question

Handwashing principles

answer

1. Soap 2. Friction 3. Rinsing 4. Drying 20 seconds

question

Alcohol-based sanitizers

answer

Rub hands for 15 seconds or until dry

question

When to Wash Hands

answer

1. Before/after: patient contact using gloves performing an invasive procedure eating After: sneezing and going to the bathroom

question

PPE

answer

Personal Protective Equipment Protecting oneself from patient

question

Types of PPE

answer

Gloves Gowns Masks Goggles

question

Sequence of Putting on PPE

answer

Wash hands Gowns Masks Goggles Gloves

question

Sequence of Taking off PPE

answer

Gloves Goggles Gown Mask Wash Hands

question

Assessment Techniques

answer

1. Inspection 2. Palpation 3. Percussion 4. Auscultation

question

Inspection

answer

Deliberate systemic observation Using senses (sight, hearing smell)

question

Palpation

answer

Light, moderate, deep touching Notice temperature, texture, swelling, vibration Rules: Warm hands Touch area that hurts last

question

Percussion

answer

Finger functions as a hammer Tone is determined by the density of the material that the sound wave passes through (quiet tone for more dense) Direct, blunt, indirect

question

Percussion notes: Tympany Hyperresonance Resonance Dullness Flatness

answer

Gastric bubble (hollow) Emphysema (extra air) Resonance (normal lungs) Dullness (liver) Flatness (muscle or bone)

question

Auscultation

answer

requires a stethoscope Diaphragm: high pitched sounds (firmly on skin) Bell: low pitched sounds (below) (lightly on skin) Tubing 12-18 inches to minimize distortion

question

Auscultation: Quality of Sounds

answer

Pitch: high to low Loudness: soft to loud Duration: short, medium, long Quality: description (ex. raspy)

question

General Survey

answer

Clues to overall health Observational skills necessary Vital signs, height and weight

question

General Survey: What to Observe for

answer

Signs of distress Stature, build Dressing, grooming Posture, gait, coordination Eye contact Level of consciousness, mood Speech patterns Vision or hearing problems Nutritional state Significant others accompanying patient

question

Bed Making

answer

1. Close curtains for privacy 2. Put a bed rail up and move bed up to elbow length 3. Fold soiled linen into itself - no contact w/ scrubs 4. Blanket and bedspread frequently reused 5. Fanfolding if bed is occupied 6. Think energy conservation for nurse and patient

question

Self-Care

answer

ADLs - Activities of Daily Living IADLs - Instrumental Activities of Daily Living

question

Principles for providing hygeine

answer

Don't assume need for assistance Determine preferences Assess ability to assist Assess activity tolerance Be respectful

question

Factors Affecting Self-Care

answer

Health state Developmental level Socioeconomic status Culture, values, beliefs Personal preferences

question

Therapeutic Effects of Bathing

answer

Cleanses body secretions Stimulates circulation Improves joint mobility Provides opportunity to assess skin Positive interaction Relaxation/comfort Sense of well-being Infection control

question

General Skin Care Principles

answer

Assess skin daily Use pH no rinse cleanser Avoid: Soap and hot water Minimize skin exposure to moisture Use emollients

question

Bedbath

answer

Privacy: put on gloves, draw curtains Bath blanket Expose 1 body at a time Cover wet area

question

Bedbath Sequence

answer

Eyes Abdomen Legs Feet Back (back of legs) Perineum Hair

question

As Needed Care

answer

PRN

question

Ear Care

answer

Cleanse pinna or auricle of the ear Cerumen is removed via capillary action No Q tip

question

Hearing Aids

answer

Wear at intervals to adjust Adjust volume to lowest level needed Check batteries daily Clean ear piece only Feedback noise (whistling) can be distressing

question

Nutrition

answer

Set up assistance: Open cartons Cut food up Food preferences Appropriate utensils Use clock location

question

Feeding a Paitent

answer

Be aware of environment Position upright Mouth care before meal Toilet before meals Provide pain med prn Napkin or bib Dentures, hearing aids, glasses Involve patient Sit at eye level Encourage conversation

question

Perineal Care

answer

Wipe from least dirty to most dirty

question

Dressing a Patient

answer

Strive to maintain independence Dress painful/weak/paralyzed side first

question

Foot Care Considerations

answer

Feet are vulnerable to injury Older Patients with diabetes Poor circulation, decreased sensation, peripheral neuropathy

