Nursing Intervention Exam 1 – Flashcards
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When do you wash your hands?
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Before meeting a patient After meeting a patient Before preparing meds After you remove your gloves After your sneeze Before you eat
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What is the order of assessment?
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Inspection Palpation Percussion Auscultation
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Inspection
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Before touching a patient
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Palpation
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Warm hands, use light before deep, touch the area that hurts last
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Auscultation
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Diaphragm is best for high pitched sounds Bell is best for low pitched sounds
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Sounds to listen for when auscultating
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Pitch- high or low Loudness - soft to loud Duration -- short, med, long Quality - give a description
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What to observe for when assessing a patient
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- signs of distress - stature, build - dressing and grooming - posture, gait, coordination - eye contact - level of consciousness,mood - speech patterns -vision or hearing problems - nutritional state - significant others accompanying patient
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Duration of pain?
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acute chronic acute or chronic remission and exacerbation
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sources of pain
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cutaneous or superficial somatic visceral
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etiology of pain
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referred pain neuropathic pain intractable pain phantom pain psychogenic pain
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responses to pain
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voluntary behavioral responses involuntary physiologic responses psychological responses
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What does COLD ERA stand for?
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C- Character of the complaint, pain etc O - Onset of the symptom L - Location of the complaint D - Duration of the problem E - Exacerbated by what? R - Relieved by what? A - Associated symptoms/problems
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What does OLD CARTS stand for?
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O - onset L - Location D - Duration C - character A - Aggravating factors/ associated symptoms R - Relieving factors T- temporal factors S - severity
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What is the Wong Baker FACES Pain rating scale?
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using smiley faces to frowney faces to determine how a patient feels.
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What is the 0-10 numeric pain distress scale?
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0 is no pain 10 is the worst pain you have ever felt
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what is the visual analogue pain scale?
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It looks like a scale
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What is the abbey pain scale?
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it has a series of questions. Find an example of this one.
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What are nonpharmacologic pain relief measures?
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Distraction Music Humor Imagery Relaxation Cutaneous stimulation Therapeutic touch
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What are the vital signs?
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Temperature Pulse Respirations Blood pressure O2 saturation
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What is a normal core body temperature
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97 - 99.5 * F 36-37* C
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febrile
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a temperature above normal signals infection and increased immune function
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afebrile
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normal temperature
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Hypothermia
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body temperature below lower limits of normal
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In which groups of people is temperature a good indicator of illness?
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Older adults Premature infants immunocompromised individuals
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What is a normal temperature for an oral temp
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37.0 C 98.6 F
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What is a normal temp for tympanic temp?
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37.5 C 99.5 F
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What is a normal temp for a rectal temp?
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37.5 C 99.5 F
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What is a normal axillary temp?
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36.5 C 97.7 F
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What is a normal forehead temp?
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34.4 C 94.0 F
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When is an oral temp indicative of an infection?
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101 F
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what are nursing interventions for fevers?
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monitor temp monitor pulse, respiration and BP monitor fluid intake and output monitor for seizure activity administer antipyretic medication administer IV fluids as appropriate apply ice bag covered with a towel to the groin and axilla
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How should you document a temperature?
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Document the reading and the route.
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How do you characterize a pulse?
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0 = absent 1 = thready 2 = weak 3 = normal 4= bounding
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How do you calculate cardiac output
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heart rate x stroke volume
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How do you document a pulse?
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Document rate, rhythm and quality Document pulse location if not radial
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What factors affect respirations?
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Age gender stress, anxiety exercise acid-base balance medication altitude anemia fever respiratory diseases body position
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What are normal respirations (Eupnea)?
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12-20 breaths/min
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What is tachypnea?
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>20, shallow breaths
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What is Bradypnea?
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<12, regular depth
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What factors affect blood pressure?
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Age Circadian rhythm Gender food intake exercise weight emotions body position race medication
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How do you know if a BP cuff fits?
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Bladder width should be 40% of circumference of arm. Bladder length should enclose 2/3 of the upper arm.
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What is a normal BP in adults?
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Systolic 100-120 Diastolic - 60-80
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What is a prehypertensive BP?
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120-139 80-89
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What is mild hypertension?
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140-159 90-99
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What is moderate hypertension
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160-179 100-109
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What is severe hypertension
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180-209 110-119
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What is crisis hypertension
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>210 >120
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What is normal oxygen saturation?
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>96% <93% needs supplemental oxygen GOAL = Above 93%
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What are major landmarks on the sternum?
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sternal notch manubrium angle of Louis Xiphoid process
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What are major landmarks on the ribs
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Intercostal spaces
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What are other major landmarks in the thorac?
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costal margins sternal borders (LSB, RSB) midclavicular line (MCL)
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What should you ask about in a CV focused interview?
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General state of health Family history Medication history Activity level Weight Dietary habits Personality Stress Work Habits: smoking, alcohol use
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CV inspection what to look for in the skin color?
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general color lips (blue) circumoral area nailbeds Capillary refill
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CV inspections posture?
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tripod position, nasal flaring
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CV inspection breathing patterns?
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Rate, rhythm, depth, and effort of breathing distressed, diaphragmatic, labored pursed-lip breathing ability to speak
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Review pulse rate deficit!
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Just review it
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What are therapeutic effects of bathing?
