FINALS Flashcards

Question

technique for physical assessment

Answer 1

inspection -looking palpation -touch auscultation -listening percussion -tapping

Answer 2

what ever the patient says about how they are feeling | naseau , pain

Answer 3

measurable - the nurse findings - temp b/p urine output

Answer 4

``` kosher diet no pork (no sea food , shellfish ) no mix of meat & diary utensils separate (prepackage ) meat slaughterd a certain way no activity on Saturdays rabbi to visit ```

Answer 5

assessment #don't assume

Answer 6

get and interpreter - a medical interpreter | not family member

Answer 7

``` assessment learning styles - kinestic visual auditory ---find out , what they know and what they need to know ```

Answer 8

get sepcific feedback information thought let the patient explain so you know they understand

Answer 9

``` ball point pen -no gel black ink pen only specific terms - don't be vague do not chart your opinion every entry write - date , time and sign don't leave spaces in entry late entry if forge to chart something and sign if error - draw a line though it ```

Answer 10

narrative _ charing in chronological order , storyytelling SOAP -subjective , objective , assessment , plan , intervention , evaluation ,revise SOAPIER - problem oriented medical record (POMR) CBE-(charting by exception ) - anything that changes

Answer 11

to prevent infection

Answer 12

purulent - thick , yellow , green , tan and brown serous - clear watery , plasma sanguineous - bright red indicate active bleeding serosanguineous - bloody and serum discharge from wound , pale , red , watery ----mixture of serous and sanguineosus

Answer 13

``` purulent inflammation fever tenderness swelling /edema redness(rubor ) ```

Answer 14

away from the incision form the cleanes to the dirtiest for irrigation clean each area with different swipes from in to out

Answer 15

``` keep the patient of bony prominences turn pt q2hrs uses pillows heel protectors good hygiene nutrition skin assessment once a shift ```

Answer 16

massage the surrounding area | not the direct area

Answer 17

A- ASSESSMENT - gather and analyze D-DIAGNOSIS -nanda related to the etiology as evidenced by the symptoms P-PLAN - goal & intervention I-INTERVENTION -carry out the plan E-EVALUATION - evaluate to see if the plan worked , or comparing actual outcome /desired outcome

Answer 18

P.E.S - problem , etiology , symptoms | nanda r/t cause aeb defining charachteristics

Answer 19

ABC- airway , breathing , circulation maslows heirchay _ self aculization - growth and fulfillment esteem needs - reputation , achievement , status , responsibility belonging & love needs : work group , family , affection , relationship safety needs : protection , security , order , law limits , stability etc biological and psychosocial needs : basic life needs - air, food, shelter , warmth , sex , sleep , elimination

Answer 20

to see if the plan worked out and if any changes are needed with the care plan let the patient be involved autonomy - imput from patient

Answer 21

Help stimulate pt to voiding like running getting up Voiding programming Increase awareness about using the bathroom Don't embarrass the pt or humiliate pt about when they urinate or have and accident Increase fluid intake Bladder training Offer restroom q2hrs Use proper briefs , pads or liners Give medication for incontinence As order (ditropan&detrol)

Answer 22

sterile technique place equipment between pt legs set up test balloon lubricate tube clean the female or male female 3-5 inches male 6-8 inches insert inflate the bbaloon pull on it to make sure its in the bladder female catheter size 14-18 male - 18-22 French

Answer 23

tell the patient to take a deep breath | if pain , deflate and insert further into the bladder

Answer 24

for care clean it with soap and water around the perineal area once a shift (q8hrs ) no kinks keep bag below the bladder prevent with cranberry juice water

Answer 25

use a needle and take it from the aspiration port

Answer 26

weight gain JVD (jugular vein destention ) edema /swelling increase B/P

Answer 27

``` dry mucus membrane thrist decrease urine output poor turgor weight loss pale cool skin tenting of the skin ```

Answer 28

``` left sims position large volume enema 12-18 inches lubricate w/water soluble lubricant insert 2-4 inches for 5 mins if cramping slow it down if bleeding stop and notify the physican ``` small enema 30mins fecal impaction _ oil retention

Answer 29

patient void before they start (empty bladder ) Collect urine for 24hrs Void before the 24hrs is over If any of the urine is not collected within the 24hrs you have to start all over Urine is kept on ice w/a preservative

Answer 30

With Kegel excersize | Frequent offering the restroom q2hrs

Answer 31

Measure from the nose to earlobe to xiphoid process Assess the patentcy first on the nose Have patient in high fowlers position Then chin to chest when you reach throat Tell the patient to swallow or give a straw to sip some water CHECK FOR PLACEMENT : 30 cc of air X-ray most reliable p-h strips Acultate while inserting air #always put content back

Answer 32

Prone to having dry mouth Frequent mouth care NPO - nothing by mouth Moisten pr mouth

Answer 33

Check patentcy Q2hrs Check setting and to make sure it is flowing Humidify the oxygen so it becomes moist Oxygen get dry

Answer 34

``` Like a trach Sterile technique Hyperoxygenate 100% Suction 10-15 secs Circular motion Intermittently If resistance don't force it ```

Answer 35

``` Chewing Swallowing Appetite Small frequent meal Purée ( machanical soft ```

Answer 36

Approval by pt Signed before any procedure Md is responsible to give pt full info , risk , benefit or potential harm , outcome , consequence , of refuse , Pt cannot sign if medicated Under 18 parent must sign Nurses with was competency if it's an emergency Do whatever to save a life , can be done without a concent of can't sign

Answer 37

Legal document that authorize a person to make choices for the pt when they are not able to physical injury or mental health -the person that can make decision for you

Answer 38

Ask questions abouth the therapy the patient is interested in Be knowledgeable about the multiple CAM availed and the therapies used by your patient Have accurate information for the doctor Don't discourage pt Five information to pt Pt teaching and only facts

Answer 39

``` Infancy - trust vs mistrust Toddler - autonomy vs shame and doubt Pre-k - initiative vs guilt School age - industry vs inferiority Adolescence - identity vs role diffusion Young adult - intimacy vs isolation Middle adult - genrativity vs stagnation Late adult - integrity vs despair ```

Answer 40

Pain is subjective , whatever the patient says it is Pain is unpleasant sensory & emotion On a scale from 1-10 Ask when it started & what makes it better THEORY - pain impulse does not travel to the brain Other stimuli that can distract the brain and pain impulses are blocked

Answer 41

The 5th vital sign | Numerical pain intensity scale

Answer 42

Constipation Respiratory prob ( decrease breathing ) Addiction To prevent complication Monitor very close NARCAN - if they get too much

Answer 43

``` NREM-non rapid eye movement Decides into 4 stages Restores and rest the physical body V/s decrease / slow body function Stage 4 is the deepest , where the sleeper may sleep walk and eneurisis may occur ``` REM-rapid eye movement Important for the mind - dream vividly 6-8 hrs of sleep

Answer 44

``` DABDA Denial Anger Bargaining Depression Acceptance ```

Answer 45

Abandonment Loneliness Pain -anxiety producing event -medication help Being in control in their own care helps -constantly calling the nurse because of loneliness

Answer 46

Give them time Sit and wait for them to speak -then clean the patient , tag bag , -therapuetic communication

Answer 47

Deal with pain right away when the patient informs you -it's best to schedule pain MEDS for ongoing pain -reassess the patient and how the patient respond to pain Order pain MEDS NSAIDS - steroids / codeine / / oxycodone /morphine

FINALS Flashcards

(72 cards)