question

Diabetic Foot and Nail Care

answer

Inspection File nails straight across (no clipping) Do not soak/rub feet vigorously Moisturize skin, not between toes

question

Special Considerations for Feet of Diabetics

answer

Lukewarm water Never trim own calluses or bunions Avoid tight socks/shoes Shake shoes out before putting on Discourage going barefoot

question

Antiembolism Stockings (TEDS)

answer

Type of compression stocking Prevents deep vein thrombosis (prevents edema and venous stasis) Exerts 15 mmHG pressure

question

TEDS: care considerations

answer

Correct fit Avoid wrinkles Put on in morning Remove for 30 minutes

question

Nursing Diagnosis

answer

Bathing/Hygiene Impaired oral mucous membrane Dressing/grooming Toileting Feeding Impaired social interaction Caregiver role strain Altered family processes Ineffective coping

question

Pain

answer

Known as the 5th vital sign Subjective experience Highly individual Expression of pain might not be consistent with degree of pain

question

The Joint Commission

answer

Patients have the right to effective pain management Published standards Care plan is based on mutually set goals to reduce or eliminate pain

question

Duration of Pain

answer

Acute Chronic Acute on chronic Remission and exacerbation

question

Source of Pain

answer

Cutaneous or superficial Somatic (skin and deep tissue) Visceral (organ pain - can be vague or intense)

question

Referred pain

answer

Pain that goes somewhere else because of attached nerves ex. left arm and heart attack right shoulder and gallbladder/liver pain

question

Neuropathic pain

answer

Abnormal functioning of nerve pathway Tingling/burning

question

Intractable pain

answer

Unrelieved pain

question

Phantom pain

answer

Amputation of limb and still feel pain in area

question

Responses to Pain

answer

Voluntary behavioral Involuntary physiologic Psychological responses

question

Involuntary physiologic responses

answer

Sympathetic responses: increase in HR, increase systolic BP, pupil dilation, diaphoresis (sweat) Parasympathetic responses: decrease in HR, decrease in BP, pupil constriction

question

COLD ERA

answer

Character of complaint Onset of symptom Location of complaint Duration of problem Exacerbated by what Relieved by what Associated symptoms

question

OLD CARTS

answer

Onset Location Duration Character Aggravating factors/symptoms Relieving factors Temporal factors - sequence: coming and going Severity

question

Pain Assessment Tools

answer

Wong Baker Faces Rating Scale 0-10 Numeric pain distress scale Abbey Pain Scale Non-Verbal Pain Scale

question

Pain Relief Measures

answer

Analgesics Non-Pharmalogic: distraction, music, humor, imagery, relaxation, cutaneous stimulation, therapeutic touch

question

Things to Know 2

answer

Define the principles of providing skin care and hygiene. Identify types of hygiene used in patient care. State special hygiene measures for the unresponsive patient Discuss assisting patients with activities of daily living (ADL). Discuss the importance of foot care for the diabetic patient. Identify the purpose and principles for using anti-embolic stockings.

question

Things to Know 1

answer

Recognize handwashing as fundamental to infection control. Identify components of skilled general survey Recognize the link between skilled general survey and patient assessment State purpose of various health assessment techniques Identify the purpose for the use of PPE in the performance of patient care

question

Normal Movement and Alignment

answer

Alignment and posture Balance Coordinated Movements

question

Postural Reflexes

answer

Labyrinth sense: inner ear Proprioreception: awareness of where the body is Visual reflexes Extensor or stretch reflexes - maintaining posture and safety

question

Factors affecting movement and alignment

answer

Physical health: Muscular, skeletal, and nervous system problems Trauma to MS system Problems affecting CNS Respiratory Cardiac Negative nitrogen balance Mental health Lifestyle Attitudes, values External factors

question

Primary benefits of exercise

answer

Increases endurance and lung capacity Decreases pulse, BP, risk of atheroscelrosis Prevents constipation Stimulates appetite Improves sleep quality Strenghtens muscles

question

Isotonic Exercise

answer

Muscle shortens, active movement Increased muscle mass, joint mobility, cardiac and respiratory function, circulation, bone formation ex. running

question

Isokinetic Exercise

answer

Muscle contraction with resistance Constant rate by external device, capacity for variable resistance Helps with joint movement ex. weights on ankles

question

Isometric Exercise

answer

Muscle contraction without shortening Increased muscle mass, tone, strength, circulation, osteoblastic activity ex. yoga pose