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Cleanses body secretions stimulates circulation improves joint mobility provides opportunity to assess the integument provides opportunity for positive client-nurse interaction provides relaxation and comfort fosters a sense of wellbeing
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Skin care principles
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assess skin daily use a ph balanced no-rinse cleaner avoid soap and hot water avoid excessive friction and scrubbing minimize skin exposure to moisture (incontinence, wound leakage) Use emollients
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What is the correct sequence when giving a bedbath
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head to toe (basically) do eyes first don't use soap, wipe inside to outside do perineum last with a new cloth
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What are food care considerations?
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older adults (vulnerable to injury) diabetics
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causes of foot problems
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structural changes decreased peripheral circulation peripheral neuropathy
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Diabetic foot and nail care
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NO nail clippers do not soak feet do not rub vigorously
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Things to consider when assisting with feeding
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- be aware of the environment - toilet before meals - provide pain med prn - involve the patient - sit at eye level - encourage conversation - place napkin/bib for clothing protection - dentures, hearing aids, glasses - set up tray - feed with patient preferences in mind
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Antiembolism stockings (TEDS)
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correct fit avoid wrinkles put on in am remove for 30 minutes q8h
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factors affecting safety
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developmental considerations lifestyle mobility sensory perception knowledge ability to communicate physical health state psychosocial health state
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safety considerations for older adults
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-impaired eyesight - impaired hearing - decreased proprioreception and balance - decreased sensitivity to touch - impaired thermoregulation - slower reflexes - decreased flexibility and strength
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factors contributing to falls
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- older age - slowed reaction time - previous history of falls - impaired vision - impaired sense of balance - altered gait or posture - impaired mobility - weakness or physical frailty - postural hypotension - medication - confusion or disorientation - unfamiliar environment
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using restraints safely
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- release restraint every 2 hours - check tightness and circulation - fit 2 fingers - check skin integrity - check ability to move and provide range of motion - renew physician's order every 24 hours
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benefits of exercise
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Strengthens muscles Increases endurance Increases lung capacity Decreases pulse and blood pressure Decreases risk of atherosclerosis Prevents constipation Stimulates appetite Improves sleep quality
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isotonic exercise
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exercise in which opposing muscles contract and there is controlled movement (tension is constant while the lengths of the muscles change)
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isokinetic exercise
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exercise that involves moving a muscle through a range of motion against a resistance that changes
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isometric exercise
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muscle-building exercises (or a system of muscle-building exercises) involving muscular contractions against resistance without movement (the muscles contracts but the length of the muscle does not change)
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consequences of immobility
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decreased muscle size, tone and strength decreased endurance and stability bone demineralization
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decreased joint mobility and flexibility
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- risk for contractures - risk for footdrop with immobility
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cardiopulmonary consequences of immobility
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Increased cardiac workload Increased risk for orthostatic hypotension Increased risk for thrombus formation Decreased lung expansion Decreased rate of respirations Pooling of secretions Impaired gas exchange
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metabolic consequences of immobility
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decreased appetite decreased metabolic rate impaired immunity
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elimination consequences of immobility
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constipation increased risk of urinary stasis increased risk of renal calculi decreased smooth muscle tone
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psychosocial consequences of immobility
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altered mental status altered sleep-wake pattern decreased self concept decreased social interaction decreased sensory stimulation altered roles and relationships increased risk for depression increased sense of powerlessness
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nursing diagnoses
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Activity intolerance Ineffective tissue perfusion: thrombus formation Risk for injury: orthostatic hypotension Ineffective breathing pattern Ineffective airway clearance Impaired gas exchange Impaired physical mobility Constipation Impaired tissue integrity Risk for infection: urinary track Urinary retention Impaired social interaction Disturbed sleep pattern Risk for injury
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what is a high-fowlers position?
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Sitting up in bed
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what is semi-fowlers
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30-60 degrees
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lo-fowlers
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below 30 degrees
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prone
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on stomach
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supine
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on back
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sims
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one knee up, pillow supporting trunk
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side-lying
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pillow below arm and in between knees
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Mini Mental status exam
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Orientation registration recall calculation and attention language
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orientation
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year, month, date, day, time where are we?
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registration
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name 3 objects ask patient to repeat the objects
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attention and calculation
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serial 7's, spell words backwards
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recall
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ask to repeat the previous 3 objects
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language
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ask the patient to identify 2 objects ask patient to repeat "no, ifs, ands, or buts 3 stage command write a command on a piece of paper ask them to write a sentence ask the patient to copy a design of intersecting pentagons
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cranial nerves
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On Old Olympus Towering Tops A Fin and German Viewed Some Hops O - Olfactory O - Optic O- Oculomotor T - Trochlear T - Trigeminal A - Abducens F- Facial A - Acoustic G - Glossopharyngeal V - Vagus S - Spinal accessory H - Hypoglossal
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CN VIII Vestibulocochlear
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test balance test hearing
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CN XI
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inspect for atrophy or asymmetry of the trapezius and SCM muscles test strength
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Deep tendon reflexes scale
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0 - no response 1+ - low normal, somewhat diminshed 2+ normal, average 3+ brisker than average; more reflexive than normal 4+ very brisk, hyperactive; often indicative of disease
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spasticity
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increased muscle tone
