Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Nursing > Module 1 PA > Flashcards

Module 1 PA Flashcards

(87 cards)

Start Studying
1
Q

Nursing Process

A

ADOPIE
A - Assessment
D - Diagnosis
O - Outcome
P - Planning
I - Implementation
E - Evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Evidence-Based Practice

A

Proven effective with research

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Priority Problem Levels
1st Level

A

Emergent, life-threatening, and immediate
Airway
Symptomatic abnormal blood pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Priority Problem Levels
2nd Level

A

Requiring attention to avoid further deterioration
Acute pain
AMS
Inncontiant patient needing to be cleaned up

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Priority Problem Levels
3rd Level

A

-Is vital to health but, can be addressed after more urgent problems are addressed
-Things that need to be done but take longer
Patient Education
Depression
Enema
Patient Mobility

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Collecting Four Types of Data
Complete total health database

A

Describes current and past health state and forms a baseline to measure all future changes
Has everything about the patient, used with a brand new patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Collecting Four Types of Data
Episodic or problem-centered database

A

-Collect “mini” database, smaller scope and more focused than complete database
-Focuses on what’s going on now with the patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Collecting Four Types of Data
Follow-up Database

A

-The status of all identified problems should be evaluated at regular and appropriate intervals
-Make sure that the medication is working

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Collecting Four Types of Data
Emergency database

A

Rapid collection of data often compiled concurrently with lifesaving measures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Collecting Four Types of Data

A

-Complete total health database
-Episodic or problem-centered database
-Follow-up Database
-Emergency database

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Open-ended questions vs. close-ended questions

A

-Open - provide patient to set the narrative
What brought you in today?
-Closed - Specific information, and direct conversation
Did you get your flu shot this year?
Have you had a fever?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

2 types of SBAR

A

a summary, a communication tool
Nurse to nurse
Nurse to Dr.
-Situation - diagnosis, location, and patient variables
-Background - related to what is happening with the patient
-Assessment - finding with the interpretation of data, and vitals
-Recommendation or request - state what you need or want for the patient in terms of medical treatment or assistance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

PQRSTU Mnemonic (Pain)

A

P - What provokes it, makes it worse or brings it on
Q - Quality or quantity, more descriptors
R - Region or radiation
S - Severity scale 1 to 10
T - Timing or onset
U - Understand the patient’s perception of the problem

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Levels of consciousness (ALOSC)

A

Alert
Lethargic
Obtunded
Stuber
Coma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Levels of consciousness (ALOSC)
Alert

A

awake or readily aroused, conduct meaningful interpersonal interactions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Levels of consciousness (ALOSC)
Lethargic

A

response to minimal stimuli, can follow verbal commands, reflex movement, loses train of thought, someone who just woke up, anemic patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Levels of consciousness (ALOSC)
Obtunded

A

need constant stimulation or will fall back asleep (drug overdose patient) confused when aroused, mumbled speech, decreased movement, acidosis patient, seizure patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Levels of consciousness (ALOSC)
Stuber

A

Unconcus, poor response to stimuli, groaning, incoherent, needs constant vigorous stimuli, will pull away, restless moving, AMS, reflex intact but also may be decreased. 1 step away from a coma and minimally responsive could be someone who just passed out, practically non-verbal, organ failure patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Levels of consciousness (ALOSC)
Coma

A

No reaction to stimuli, no purposeful movement, may have slight reflexes, plantar flexion, traumatic brain injury chronic repeat seizure, patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Acculturation

A

The process of adopting a culture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Assimilation

A

Taking on the characteristics of the dominant culture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Biculturalism

A

Two different cultures in the same country or region but maintaining aspects of the original culture in one ethnic identity. Can not tell the difference

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Hot/Cold theory

A

-Treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness
-Perceived effects on the body, the person is whole, not just a particular ailment
-4 humors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Yin/Yang theory