question

Fowlers positioning

answer

45-60 degrees

question

Low/Semifowlers

answer

30 degrees

question

Hi-fowlers

answer

Over 80 degrees

question

Supine Positioning

answer

Laying on back

question

Prone Positioning

answer

Laying on stomach

question

Sims Positioning

answer

Lying on side, legs apart, pillow under arm

question

Side-lying Positioning

answer

Legs together, pillow between, arm supported by pillow

question

Trendelenburg Positioning

answer

Head down, feet elevated

question

Consequences of Immobility

answer

Decreased: muscle size, tone, strength, endurance, stability, demineralization, joint mobility, flexibility Increased: risk for contractures with immobility, foot drop, pressure sores

question

Cardiopulmonary Consequences of Immobility

answer

Increased cardiac workload Increased risk for orthostatic hypotension Increased risk for thrombus formation Decreased lung expansion Pooling of secretions Impaired gas exchange

question

Nutrition/Metabolic Consequences of Immobility

answer

Decreased appetite Decreased metabolic rate Impaired immunity

question

Elimination Consequences of Immobility

answer

Constipation Increased risk of urinary stasis Increased risk of renal calculi Decreased smooth muscle tone

question

Psychosocial Consequences of Immobility

answer

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

question

Why are nurses at risk for injury?

answer

Frequency Force Position Duration

question

Key Principles of Body Mechanics

answer

Wide base of support Feet wide, knees bent, back straight Utilize leg muscles Work at proper height Face direction of movement Keep patient as close to body as possible

question

Ambulation Guidelines

answer

Assess for dizziness ; weakness Dangle feet and rest on side of bed before rising Non-slip footwear Gait belt Stand to side and slightly behind

question

Ambulation with a Walker

answer

Place walker directly in front of patient Stand to side and slightly behind Patient moves walker forward, sets it down, steps forward

question

Using Crutches

answer

Standing up Place both crutches on uninjured side Grasp chair arm with other hand Stand up with pressure on uninjured leg Tripod standing position Crutches at a 45 degree angle from feet

question

Ways to Use Crutches

answer

4 pt gait: both legs weak 3 pt: 1 leg weight bearing 2 pt: both legs weak Swing through gait: 1 leg weight bearing Swing to gait: paraplegic

question

Using crutches on stairs

answer

Up with the good, down with the bad UP: step up with stronger leg, step up with weaker leg, bring crutches up DOWN: put crutches on next step, step down with weaker leg, step down with stronger leg

question

Ambulation Using a Cane

answer

Single pronged, 4 pronged Hold cane on stronger side close to body Nurse stands on weaker side and slightly behind Cane opposite affected leg

question

Things to Know 3

answer

Use examination techniques appropriately to perform a musculoskeletal and neurological assessment. Use the MMSE appropriately assess mental status. Use examination techniques appropriately to assess cranial nerves VIII and IX. Begin to interpret musculoskeletal and neurological physical examination findings.

question

The Physical Assessment

answer

Gathering relevant history Mental status evaluation Cranial nerve testing Sensory testing Motor Testing Reflexes

question

Assessing Mental Status

answer

Level of awareness A;O x3: Person, place, time Awake and alert lethargic stuporous comatose - no response

question

Glasgow coma scale

answer

LOC - level of consciousness Higher # - more alert the patient is As # goes down, less conscious

question

MMSE

answer

Mini Mental Status Exam Assess cognitive mental status Follow course of an illness Monitor response to treatment Possible score of 30 - higher the better Orientation, registration, recall, calculation and attention, language

question

MMSE: Orientation

answer

Year, month, date, day, time (5) State, Country, Town, Building, Floor (5)

question

MMSE: Registration

answer

Name 3 objects Use 1 second interval Ask patient to repeat the objects (1 point for each correct)

question

MMSE: Attention and Calculation

answer

Serial 7's Spell "World" backwards (1 point for each correct)

question

MMSE: Recall

answer

Repeat 3 object previously learned (1 point for each correct)

question

MMSE: Language

answer

Ask patient to identify 2 objects (1 point for each correct) Repeat "No if, ands, or buts" (1 point if correct) Ask patient to follow 3 step command: "Take paper in your right hand, fold it in half, and put it on the floor" (1 point for each correct action) Write "close your eyes" on a piece of paper, hand it to the patient and ask them to obey the sentence (1 point if correct) Write a sentence (1 point if has a subject and a verb) Ask the patient to copy a design of intersecting pentagons (1 point if correct)

