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NURS 335 > Quiz 1 > Flashcards

Quiz 1 Flashcards

(45 cards)

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1
Q

10 Attributes of Signs/Symptoms

A

1) Location
2) Associated signs/symptoms
3) Time
4) Environment/Exposure Factors
5) Relieving Factors
6) Severity
7) Nature/Quality
8) Aggravating Factors
9) Patient Perspective
10) Significance to Patient

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2
Q

Nursing Values & Ethical Responsibilities

A

A. Providing safe, compassionate, competent and ethical care
B. Promoting health and well being
C. Promoting and respecting informed decision making
D. Honouring dignity
E. Maintaining privacy and confidentiality
F. Promoting justice
G. Being accountable

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3
Q

Levels of Prevention Strategies

A

Primary
Secondary
Tertiary

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4
Q

Primary Prevention Stratgey

A

Avoid development of Disease
Remove Risk Factor
Eg) Immunizations, health teaching, nutrition counselling, safety precautions (condom)

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5
Q

Secondary Prevention Strategy

A

Early diagnosis of health issues and prompt treatment to prevent complications/progression
Eg) Pap smears, prostate exams, Vision screening, TB skin testing

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6
Q

Tertiary Prevention Strategy

A

Preventing complications of existing disease and promoting highest level of health possible
Eg) diet teaching for diabetes pt, inhaler teaching for asthmatics

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7
Q

Health Assessment Overview

A

General Survey + Health History + Review of Systems + Physical Examination
Collection of subjective and objective data in order to develop an individualized plan of care

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8
Q

Nursing Process

A

Systematic problem-solving approach to identifying and treating human responses to actual or potential health conditions.
Framework for providing individualized care not just for individuals but their families, the community, populations and groups

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9
Q

5 Phases of Nursing Process

A

1) Assessing
2) Analyzing
3) Outcomes/Planning
4) Implementing
5) Evaluating

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10
Q

Assessing

A

Evaluate care during assessment
Collect data, organize data and validate data

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11
Q

Analyzing

A

Purpose and end result of assessment
Also known as “Diagnostic phase”
Gather all data to make judgement of patients condition
Recognize patterns
Assists in selecting nursing interventions

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11
Q

Outcomes/Planning

A

Formulation of specific, measurable, attainable, realistic, and time-oriented goals for patient-centred goals.
Collaborate w/ pt
Writing care plan, determining resources

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12
Q

Implementing/Intervention

A

Actions performed based on clinical judgement to enhance pt outcomes
Eg) Written goals for pt, ADLs, counselling, teaching, preventative measures

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13
Q

Evaluation

A

Interpret and summarize findings, make judgements about pts progress, monitor the nursing care and its effect on pt

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14
Q

Types of Health Assessments

A

Urgent
Comprehensive
Focused

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15
Q

Urgent Assessment

A

Life-threatening/unstable situations

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16
Q

Comprehensive Assessment

A

Complete health history and physical examination.
Outpatient basis (annual physical, wellness clinic), Long-term care admission, Admission to the hospital, or every 8hrs for ICU pts.
Conduct health screenings. Head-to-toe assessment, body systems,

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17
Q

Focused Assessment

A

Based on pt’s issues.
Can occur in all settings
1-2 body systems (or more)
Narrower in scope than Comprehensive
More in-depth on specific issues
Eg) Pt with cough, we focus more on the health historyetiology of the cough

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18
Q

Non-therapeutic responses

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A

Sympathy
Negativity
Biased Questions
Unwanted advice
False reassurance
Technical lingo

19
Q

Therapeutic Responses

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A

Restatement
Active Listening
Reflection
Silence

20
Q

Interview Phases

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A

Preinteraction
Beginning
Working
Closing

21
Q

Preinteraction Phase

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A

Reviewing pt record/chart
(like nursing does at WOWs before talking to pt)

22
Q

Beginning Phase

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A

NOD
Clarify pt identity/name
General Survey
Privacy

23
Q

Working Phase

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A

Collection of Data via open-ended questions slowly morphing to close-ended
Clarify pt. info
Work collaboratively w/ pt.
Shared understanding of concern

24
Closing Phase
Summarize 2-3 most important points Let pt know next steps
25
Priority Setting
Depend on acuity of situation Use knowledge, clinical judgement, expertise, and professional judgement. Expert nurses may prioritize different because of experience Patients top priorities are also important
26
General Survey
Behaviour - LOC, facial expression, speech Physical Appearance - Breathing, hygiene, dress, skin colour/lesions Mobility - Posture, Range of Motion (ROM), gait & position of comfort
27
Initial Data
Height & Weight & BMI Vital Signs Nutrition/hydration
28
Sign vs Symptom
Sign - Vomiting, objective, observable through senses, collected via physical exam Symptom - Nausea, subjective, not observable to others, collected via interview
29
Vital Signs
Temperature Pulse Respiration SpO2 BP
30
When to take Vitals
During Health visit Upon Admission Before/after procedure Before/during/after medications Physician routine orders
31
Why do we take Vitals?
Discover baseline Screening Response to treatment Monitoring for complications Change in health status
32
Before Vitals
Check Patient -general survey -health history -Assoc. signs/symptoms -Check your technique
33
Temperature differences
Axillary = 0.5 lower Tympanic/Rectal = 0.5 higher
34
Oral Temp Pros/Cons
Pro - Accessible, comfy, easy, Gold Standard accurate Con - Smoking/oral intake alters, bodt fluid precautions
35
Tachycardia vs Bradycardia
Tachy = > 100bpm Brady = < 60bpm
36
Respiratory Rate
12-20 breaths/min Older adults: 12-24 Tachypnea = > 20 (persistent)/min bradypnea = < 12/min Eupnea = Normal
37
MAP
Mean Arterial Pressure: Syst - (Dia x2)/3
38
Pulse Pressure
Systolic - Diastolic
39
Pressure Cuff
Bladder is 40% arm circumference Bladder length = 80-100% arm circum
40
False Readings
False HIGH reading = bladder cuff too small, white coat syndrome, legs crossed, anxious patient, pt talking, False LOW reading = bladder cuff too big, noisy environment, steth in wrong place, hearing deficit, improper placement of steth ear pieces
41
Korotkoff Phases
Phase 1 - First taps heard Phase 2 - Swishing Phase 3 - Return of louder sounds Phase 4 - Muffling of sounds Phase 5 - Silence
42
Kids Changes
BP goes up as they age HR/Respiratory rate goes down (heart and lungs get stronger and more efficient)
43
4 characteristics of a pulse
Rate Rhythm Force (amplitude) Elasticity
44
Orthostatic Vitals
Supine, sitting, then standing

NURS 335 (4 decks)

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