What are the steps of the nursing process?
ADPIE
Assessment - gather information about patient's condition
Diagnosis - identify patient's
... [Show More] problems
Planning - set goals of care and desired outcomes and identify appropriate nursing actions
Implementation - perform nursing actions identified in planning
Evaluation - determine if goals and expected outcomes are achieved
What is the critical thinking approach?
while gathering data, you synthesize knowledge and attitudes and use professional standards of practice to direct knowledge from physical, biological, and social sciences to ask relevant questions and collect relevant history
What are the four assessment techniques?
Inspection
Palpation
Percussion
Auscultation
What is the purpose of SBAR?
To help improve communication and reduce errors in healthcare
What does SBAR stand for and what are the parts of it?
Situation - name of patient and their complaints
Background - Reason for being seen, medical history, time frame
Assessment - Recalls what was observed when checking patient
Recommendation - Giving advice for treatment plan
What is cultural competency?
Respecting patient's health beliefs and understanding the effect of those beliefs on health care delivery
Must understand one's own biases and stereotypes (culturally congruent care)
Understand medical practices of other cultures
What do cultural skills mean?
the ability to assess factors that influence patient care and treatment
What is pulse pressure?
difference between systolic and diastolic pressure
Pulse pressure should be in what range?
30-40 mm Hg
What is orthostatic hypotension?
A drop in blood pressure due to a sudden change of posture.
How do we determine if orthostatic hypotension is occurring?
take BP lying, sitting and standing
What are we listening for when assessing blood pressure?
the first and fourth Korotkoff sounds
What five factors control blood pressure?
age
stress
ethnicity
gender
daily variation
Blood pressure depends on
peripheral vascular resistance (arteries constrict or dilate)
What is the normal range for heart rate?
60-100 bpm
What is a pulse deficit?
difference between apical and radial pulse
What is the scale for measuring pulses? What is normal?
0-4
0 = absent
1+ = weak/threaded
2+ = normal
3+ = full
4+ = bounding
What can we tell about the pulse if taken at the radial site?
the rhythm, strength and symmetry
What can we tell about the pulse if taken at the apical site?
rate and rhythm only
Normal respiration range and description
12-20 bpm
deep and regular
Temperature is regulated by the
hypothalamus
What is the normal range for temperature?
96.8-100.4 F
36-38 C
The fifth vital sign is
pain
What questions do we ask about pain?
OPQRSTU
Onset
Provoking
Quality
Radiation
Severity
Time
U: How does it affect you?
ABCDE for pain
A: Ask about pain regularly and assess systematically
B: Believe the patient and family when pain is reported
C: Choose pain control options appropriate for patient
D: Deliver interventions in a timely, logical, coordinated way
E: Empower patients and their families
The normal range for BMI is?
Overweight?
18.5-24.9
25-29 = overweight
How do you palpate lymph nodes? Easy or difficult? Should they be visible?
Palpated with fingers in a circular motion
Difficult to palpate and should not be visible
Seven lymph nodes to palpate in the head
OPPRSSS
Occipital
Postauricular
Preauricular
Retropharyngeal
Submandibular
Submental
Supraclavicular [Show Less]