question

Cranial Nerves

answer

Olfactory Optic Oculomotor Trochlear Trigeminal Abudcens Facial Acoustic Glossopharyngeal Vagus Spinal Accessory Hypoglossal

question

Cranial Nerve VII: Acoustic

answer

Test for balance Romberg Test: Have patient stand with heels together, arms at side and eyes closed Losing Balance: positive test + test: cerebellar dysfunction, vestibular dysfunction, or sensory deficit Whisper test: block one ear while someone whispers in the other

question

Cranial Nerve XI: Spinal Accessory

answer

Inspect atrophy or asymmetry of the trapezius and sternocleidomastoid muscles Test for strength - check resistance

question

Deep Tendon Reflexes

answer

Reflex depends on the force of stimulus Tendon Reflex Grading Scale 0 no response 1+ low normal, somewhat diminished 2+ normal, average 3+ brisker than average 4+ very brisk, hyperactive, indicative of disease

question

Assessing the Knee Reflex

answer

Have the patient sit with the lower leg hanging freely off of the bench Strike the quadriceps tendon just below the patella Quadriceps and extension of the knee

question

Hypertrophy

answer

Increase in muscle mass

question

Atrophy

answer

Decrease in muscle mass

question

Flaccidity

answer

Decreased muscle tone

question

Spasticity

answer

Increased muscle tone

question

Assessing Gait

answer

Walk across the room and back Heel to toe in a straight line Walk on toes in a straight line Wak on their heels in a straight line Rise from a sitting position

question

Abduction

answer

Motion in which the body part is moved away from the body

question

Adduction

answer

Motion in which the body part is moved toward the midline of the body

question

Crepitus

answer

A cracking sound heard in the joint when dry synovial surfaces rub together

question

Plantar

answer

Down (plants grow down in the ground so flex down)

question

Dorsi

answer

Up (flex up)

question

Dorsiflexion

answer

Moving body part towards the dorsum when the ankle moves up toward leg, toes point to ceiling

question

Eversion

answer

Turning outward

question

Extension

answer

Increase in the angle of a joint between two bones

question

External rotation

answer

Rotation of a joint outward

question

Flexion

answer

Motion involved in a decrease in the angle of a joint between two bones

question

Hyperextension

answer

Extending beyond the specified neutral position

question

Internal rotation

answer

Rotation of a joint inward

question

Inversion

answer

Turning inward

question

Lateral

answer

The area toward the outer aspect of the body, away from midline

question

Medial

answer

Area nearest the midline of the body

question

Plantar flexion

answer

Motion of the ankle moving the foot/toes downward

question

Pronation

answer

Movement of the forearm leading to a palm down movement

question

Supination

answer

Movement of the forearm leading to a palm up movement

question

Musculoskeletal Assessment

answer

Normal level of function Acute/chronic mobility problems

question

Cardinal signs of musculoskeletal disease

answer

Pain Redness Swelling Increased warmth Deformity Loss of function

question

MS Inspection

answer

Note position and alignment of body Ability to stand erect; posture Symmetry of body parts; compare contralateral side Note discolorations, swelling, masses Appearance of muscles Muscle tone Fasiculations, spasms

question

MS Palpation

answer

Feel tone of muscle (flaccid, spastic, good) Note tenderness, heat, swelling, crepitus Assess range of motion Test strength

question

Active Range of Motion

answer

Ask patient to move each joint through full range of motion Note degree and type of any limitations Increased or decreased range of motion of instability Compare with other side

question

Passive Range of Motion (PROM)

answer

Support the major joints of the extremity Gently move joint through its full range of motion Note degree and type limitation: pain or mechanical Compare with other side

question

Muscle Strength

answer

0: no muscle contraction 1: trace contraction 2: actively move muscle w/help 3: can move muscle, not against resistance 4: may move muscle against some resistance, weak 5: moves muscle, overcomes resistance of examiner (normal)

question

Cervical Spine

answer

Note alignment and symmetry of skin folds Palpate posterior neck, cervical spine, area muscles ROM: flexion/extension/lateral bending right/left rotation CN XI

question

Shoulders

answer

Inspect contour, clavicle, scapulae Palpate joints ROM: shrug shoulders, forward flexion and hyper extension, internal/external rotation, abduction/adduction