A

-Exists when all aspects of the person are in perfect balance, opposing forces are maintained
-Yin energy represents the female and negative forces such as emptiness, darkness, and cold
-Energy forces
-Yang forces are male and positive, emitting warmth and fullness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Biomedical
all events in life have a cause and effect
26
Natural
the forces of nature must be kept in natural balance or harmony
27
Magico Religious
the face of the world and those in it depend on the action of supernatural forces for good or evil
28
Safe environment
take all steps to avoid any possible transmission of infection -Wash hands for 20 seconds -Most viruses use to rub all hand surfaces with 3 to 5ml of alcohol for 20 to 30 seconds
29
When examining all young ages the goal is to increase comfort
-Infant - as much of the examination as possible should be performed while the infant is on the caregiver's lap -Toddler - form trust -Preschool child - don't allow choice when there is one -School-aged child - allow helping when there able
30
Functional Assessment
-Self - esteem -Activity and exercise -Sleep and rest -Nutrition and elimination -Interpersonal relationships -Spiritual resources -Coping and stress management -Personal habits -Occupational health -Relationships
31
Mental status assessment (ABCT)
Can be integrated into the health history interview -A - Appearance (visual assessment of patient: clothing clean? Bruises?) -B - Behavior (facial expressions, speech, mood, affect) -C - Cognition (able to answer orientation ?’s, memory “recent and remote”) Recent - 24-hours, remote - long-term memory -T - Thought processes and perceptions (the way a patient thinks, rational/irrational, their idea of reality, awareness, hallucinations)
32
Mini cog vs MMSE
Mini cog Tests the person's executive function, like a plan, managing time, organizing activities, and managing working memory not influenced by educational level Passing score 26 (30 points) 10 minutes MMSE Test of the cognitive functions of the mental status examination Determine if the patient has delirium vs dementia Use caution with people who have low education Lacks sensitivity for mild cognitive impairment 20?’s passing score is 24-30 (30 points), 5 - 10 minutes
33
Delirium vs Dementia
-Delirium - acute confusion and can be resolved -Dementia - is a gradual, progressive process, causing the decreased cognitive function
34
Aphasia
Loss of ability to speak or write coherently or to understand speech or writing due to a cerebrovascular accident
35
Glasgow coma scale
-useful in testing consciousness in aging persons in whom confusion is common -Gives numerical value to person response in eye-opening, best verbal response, and best motor response -Max score 15, 7 or less patient is in a coma
36
IPPA (physical examination)
I - inspection P - palpation P - percussion A - auscultation With the abdomen IAPP
37
Percussion sounds
caused vibrations that produce characteristic waves and that are heard as “notes” -Amplitude - a loud or soft sound -Pitch - number of vibrations per second -Quality - caused by the distinctive overtones of a sound -Duration - length of time the note lingers -Resonant - normal lung tissue -Hyperresonant - ABNL lung tissue -Tympany - distended abdomen, air or gas in stomach, intestines -Dull - dense organs like the liver, spleen
38
Stethoscope
does NOT magnify sound but blocks out extraneous room sounds -Diaphragm - used for high-pitched sounds like breath, bowel, and normal heart sounds -Bell - used for low-pitched sounds such as extra heart sounds, carotid, arteries, bruit, or murmurs -Bruit - swishing sound in the arties -Auscultation - using a stethoscope -2ft recommended length for a stethoscope
39
General survey characteristics -
launch a general surgery the moment you first encounter a person A general survey is a study of the whole person General health, Physical characteristics Overall impression Objective parameters Physical appearance, body structure, mobility, and behavior Age, sex, level of consciousness, skin color, facial features, stature, nutrition, symmetry, posture, position, gait, facial expression, mood and affect, speech, dress, and personal hygiene Objective data Measurements, weight, vital signs Vital signs
40
Vital signs Temperature
-Oral - 96.4 - 99.1F -Rectal - measures 1F higher than an oral measurement -Tympanic membrane thermometer (TMT) -Temporal artery thermometer
41
Vital signs Pulse
palpable flow felt in the periphery as a result of pressure wave generation from stroke volume Stroke volume - the amount of blood pumped into the aorta (70ml in an adult)
42
Vital signs Heart rate
Normal HR is 60 - 100 bpm Higher in infancy Varies with age and gender HR > 60 is bradycardia HR < 100 is tachycardia
43
Vital signs Heart force
the strength of the pulse Weak = pulse reflects a decreased stroke volume Full = pulse results increased stroke volume 3+ = full bounding 2+ = normal 1+ = weak, thready 0 = absent
44
Vital signs Respirations
Normally, a person's breathing is relaxed, regular, automatic, and silent Avoid 15-second intervals, result may vary from + or - 4
45
Vital signs Blood pressure
is the force of blood pushing against the side of its container, vessel wall -The average BP is 120/80 mm Hg -Varies normally with age (rise through childhood into adult years), gender, race, diurnal rhythm, weight, exercise, emotions, and stress - Strength of push changes with events in the cardiac cycle
46
Vital signs Blood pressure Systolic pressure
Maximum pressure felt on artery during left ventricular contraction or systole
