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NUR230 Exam 1
| Question | Answer |
|---|---|
| OLD | Onset = did the chief complaint occur abruptly or gradually Location = where is the chief complaint located Duration = how long has the chief complaint being going on for |
| CAR | Character = is the chief complaint burning, aching, sharp, dull, or throbbing Aggravating Factors = what worsens the symptom Reliving/ Radiating Factors = what improves the symptom/ does the symptom travel |
| TS | Timing = is it constant or intermittent (comes and goes) Severity = on a scale of 0 to 10 how bad is the pain |
| ADO | Assessment: complete, accurate health data Diagnosis: clustering data to make a judgement or statement about patients difficulty or condition Outcome identification: formation of patient-centered goals |
| P | Planning: determining how the nurse is going to help the patient reach their goals with the use of nursing interventions aka writing the plan of care |
| IE | Implementation: any treatment, based upon clinical judgement and knowledge that a nurse performs to enhance patient outcomes Evaluation: judgement of effectiveness of nursing care in meeting patient goals and outcomes |
| Body Temperature Normal range | 97.7 ℉ to 98.6 ℉ |
| What temp can vary from what? | Axillary 1 ℉ less than oral temperatures |
| Pulse Normal range for adults | 60 – 100 bpm |
| Tachycardia - Bradycardia - Asystole - | greater than 100 bpm less than 60 bpm 0 bpm |
| Respirations Normal range for adults | 12 to 20 breaths per minute |
| Dyspnea ~ Bradypnea - Tachypnea - Apnea - | shortness of breath less than 12 breathes greater than 20 breathes 0 breathes |
| Normal range for pulse oximetry (SpO2): | 92% to 99% |
| Normal ranges for adults BP: Systolic = Diastolic = | 90 – 120 mm Hg 60 – 80 mm Hg |
| When should a rapid response team may be called | Acute change in mental status Stridor, high pitched sound that occurs during breathing caused by narrowing airway |
| When should a rapid response team may be called Respirations | Less than 10 or greater than 32 breaths per minute Increasing effort to breathe |
| When should a rapid response team may be called Oxygen saturation | Less than 92% |
| When should a rapid response team may be called Pulse | Less than 55 bpm or greater than 120 bpm |
| When should a rapid response team may be called Blood pressure | Systolic less than 100 or greater than 170 mmHg |
| When should a rapid response team may be called Temperature | Less than 95℉ or greater than 103.1℉ |
| Types of Pain Acute | (recent) |
| Types of Pain Chronic | (long term) |
| Types of Pain Somatic | (muscles, skeleton, joints, and connective tissues) |
| Types of Pain Cutaneous | (skin → injury to skin or superficial tissues) |
| Types of Pain Referred | (injury in one area of body but feel pain somewhere else) |
| Types of Pain Phantom | (painful sensation perceived in a body part that is no longer present following a surgical or traumatic removal) |
| Types of Pain Neuropathic | (nerve damage or dysfunction in which pain is more constant) |
| Types of Pain Nociplastic | (no identifiable cause) |
| FLACC scale | Face Legs Activity Cry Consolability |
| Whats the FLACC scale used for? | to assess pain when a patient cannot self-report their pain |
| FLACC scale range? | 0-2 (2 being worst) |
| Droplet PPE | hand hygiene before entering the room, gown and gloves, surgical mask, googles, hand hygiene after leaving room, and keep patient in private room |
| Airborne PPE | hand hygiene and N95 mask before entering room, patient needs to be in a negative pressure room, the door closed, when transporting patient make sure patient is wearing a surgical mask |
| Contact PPE | hand hygiene, gloves, gown, dedicate equipment to patient only |
| Neutropenic PPE | hand hygiene before entering room, private room, no fresh flowers/fruit, limit visitors, mask for patient when leaving room |
| IAPP | Inspection- what is seen Auscilation- what is heard through stethoscope Palpation- what is felt Percussion- what is heard through tapping |
| Percussion tones Flat | soft, high pitch, sound over bone |
| Percussion tones Dull | moderate, high pitch sound over organs |
| Percussion tones Resonant | loud, low pitch over lungs |
| Percussion tones Hypersonic | very loud, low pitch, sound over diseased lungs |
| Percussion tones Tympanic | loud, high pitch, sound over stomach |
| Color changes to be concerned about Flushing | sudden widespread redness on the face |
| Color changes to be concerned about Pallor | white/pale skin |
| Color changes to be concerned about Rubor | redness due to inflammation |
| Color changes to be concerned about Cyanosis | bluish skin |
| Color changes to be concerned about Jaundice | Yellowish skin |
| Color changes to be concerned about Erythema | abnormal redness of the skin of the skin or mucous membranes caused by increased blood flow in superficial capillaries |
| Edmea 1+ | mild pitting (2 mm) |
| Edmea 2+ | moderate (3-4) |
| Edmea 3+ | deep pitting (5-6) |
| Edmea 4+ | very deep pitting (8 mm) If skin stays indented it shows fluid buildup |
| Potential Abnormal Findings Shapes & Configurations of Lesions Annular | (circular) |
| Potential Abnormal Findings Shapes & Configurations of Lesions Confluent | (running together) |
| Potential Abnormal Findings Shapes & Configurations of Lesions Discrete | (separate) |
| Potential Abnormal Findings Shapes & Configurations of Lesions Grouped | Straight forward |
| Potential Abnormal Findings Shapes & Configurations of Lesions Target or iris | Straight forward |
| Potential Abnormal Findings Shapes & Configurations of Lesions Linear | (straight) |
| Potential Abnormal Findings Shapes & Configurations of Lesions Zosteriform | (linear along a nerve) |
| Pressure Injuries Stage 1 | (early tissue damage) Skin looks red or pink No open wound Nonblanchable (when you press it with your finger, it doesn't turn white) On darkly pigmented skin blanching may not be visible |
| Pressure Injuries Stage 2 | Partial thickness skin loss involving the epidermis and dermis DOES NOT go into subcutaneous layer No slough |
| Pressure Injuries Stage 3 | Full thickness loss of skin that extends to the subcutaneous tissue DOES NOT go through the fascia (the layer covering muscle, tendon, or bone) and may have slough (yellow tissue) |
| Pressure Injuries Stage 4 | Full thickness skin loss extending through fascia with tissue loss Possible involvement of the muscle, bone, tendon, or joint May have slough or black dead tissue Tunneling may be present |
| Unstageable | (not clear what stage it is) The base wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black Not clear what stage it is because the wound bed is completely covered by slough Eschar ~ type of dead tissue |
| What's clubbing in fingernails? | (low oxygen aka hypoxia) |
| Hirsutism | (excessive hormones, excessive hair growth) |
| Venous (Vascular) Ulcer | Chronic pooling of blood in the extremity. Usually occur betweenankle and knee. The wound edges are irregularand beefy red with surrounding tissuehyperpigmented. Usually painless |
| Arterial Ulcers | Result from chronic ischemia andimpaired arterial circulation. Usually appear at toesor fingers. Wound edges are defined. The color willswitch from ruddy when dependent to pallorwhen elevated. Most of the time they are deep,sometimes infected, and painful |
Created by:
liladdoyle