question

Hips

answer

Inspect while patient stands Symmetry of iliac crests, greater trochanter of femur, gluteal folds Palpate for instability, tenderness, crepitus ROM: flexion, hyperextension, abduction, adduction, internal, external rotation

question

Vital Signs

answer

1. Temperature 2. Pulse 3. Respiration Rate 4. Blood Pressure O2 saturation 5th: Pain

question

Baseline Information

answer

Usual measured vital signs Important to monitor changes in trends

question

Body Temperature

answer

Core Body Temperature Range 97.0-99.5 (36-37 degrees Celsius) Rectal temperature, tympanic temperature

question

Body Temperature Regulation

answer

Homeostasis and set point Heat production Heat loss

question

Factors that Affect Body Temperature

answer

Circadian rhythm Age Gender Environmental Temperature Increases in metabolic rate (exercise, stress, illness)

question

Febrile

answer

Temperature above normal Signals infection and increased immune function

question

Afebrile

answer

Normal temperature

question

Hypothermia

answer

Body temperature below normal

question

Decreased Temperature regulation

answer

Older adults Premature infants Immunocompromised status

question

Oral Temperature

answer

98.6 37.0 (101 is indicative of infection)

question

Tympanic Temperature

answer

99.5 37.5

question

Rectal Temperature

answer

99.5 37.5 Use lubricant, ask patient to relax

question

Axillary

answer

97.7 36.5

question

Forehead/Temporal

answer

98.6 37.0

question

Nursing Interventions for Febrile Patients

answer

Monitor temperature Monitor pulse, respirations, BP Fluid intake and output Monitor for seizure activity Administer antipyretic IV fluids Ice bag to axilla and groin

question

Types of Thermometers

answer

Glass (mercury free) Digital Tympanic membrane Temporal artery Disposable paper (Temp-A-Dot) Temperature sensitive strips

question

NANDA Nursing Diagnosis: Temperature

answer

Hyperthermia Hypothermia Risk for imbalanced Ineffective thermoregulation

question

Pulse Rate

answer

Indirect measurement of how well heart is pumping to the body

question

Factors Affecting Heart Rate

answer

Age (high - young, slow - old) Autonomic Nervous system Sympathetic Nervous System (increases) Parasympathetic Nervous System (decreases) Medication Hydration

question

Normal HR

answer

60-100

question

Tachycardia

answer

Fast Over 100 BPM

question

Bradycardia

answer

Slow HR Under 60 BPM

question

Rhythm of Heart

answer

Regular Dysrhythmias (regularly irregular, irregularly irregular)

question

Characteristics of a Pulse

answer

0 absent, unable to palpitate +1 diminished +2 brisk, normal +3 bounding

question

Cardiac Output

answer

HRxSV

question

Peripheral Pulse Sites: Upper Body

answer

Temporal Carotid Apical Brachial Radial

question

Peripheral Pulse Sites: Lower Body

answer

Femoral Popliteal Dorsalis pedis - Pedal (on top of foot) Posterior tibial (inner ankle)

question

Doppler Ultrasound

answer

Amplifies sound waves: used to assess pulses that are difficult to hear The device Handheld probe Conduction gel

question

Pulse Documentation

answer

Rate, rhythm, quality, location

question

NANSA Nursing Diagnoses: Pulse

answer

Decreased Cardiac output Ineffective tissue perfusion Deficient fluid volume Acute pain

question

Respirations

answer

1 breath in, 1 breath out

question

Factors that Affect Respiration

answer

Age Gender Stress/anxiety Exercise Acid-base balance Medications Altitude Pain Anemia Fever Respiratory Diseases

question

Counting Respirations

answer

Count for 15 seconds, multiply by 4 If irregular, count for 1 min

question

Respiration Interpretation #

answer

12-20 breaths/minute

question

Tachypnea

answer

Over 20 breaths, shallow

question

Bradypnea

answer

Less than 12 breath, regular depth

question

Apnea

answer

No breathing

question

Respiration Quality

answer

Unlabored Quiet Effortless Labored Shallow Deep Gasping Painful

question

NANDA Nursing Diagnoses: Respiration

answer

Ineffective breathing patterns Impaired gas exchange Risk for activity intolerance

question

Factors Affecting Blood Pressure

answer

Age Circadian rhythm Food intake Exercise Weight Emotional Body position Race Medication

