Exam 1 Flashcards
(25 cards)
What does ADPIE stand for?
Assessment, diagnosis, planning, implementation, evaluation
What does SMART stand for?
single specific action, measurable, attainable, relevant, time limited
What is the normal pulse and range for an adult?
80, 60-100
How do you measure pulse?
4 point scale to measure force, equality (compare from side to side, noting any differences between arms), rhythm (irregularity could indicate heart arrhythmia), pulse deficit (when the apical pulse is faster than pulses in other areas)
How do rectal, tympanic, and axillary temperature readings differ from oral temperature readings?
rectal and tympanic are 0.5C/0.9F higher while axillary is 0.5C/0.9F lower
What are the lifespan considerations when checking the temperature of someone who has a suspected fever?
oral is for adults and older children (+2), method of choice for most hospital pts
rectal for infants and young children; do not use on pts with cardiac issues as it may stimulate the vagal response
What are the considerations when taking a routine temperature check?
Axillary: only accurate with proper placement
Tympanic (ear): quick, non-invasive, done incorrectly about 90% of the time, should straighten ear canal and point toward inner ear, pain if inserted too far, ear wax can impact results… not a method of choice
Temporal: very quick, non-invasive, technique can vary; environment can change results (come in from cold weather, sweating etc)
How do you calculate BMI?
weight (lbs)/height (in) X 703
What is a focused health assessment?
short, used if an injury occurs or if with a long term PCP with no health changes
What are head-to-toe assessments?
done upon assessment to review biographical data, source of history, reason for seeking care, present health or history of present illness, past health, family history, review of systems, ADLs, perception of health
What does the history and physical tell the nurse? Why are they done?
Patient history and a physical can indicate the current baseline for the patient and if there are dysfunctions to any of their current baseline it could be attributed to the patient history and not a new disorder causing it.
When is an appropriate use of an interpreter?
An interpreter can be used for patients whose primary language is not the same as the health care worker’s. The interpreter can be brought in for any conversations done between the health care worker and the patient. A family member should never be an interpreter.
What is important to keep in mind during patient centered interviewing?
therapeutic communication, conscious and unconscious communication
What are the advantages and disadvantages of clinical information systems?
Advantages: the ability to store, retrieve, and share information about each patient. It can support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting
Disadvantages: privacy and security of highly sensitive personal data
What is the nursing responsibilities for clinical information systems?
ANA (American nursing association) states that all nurses should be able to practice safely in a technology-intensive health care environment.
What are the sciences involved in clinical information systems?
Information science: applied math and electrical engineering
Computer science: theoretical foundations of information and computation and how these techniques relate to implementation and application of computer systems
Cognitive science: interprofessional study of mind, intelligence, and behavior from an information processing perspective
Organizational science: emerging field that focuses on behavior of organizations that includes a variety of topics: individual, group and organizational decision making; management of human resources; design of organizations and interorganizational networks
What is the decision support system?
Computer software applications that match patient characteristics with a knowledge base to generate specific recommendations.
Apply evidence-based recommendations at the point of care, they are termed evidence-adaptive.
Ex/ Branden scale, fall risk, allergies
What is the order of a MSK assessment?
Posture, movement and general body symmetry (Symmetry of the skeletal framework; noticing any joints that look asymmetrical or cause pain with palpation) Temporomandibular Joint (TMJ) (Fluidity and ease of joint movement; noticing and clicking or popping, decreased ROM) Cervical Spine Shoulders Elbows Wrists Hands & Fingers Hips Knees Ankles & Feet Gait
What are the signs and symptoms of altered mobility?
Pain Reduced joint movement Reduced sensation or loss of sensation Falls Fatigue Altered gait or imbalance Reduced functional ability
What is flexion and extension?
flexion is the bending of a limb at a joint while extension is the straightening of a limb at a joint
What is abduction and adduction?
abduction is the moving of a limb away from the midline of the body while adduction is moving a limb towards the midline of the body
What is pronation and supination?
turning the forearm so the palm is down and turning the forearm so the palm is up
What is circumduction and rotation?
moving the arm in a circle around the shoulder and moving the head around a central axis
What is inversion and eversion?
moving the sole of the foot inward at the ankle and moving the sole of the foot outward at the ankle
