
Definition
|
|
Term
ID Skin lesion:
>1cm, deep into dermis, firm or soft, |
|
Definition
|
|
Term
ID Skin lesion:
<1cm, contains clear fluid |
|
Definition
|
|
Term
ID Skin lesion:
>1cm, contains clear fluid (blister) |
|
Definition
|
|
Term
ID Skin lesion:
encapsulated fluid filled cavity in dermis/SQ |
|
Definition
|
|
Term
ID Skin lesion:
wheal, superficial, raised, erythematous (mosquito bite) |
|
Definition
|
|
Term
ID Skin lesion:
many pruritic wheals (hives) |
|
Definition
|
|
Term
ID Skin lesion:
elevated, pus filled elevation |
|
Definition
|
|
Term
| What areas of the body are checked for edema and how? |
|
Definition
| ankle malleolus or tibia; press thumb firmly against it and release |
|
|
Term
| Describe the Pitting scale |
|
Definition
1+: mild, slight indentation (1cm)
2+: moderate, indentation subsides quickly (2cm)
3+: deep pitting, indentation remains a shorts time (3cm)
4+: very deep, lasts long time, (4cm) |
|
|
Term
| What is the documentation for someone whose skin is WNL? |
|
Definition
| skin is warm, dry, pink, and intact with no rashes or lesions (for dark skinned substitute skin color) |
|
|
Term
| What are the two abnormal descriptors for hair? |
|
Definition
|
|
Term
|
Definition
| round patches of hair loss |
|
|
Term
|
Definition
| hair growth on the body in an amount considered abnormal |
|
|
Term
| What is another name for dandruff? |
|
Definition
|
|
Term
| What system is comprised of the skin, hair, and nails? |
|
Definition
|
|
Term
ID:
red/swollen tender nail folds |
|
Definition
|
|
Term
| What is an abnormal observation for nails? |
|
Definition
| thin, depressed with edges tilted up (koilonychia)-spoon shaped |
|
|
Term
| What is the cause of koilonychia? |
|
Definition
|
|
Term
| What are the 4 aspects of a nail inspection? |
|
Definition
| color, shape, consistency, clubbing |
|
|
Term
| What is the normal angle of the nail to nailbase? |
|
Definition
|
|
Term
ID:
loss of 160 degree angle in nails; caused by chronic hypoxia; nail base is spongy to palpation |
|
Definition
|
|
Term
| At what point is capillary refill considered abnormal? |
|
Definition
| When it takes 3 seconds or more |
|
|
Term
| What are 7 categories to consider when assessing skin, hair and nails for aging adults? |
|
Definition
| skin color/pigmentation, moisture, texture, sebaceous hyperplasia, thickness, mobility, turgor |
|
|
Term
|
Definition
|
|
Term
ID:
nonmalignant melanocyte clusters |
|
Definition
| liver spots (senile lentigines) |
|
|
Term
ID:
raised yellow papules with central depression (pebbly) more common in men |
|
Definition
|
|
Term
| At what age does BP measurement begin? |
|
Definition
|
|
Term
| What is the purpose of measuring head circumference and how it is done? |
|
Definition
| measures brain growth; measured from occipital to frontal twice; should be no more than 2cm difference |
|
|
Term
| What is the sequence of vital signs for peds? |
|
Definition
| respirations, HR, temp, BP |
|
|
Term
| What are the normal respiration ranges for peds? |
|
Definition
newborn: 30-60
infant: 30-40
Toddler: 25-32
6-10: 20-26
10-adult: 18-22 |
|
|
Term
| How long should a peds HR be measured? |
|
Definition
|
|
Term
| What are the normal HR ranges for peds? |
|
Definition
Newborn:110-160
Infant: 80-150
2-10: 70-110
10-adult: 55-90 |
|
|
Term
| What is the normal temp range for peds? |
|
Definition
|
|
Term
| What are the 4 pain scales in peds? |
|
Definition
| FLACC (can't verbalize), FACES, finger span, self report |
|
|
Term
| What is the most common sign of pain in a toddler? |
|
Definition
|
|
Term
| What is a common issue with pain reporting in adolescents and adults? |
|
Definition
| they deny pair to appear strong and/or go home sooner |
|
|
Term
| What is cradle cap and how is it treated? |
|
Definition
| seborrheic dermatitis; any natural oil and dandruff shampoo |
|
|
Term
| What 4 categories should be assessed for peds rashes? |
|
Definition
| appearance, color, location, pattern |
|
|
Term
| What are 6 common skin rashes for peds? |
|
Definition
| diaper dermatitis, candidiasis, atopic dermatitis (eczema), scabies, tinea (ringworm), impetigo-honey crusted lesions |
|
|
Term
|
Definition
| fungal infection of the nail |
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|