question

Korotkoff Sounds

answer

5 Separate phases Systolic Diastolic

question

Blood Pressure Measurement

answer

Rested for 5 minutes Has not consumed caffeine Has not smoked for 30 minutes Sitting in a straight back chair Feet resting on ground Arm supported at heart level Patient is quiet

question

Obtaining an Accurate Reading

answer

Cuff size Can give false low or high

question

Taking a Blood Pressure

answer

Support arm at heart level Locate the brachial artery Medial aspect of antecubital fossa Wrap cuff with bladder centered over artery and 1-2 inches above the antecubital fossa Line artery marking on cuff up with brachial artery Tubing should extend near the elbow Close cuff valve by turning clockwise and palpate the brachial or radial artery while inflating cuff When you no longer feel the pulse, note the pressure and deflate cuff Wait 15 seconds Place stethoscope over brachial artery and reinflate the cuff to 30 mmHG above palpated pressure Deflate cuff at rate of 2-3 mm per second Note manometer reading when first clear sound is heard Note manometer reading when sound disappears Document as systolic/diastolic noting RA or LA (right or left arm) If you have to retake BP, wait 2 minutes Specify if R or L arm

question

Blood pressure 18-59

answer

140/90

question

Blood pressure 60 DM, Kidney Disease

answer

140/90

question

Blood pressure 60 or older

answer

150/90

question

BP #s Important

answer

How hard heart has to work to pump

question

Pulse Pressure

answer

Difference between systolic and diastolic reading Reflects how stiff or resistant the arteries are (can be hardening of arteries w/plaque) Higher PP more resistance Determined by: SV, aortic artery compliance

question

Orthostatic Hypotension

answer

Decrease in BP from standing

question

Pulse Oximetry

answer

SpO2: 95-100%: Normal SpO2: <90: Need for O2

question

Serial Weights

answer

Usually same time each day Before breakfast, after voiding

question

Tracing Blood Through the Heart

answer

Superior/inferior vena cava Right atrium Tricuspid/AV valve Right ventricle Pulmonary/semilunar valve Pulmonary artery Pulmonary veins Left atrium Semilunar valve Left ventricle Aortic Valve Aorta

question

Systole

answer

Ventricles contract AV valves close: 1st heart sound

question

Diastole

answer

Ventricles fill Opening of AV valves Semilunar valves close: 2nd heart sound

question

Factors that Effect CV Status

answer

High BP Obesity Smoking Lack of Exercise Diet

question

Cardiovascular Focused Interview Assessment

answer

Fatigue Distress Chest Family history Medication history Activity level Weight (gains, losses) 1 kg: 1 L fluid

question

BMI

answer

<18.5 kg/m2 = underweight 18.5-24.9 kg/m2 = normal weight 25-29.9 kg/m2 = overweight 30 kg/m2 or higher = obese

question

Waist circumference

answer

Increased risk of DM, dyslipidemia, HTN and CVD with: Women > 35 inches Men > 40 inches

question

% weight change calculation

answer

Usual-present/usual x100

question

Dietary Habits and CV

answer

Calories/day (gender, height, weight, activity level) Sodium intake (2300-1500 mg) Fat intake 20-35% cal (poly, mono)

question

Lipids

answer

Triglycerides (TGs) <150 mg/dL CHOL levels Total CHOL < 200mg/dL LDL 60 mg/dL Screening every 5 yrs starting at age 20

question

Smoking and CV Assessment

answer

Type of tobacco Pack years: #years x #packs

question

Alcohol and CV Assessment

answer

Consumption guidelines Risk factors for women w/elders 1/day or m 2/day

question

CV Inspection

answer

Skin color, lips, nail beds (capillary refill) Body position - tripod Finger clubbing Nasal flaring Anxiousness/restlessness Breathing (rate, depth, effort, pursed lips)

question

Sternocleidomastoid Muscle Trapezius Muscle

answer

Attach to the manubrium of the sternum and to clavicle Arises from occipital bone in head and all the throacic vertebrae

question

Pulse deficit

answer

Difference between apical and radial pulse rates

question

SBAR

answer

Situation Background Assessment Recommendation

question

S: Situation

answer

Describe situation ID caller's name, status, unit, patient's name, room # State reason for call in 1 sentence

question

B: Background

answer

Concise history What led to situation Diagnosis Date admitted Meds, allergies, IV fluid Vital signs Labs Code status

question

A: Assessment

answer

What you think is happening in the situation

question

R: Recommendation

answer

The course of action you expect to happen

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