Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Nursing Process
Nursing Process test
| Question | Answer |
|---|---|
| 5 components of the nursing process | Assessment, Diagnosis, Planning, Implementation, Evaluation |
| purpose of assessment | to establish a database |
| subjective data | data obtained from patient verbally |
| objective data | measurable and verifiable data |
| primary source of data | the patient |
| develop short & long-term goals or expected outcomes | planning phase of the nursing process |
| 3 criteria that goals for the patient must have | Observable/realistic, measurable, specific time frame (SMART) |
| the __________ is reassessed in the evaluation phase of the nursing process | entire care plan |
| assessment technique where examiner uses hands and sense of touch to gather data | palpation |
| assessment technique, purposeful observation | inspection |
| assessment technique, listening to sounds produced by body | auscultation |
| assessment technique, use of fingertips to tap the body's surface to produce vibration and sound | percussion |
| 3 parts of Glasgow Coma Scale | eye opening, best verbal response, best motor response |
| normal size range for pupils | 3mm-5mm |
| PERRLA | Pupils Equal Round React to Light and Accommodation |
| Snellen chart | indicates degree of visual acuity, pt is able to read line of letters at a distance of 20 feet |
| consensual response | when light is shined into one pupil, the other should adjust with it |
| Babinski sign | rub pt's foot heel->toe. toes should not fan out, should curl up. sign of a problem in the CNS |
| Weber test | hit tuning fork, place on top of pt's head for them to feel vibration, should be equally loud in both ears |
| Rinne test | compares air conduction and bone conduction, tuning fork on top of head or at mastoid process on both sides, ask to signal when sound goes away, then place at ear canal - should still hear sound |
| pulse quality 0 | absent |
| pulse quality 1+ | thready |
| pulse quality 2+ | weak |
| pulse quality 3+ | normal |
| pulse quality 4+ | bounding |
| capillary refill time | less than 3 seconds |
| pitting edema scale 1+ | trace - barely perceptible pit (2mm) |
| pitting edema scale 2+ | mild - deeper pit, rebounds in 10-15 seconds (4mm) |
| pitting edema scale 3+ | moderate - deep pit, 30sec-1min (6mm) |
| pitting edema scale 4+ | severe - 2-5min, (8mm) |
| eupnea | normal breathing |
| apnea | absence of breath |
| tachypnea | fast breathing |
| bradypnea | slow breathing |
| orthopnea | difficulty breathing when lying down flat |
| hypoxia | low O2 in cells |
| hypoxemia | low O2 in blood |
| lung sounds heard over the bronchi, upper area of chest | bronchial |
| lung sounds heard over central chest or back | bronchovesicular |
| lung sounds heard over periphery of lung fields (bottom) | vesicular |
| abnormal lung sound, produced by fluid in bronchioles and alveoli, crackling/bubbling sound | crackles |
| loud high-pitched rushing sounds through bowel | borborygmi |
| decreased bowel sounds | hypoactive |
| gives stool brown color | bilirubin |
| bloody stool | melena |
| checking for hidden blood in stool | hemocult |
| SOAPIER | Subjective, Objective, Assessment, Plan, Intervention/Implementation, Evaluation, Revision |
| Focus-charting format | Data, Action, Response/evaluation, Education/patient teaching |
| how to check for pitting (edema) | press against a bony prominence for 5 seconds, then lift finger, observe for skin rebounding and feel for presence of an indentation |
| ABC, In, Out, PS | Airway, Breathing, Circulation, What's going in?, What's coming out?, Pain, Safety |
| format used for charting by exception | Problem, Intervention, Evaluation (PIE) format |
| type of charting - assessments/vitals/IV site and rate etc.charted at beginning of each shift, and during the shift only additional changes or treatments are recorded | charting by exception (CBE) |
| APIE format | Assessment, Problem, Intervention, Evaluation |
| a card system used to consolidate pt's orders and care needs in a centralized concise way | Kardex/Rand |
Created by:
1469838250
Popular Nursing sets