Week 1-3 Flashcards by JANETH Martinez

Normal Temp range: Oral

36-37.5 C

(97.7-99.5)

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Normal Rectal Temp Range:

37.2- 37.6
(99-99.6)

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Normal pulse range

60-100 Bpm
Average= 80

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Normal Respirations

12-20/ min

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Normal BP

<120/80

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Elevated BP

120-129/ <80

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Hypertension I

130-139/80-89

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Hypertension II

> 140/ >90

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Hypertensive Crisis

> 180/>120

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Normal O2

> 95%

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Pain:
P:
A:
I:
N:

Pattern, area, intensity, nature

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Geriatric Normal temp

35-36 (95-96.8)

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Geriatric normal BP

120/80, up to 160/95

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Orthostatic vitals (Pulse and BP change)

Pulse: decrease of 30/ min
BP: decrease of 20 systolic

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How to measure for Orthostatic hypotension
What are the risks
What is it a reflection of

Measure vitals while laying down first and then while sitting up
Risk of falls and losing consciousness
Reflection of dehydration or blood loss

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If you are planning on rechecking vitals what is a reasonable time to see a significant change (for Orthostatic hypotension)

10 minutes

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What to check for a skin assessment

Oral mucous membranes, turgor, skin folds, wounds/ dressings, heals, buttocks, sacrum elbow, knees, spine, color, warmth, moisture, texture, hair and IV site

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The right of an individual to keep his or her information private

Privacy

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The duty of anyone entrusted with health information to keep that information Private

Confidentiality

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Compromise. In security or privacy of confidential into via acquisition, access, use or disclosure of use

Breach

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Utilize initials only when identifying patients
Protect PHI on computers
Do not photocopy/ fax/ e-mail PHI
Access information need to complete educational assignments or fulfill student role
Remove all identifiable elements from forms
Dispose of PHI in confidential bins
No not discuss PHI in public places or via social networks

Student requirements when identifying patients

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Speak quietly when discussing PHI in public areas
Avoid using names in public areas like elevators
Do not share passwords or log in names
Unnecessary sharing
Unnecessary browsing or medical record entry
Inappropriate use of social or electronic media
Discuss PHI as it applies to education and patient care

Patient safeguards for HIPPA

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Sequence for removing PPE

Gloves
Goggles or face shield
Gown
Mask or respirator
Wash hands

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Contact precautions

Gloves and gown for contact with patient or patient environment

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Droplet precautions

Surgical mask within 3 feet of patient

Airborne precautions

No airborne/ ISO patients while in nursing school Particulate respirator Patient should also be in a negative pressure isolation room

Based on assumption that any blood or bodily fluid could be infectious Perform hand hygiene Use PPR based on expectation of possible exposure Follow respiratory hygiene/ cough etiquette Properly clean and disinfect Safe sharps handling

Standard precautions

If touching blood, bodily fluids, secretions, excretions, and or non intact skin

When to use gloves

If clothing or exposed skin may be in contact with blood or body fluids

When to use gowns

If patient care activities are likely to generate splashes or sprays of blood, bodily fluids, secretions or excretions

When to use a mask and goggles/ face shield

What is the most cost effective way to prevent infection

Hand washing

When to use soap and water for hand washing (5)

Hands are visibly soiled Before eating After restroom At the beginning of your shift And if suspected C.diff pt

Sequence for putting on PPE

Gown Mask or respirator Googles or face shield Gloves

Be cautious of non verbal cues (if you are looking at your watch or the door) Active listening (silence) Personal space Closed vs. open ended questions Facilitating Making observations Collaboration

Therapeutic communication guidelines

Medical history vs nursing history

Medical history focuses on medical diagnosis and patient conditions A nursing history focuses on the patient’s responses to the health problem

Extensive history and physical assessment (aka head to toe)

Admission assessment

Use authority Create distance Medical jargon Interrupt/ talk too much Stereotype comments Appear time rushed Ask why

Don’ts during patient interaction

Biographical data, name, age etc Chief complaint/ history of present illness Patietns perception of status Health history Family health history

Admission assessment: History

Medical conditions aka Comorbidities (chronic health conditions Infectious diseases Childhood illness Immunization history Surgeries Social history Medications/ supplements Alternative therapies Review of body systems Known allergies

Admission assessment

Evaluation of cooperativeness Understanding Receptiveness Response

Cognition and perception assessment

What to start off your physical assessment with

Observe general appearance, vital signs, and establish rapport with patient (ask permission for what you are doing)

Patient statements Ex. Pattern Area Intensity (numerical pain scale) Nature

Subjective data

What the nurse Sees Hears Feels Smells Ex. Vital signs LOC Plus ox

Objective data

Assessment done as need throughout the shift

Focused assessment

Febrile

Having a fever

Afebrile

not having a fever

Hyperthermia

Abnormally high body temperature

Hypothermia

Abnormally low body temperature

Rigors

Body created fever to fight off infection, causing shaking/ muscle tension

Radiation

Patient is hot, may uncover patient Patient is cold, cover patient

Convection

Patient is hot, may use portable fan to cool Patient is cold, close door and turn off fan

Evaporation

Patient is hot, cool cloth on forehead/ body to cool Patient is cold, keep patient dry to reduce chills/ cold

Conduction

Patient is hot, use ice pack to reduce inflammation Patient is cold, warm pack to help healing

Variance between apical/ peripheral pulses Pulse deficit

Exertional dyspnea

Conditional difficult of breath

Apnea

Lack of respirations

Visual, hearing, smell

Inspection

Touch, temp, texture

Palpación

Listening with stethoscope

Auscultation

Tapping an area with hands and listening for sound produced

Percussion

Awake and responsive

Alert

Very drowsy, falls also between care

Lethargic

Obtunded

Difficult to arouse (may be inebriated)

Stuporous

Very difficult to arouse

Comatose

Unresponsive to stimuli (unarousable)

PERRLA

Pupils even, round, reactive to light, accommodation

SBAR

Way to communicate with HCP Situation Background Assessment Recommendation

Why is it important to obtain vital signs on a patient

To establish a baseline

Tympanic temps for adults vs children

Up and back for adults vs down and back for children

How to take pulse

If HR is regular, take pulse for 15 seconds and multiply x 4= 60 seconds/ 1 min Is irregular, apical pulse is needed, take pulse for one full min

Scale to rate pulse quality

0= absent 1+= threads, weak 2+ = normal quality 3+= bounding or full

O2 into and CO2 out of lungs

Ventilation

Exchange between blood and cells O2/ CO2

Diffusion

Distribution of RBCs/ oxyhemoglobin cells to body

Perfusion

Do geriatric respirations increase or decrease compared to adults and why?

Faster Pain, activity, anxiety, harmonic condition

How long do you count respirations for?

Regular pattern: 30 seconds and multiple by 2 Irregular pattern 60 seconds

Use this side of the stethoscope for lower pitch sounds

Bell

Use this side of the stethoscope for high pitched sounds (heart, BP and lungs)

Diaphragm

Direct method vs indirect method of blood pressure measurement

Direct- catheter in artery Indirect: BP cuff

Contraction phase of blood pressure (ejection)

Systole (listen for korotkoff sounds)

Relaxation phase (filling) in blood pressure

Diastole (listen to korotkoff sounds)

Mastectomy or lymph issues with limb Hemodialysis grafts of fistulas PICC lines in arms IV in arms

Reasons for avoiding BP limbs

HR and blood pressure taken lying down then sitting, then standing if possible Allow 1-3 mins between readings (Decrease of 10mmHg SBP when upright and increase of 20 BPM may be Orthostatic)

Orthostatic vital signs

What is the significance of Orthostatic vital signs (what does it indicate)

Dehydration, blood loss Risk for loss of consciousness and falls

Reflects the amount of hemoglobin bound with oxygen

Pulse oximetry/ O2 saturation

What is the goal after intervention for pain rating?

Erythema

Redness

Ecchymosis

Abnormal bruising

Hypoxia

Low oxygen, nails present round

Cherry angiomas and seborrheic keratoses

Adult normal skin variations

Dry skin and mucous membranes, skin tags, lentifiques, senile purpura, thinning hair

Normal geriatric skin conditions

Week 1-3 Flashcards

(91 cards)