Phases of nursing process
ADPIE- assessment, diagnosis, planning, implementation, evaluation
4 types of assessments
Initial comprehensive, ongoing, focused, emergency
Introductory phase involves
Introduing yourself
Explain purpose of interview, explain reason for taking notes, assure them of confidentiality, make sure they are comfortable and they have privacy, developing trust and rapport
Working phase
Going over history, Review of bidy systems, lifestyle and health practices developmental level, listening/observing cues/using crit thinking skills, collaborating w clients to identify problems and goals
COLDSPA stands for and is used for
Used for symptom analysis
Character(describe signs and symptoms), onset, location, duration, severity, pattern (better or worse), associated factors(what other symptoms)
ASK WHAT PT WAS DOING WHEN PAIN STARTED
ROS stands for and covers
Review of body systems
Skin/hair/nails, head/neck, eyes, ears, mouth/throat/nose/sinus, breasts/regional lymphatic, thorax/lungs, heart/ neck vessels, peripheral vascular, abdomen, genetalia, anus/rectum/prostate, musculoskeletal, neurologic
SBAR
Situation, background, assessment, recommendation
How you give report
Define health promotions and its importance
Process of enabling ppl to increase control over and to improve their health.
Improves health status of ppl, enhances quality of life, reduces premature deaths, reduces cost
Risk factor modification across lifespan
Smoking cessation, exercise, diet, vaccines
Maslows heirarchy of needs
Physiological(air,water,food)
Safety (security, job, health)
Love (friends, intimacy, family)
Esteem (respect, self-esteem, status, freedom)
Self-actualization (desire to be best you can be)
Health promotions levels of prevention
Level 1- primary- prevent problems before they occur
Level 2- secondary- early screening
Level 3- tertiary- controlling or correcting a disease state
Common side effects of vaccines
Swelling, low grade fever, decreased appetite, headache, muscle or joint aches, irritability in kids
Mmr given
If high risk 6months
If not: 12 months and 4-6 yrs
Contraindications for vaccines
Live vaccines for immunocompromised (pregnant, chemo)
Previous allergic reaction
For flu vaccine- allergy to eggs
Mmr, VAR, H2V- gelatin or neomycin allergy
Moderate to severe illness
Not a contraindication for vaccination
Mild illness, breast feeding, allergy that isnt anaphylactic, family history of adverse effects, multiple vaccines
What is the first vital sign
What is the fifth vital sign
Temp, pain
Frequency of assessment
Admission, per policy or orders, change in condition, when meds given that affect cardiac rate and rhythm, pre and post op surgery, emergency
Normal vitals
Temp: 96.6-99.5
HR: 60-100
Resp: 12-20
Bp:120/80
O2 sats: 95-100%
What can affect body temp
Older adults, ovulation, exercise, time of day, hyper or hypothetmia,
Temp differences esp the difference between tympanic and oral
Tympanic: 1.4 degree higher than oral
Rectal: 1 degree higher
Axillary: 1 degree lower
Temporal: 0.8 degree higher than axillary
Locations of peripheral pulses
Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
Brachail pulse used when
Apical used when
Carotid used when
Brachial: infants to small kids
Apical: newborns
Carotid: emergencies
Pulse amplitude
0-absent
1-weak
2-normal
3-strong
4- bounding
When to take an apical pulse and where is it. How long to take apical pulse?
Infants and kids under 2 yrs: 4th intercostal space midclavicular line
Adults: 5th intercostal space midclavicular line
If radial is abnormal/ 1 full min