47
Vital signs Blood pressure Diastolic pressure
Elastic recoil, or resting, the pressure that blood exerts constantly between each contraction
48
Vital signs Blood pressure Pulse pressure
Difference between systolic and diastolic
49
Vital signs Blood pressure Mean arterial pressure (MAP)
Pressure forcing blood into tissues averaged over the cardiac cycle
50
Vital signs Blood pressure BP determined by five factors
-Cardiac output - increased CO leads to increased BP, decreased CO leads to decreased BP -Peripheral vascular resistance - increased resistance = increase BP, decreased resistance = decreased BP -The volume of circulation blood-fluid retention leads to increase BP, hemorrhages lead to decreased BP -Viscosity - increase associated with an increase in BP -The elasticity of vessel walls - increasing rigidity associated with an increase in BP
51
Taking blood pressure
-Sitting or lying with the bare arm supported at heart level -Use the bell on the stethoscope -Note points when you hear the first appearance of sound, muffling of sound, and final disappearance of sound -Common errors Anxiety Arm position Inaccurate cuff size Orthostatic hypotension Blood pressure measurement in the thigh Leads to a high reading Following activity Emotions Not correct cuff Leads to low Decreased inflation Wrong cuff size
52
Oxygen saturation
-Measures relative amount of light absorbed by oxyhemoglobin and unoxygenated hemoglobin -Normal with no lung disease and no anemia 97% - 100%
53
Acute pain
-Short-term and self-limiting Dissipates after an injury heals -Behaviors Guarding Grimacing Moaning Agitation Diaphoresis Change in vital signs
54
Chronic
-Can be cancer-related -Does not stop when the injury heals -Behaviors Bracing Rubbing Diminished activity Sighing Change in appetite
55
Pain assessment scales
Numeric rating scales 0 - 10 Verbal descriptor scales Visual analog scales Descriptor scales
56
Wong
Bakers pain scale - used for ages 3+
57
FLACC
Behavioral pain assessment scale Used for non-verbal, bed bound, or unable to tell you as the nurse they are in pain
58
Danger signs of pigmented lesions (ABCDEF)
-Asymmetry -Border irregularity -Color variation -Diameter greater than 6mm -Elevation or Evolution -Funny looking
59
Capillary refill
A healthy color return takes 3 seconds
60
Pressure injuries
-Stage 1 - Non-Blanchable Erythema Intact skin is red but unbroken -Stage 2 - Partial-Thickness Skin Loss Loss of epidermis and exposed dermis -Stage 3 - Full Thickness Skin Loss -Stage 4 - Full-Thickness Skin/Tissue Loss Exposes muscle, tendon, or bone, and may show slough -Esher - necrotic tissue
61
Braden Scale
level of risk a patient has for skin breakdown (lower the score, higher the risk for skin breakdown)
62
Edema
accumulation of fluid in the body +1 (can't tell by looking, but leaves an indentation and quickly resolves) +2 (can tell swelling and indentation leaves slowly) +3 (indentation takes a while to resolve) +4 (swelling in arms as well, indentation)
63
Nails
160 degrees Clubbing < 180 degrees Profile sign - test to assess the nails
64
Skin Turgor
Skin's ability to rebound after being pulled Look for “tenting”
65
Lymphatics
-The head and neck have a rich supply of 60 - 70 lymph nodes -Separate vessel system from the cardiovascular system -A primary part of the immune system -Acute - enlarged <1cm, normal infection if mobile and bilateral -Chronic - possibly cancerous if unilateral, non-moveable, and hard
66
Thyroid
When palpating should feel rubbery
67
Head, Face, Neck, and Regional Lymphatics Children
The lymphatic system is fully developed by 6 years of age
68
Head, Face, Neck, and Regional Lymphatics Aging Adult
Lymphatic tissue begins to atrophy during old age
69
Head, Face, Neck, and Regional Lymphatics Pregnant Women
Enlarged lymphatic tissue is normal
70
Head, Face, Neck, and Regional Lymphatics Tonsils
Graded in +1 visible +2 double in normal size +3 touching the uvula +4 touching one another
71
Head, Face, Neck, and Regional Lymphatics Sinus’s Areas
Palpate frontal and maxillary sinuses
72
Bells Palsey vs Stroke
-Bells Palsey - facial paralysis (unable to close their eyes or raise eyebrows / can’t flirt) Effects on the cranial nerve 7 -Stroke - Able to close eyes and raise eyebrows (able to flirt)
73
Stereognosis
The patient is able to identify an object that is placed in their hand with their eyes closed
74
Primary Headaches
-Tension Band around skull Treat with rest -Migraine Pain behind the eyes, temple, or forehead, is commonly one-sided but may be one-sided Treat with darken room, take NSAID early -Cluster Always one-sided, around the temple, eye, forehead, and cheek, happens multiple times throughout the day. *Histamine* headache Treat with movement
75
Graphesthesia
patients able to recognize what was drawn in the palm of their hand with eyes closed
76
Cranial nerves 1
Olfactory, Sensory, Smell
77
Cranial nerves 2
Optic, Sensory, Vision, Visual fields
78
Cranial nerves 3
Oculomotor, Motor, Most eye movement
79
Cranial nerves 4
Trochlear, Motor, Moves eye
80
Cranial nerves 5
Trigeminal, Sensory/Motor, Face sensation, Mastication, Blinking
81
Cranial nerves 6
Abducens, Motor, Abducts the eye
82
Cranial nerves 7
Facial, Sensory/Motor, Facial expression, Taste
83
Cranial nerves 8
Vestibulocochlear, Secondary, Hearing, Balance
84
Cranial nerves 9
Glossopharyngeal, Sensory/Motor, Taste, Gag Reflex
85
Cranial nerves 10
Vagus, Sensory/Motor, Gag Reflex, Parasympathetic innervation
86
Cranial nerves 11
Accessory, Motor, Shoulder Shrug
87
Cranial nerves 12
Hypoglossal

Nursing (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions