6 categories to assess using Braden Scale
- Sensory perception
- Moisture
- Activity
- Mobility
- Friction
- Shear
Braden Scale measured elements of risk that contribute to high intensity and duration of pressure or lower tissue tolerance for pressure
Normal BP
Stage 1 BP
Stage 2 BP
N 120/ 80
Hypertension 130 <
Hoytpotension 110 >
Normal heart rate
If heart rate is high what is the term?
60-100
Tachycardia = over 100 BPM
- Air born precautions.
- Droplet precautions
Airborne: MTV (measles, tuberculosis, varicella) Droplet: Everything else
- Factors that place patients at a higher risk for skin cancer
- what is the mnemonic to help with skin cancer screening?
- Family history, burning/ being in the sun
- A symmetry
- B orders
- C olor
- D iameter
- E levated
How do you assess skin turgor?
Pinch the skin at the clavicle or back of hand.
On the clavicle normal = less than 2 second return
On hand normal = less than 1-2 second return
If greater that 3 t-here is a serious hydration problem
Characteristics to note/ assess when taking a pulse
Rate, rhythm, elasticity, contour, amplitude
0 absent
+1 weak
+2 normal
+3 bounding
Steps of the health assessment
Assessment, diagnosis, planning, implementation, evaluation
Describe a general survey
- Introduction
- Explanation
- Basic information
- Get supplies
- Provide Privacy
Observing in a grocery store
All objective data
Types of nursing diagnoses
-Problem focused
-Risk for diagnosis
- Syndrome
Type of pain that causes sensation of pain in body region distant from the actual source of pain
Referred
Purulent Drainage
Serous
Sanguineous
Purulent: puss. white, yellow or brown, sign of infection
Serous- Clear fluid (plasma)
Sanguineous: leaking of blood; fresh leakage
Pain associated with nervous system/ nerve damage: tingling, numbness
Neuropathic pain
What is clubbing of the fingernails and what does this mean?
Hypoxia and liver issues
Physical exam techniques in order
- Inspection
- Palpation
- percussion
-Auscultation
Name some physiological responses to pain
- elevated heart rate and respiration
-Grimmace on face or body tension
Types of health assessment
Initial, Ongoing, Focus, emergency
Proper order for taking vital signs
- Temp
- Pulse
- Respirations
- O2
- blood pressure
- Pain
Characteristics of skin
-Largest organ of the body
- Protects underlying tissues
- Helps maintain body temp, fluid/ electrolyte balance
- Sensation, immunity, vitamin D synthesis, part of individual identity
Objective Data vs. Subjective
Objective: factual information that can be observed or measured
Ex. Vital signs, assessment observations
Subjective: anything the patient tells you about themselves
Ex. patient description of pain, emotions …
Temp in cellcius
- Oral/tympanic: 37 C
- Rectal: 37.5 C
- Axillary: 36.5 C
*temps range 96.8 to 100.4 F
3 main components of a nursing diagnosis
- Problem statement: patients current health problem
- Etiology or related factors: possible reasons for the problem
- Defining characteristics: signs and symptoms
Another word used for bruise
Ecchymosis
The steps used to assess pain?
-C haracter
- O nset
- L ocation
- D uration
- S everity
- P attern
- A ssociated
