Study guide for Final exam Flashcards
Factors affecting detection of Adventitious sounds (sound distortion)
page 200
Box 11.3
- If you bump the stethoscope tubing against something or if the patient touches the tubing, the sound will be distorted
** If the patient is cold and shivering
*** If a patient has excess chest hair, movement of the stethoscope may give a false finding of crackles or pleural friction rub
** Extraneous environmental noises such as the rustling of a paper gown might sound like a crackle or pleural friction rub
Nursing process/6 phases
1) Assessment
2) Diagnosis
3) Outcome identification
4) Planning
5) Implementation
6) Evaluation
Best time to perform breast self examination
1 week after menstruation begins
Lie down and place a towel/pillow under the shoulder of the side of the breast to be examined
Pressure injury/Pressure ulcer
A localized defect in the skin of irregular size and shape where epidermis some dermis have been lost
Stage 1
Stage II
Stage III
Stage IV
Stage I Pressure Ulcer
Skin is intact but has evolved-so this is still a secondary lesion-Skin is intact and blanchable at this point
(((((Needs intervention/STAT))))
Stage II Pressure Ulcer
Loss of epidermis/dermis could look like a shallow abrasion
Stage III Pressure Ulcer
Goes all the way into subcutaneous tissue
Stage IV Pressure Ulcer
Involves all layers of skin and goes into muscle, bone, tendon
Excoriation
page 120
Loss of the epidermis, linear hollowed-out crusted area
Examples: Abrasion/scratch/scabies
OLD CARTS
“O” Onset- When did it start?
“L” Location- Be very specific
“D”- Duration- How long its been experienced
‘“C”- Characteristics- Descriptions (stabbing/throbbing/etc)
“A”- Aggravating/Alleviating- What makes it worse/better?
“R” Related Symptoms
“T” Treatment- Any at home/previous treatments/Did they work or not?
“S” Severity- Scale of 1-10/ Does it effect patient’s ADL’s
Novice Nurse
Has no experience w/specific pt populations & uses rules to guide performance
Experienced Nurse
Understands a patient situation as a whole rather than as a list of task, attends to an assessment data pattern, and acts w/o consciously labeling it
Cultural Diversity
page 51
Gender Religion
Age Sexual Orientation
Culture Physical/Mental disabilities
Race Social Status
Ethnicity Economic Status
Ethnicity
page 52
Characteristics that a group may share in some combination such as common geographic origin, race, language/dialect, religious beliefs, a shared tradition/symbols, literature, folklore, music, food preferences, settlement and employment patterns and an internal sense of distinctiveness
Culture
page 52
Knowledge, belief, art, morals, laws, customs, & any other capability and habits acquired by a person as a member of society
Race
page 52
Genetic in origin includes physical characteristics such as skin color, blood type, eye color and hair color
Religion
page 52
Organized system of beliefs, rituals, and practices n which individuals participates
Spirituality
page 52
“A search for the sacred”
Attaining cultural competence is not an end point
page 51
It is a process that evolves over a nurse’s career
Sex
page 52
Persons genetic composition & its phenotypic expression
Gender
Society’s percepti0n of a person’s sex as male/man or female/woman
Gender identity
page 52
Person’s internal sense of self as a man, woman, both, or neither (usually develops around age 3)
Gender expression
page 52
Person’s visible expression of social norms, such as mannerisms, dress, speech, or behaviors conventionally regarded as masculine, feminine, both, or neither
Cultural awareness
page 52
Nurses begin their cultural awareness through an indepth self examination of their own cultureal/ethnic group
