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AN midterm

Determining sterility sterile to sterile=sterile sterile to clean=contaminated sterile to contaminated=contaminated sterile to questionable=contaminated
Breaking the chain of infection? Hand washing.
Techniques of Assessment a)inspection b)Auscultation c)palpation d)percussion e)look,listen & feel
General "once over" LOC, distress, appearance and posture
Neurological Data LOC, orientation, behavior and speech
Vital signs Temp, respiratory rate, pulse, and B/P
Pain Description, location, rating(o-10 scale)and provide comfort measures.
Respiratory data -note respiratory pattern -lung sounds -oxygen use
Lung souds -clear,wheezes,crackles,rhonchi -note location,timing,clear/w coughing -compare side to side
Oxygen use -oximeter reading amount of used vs room air method of delivery insentive spirometer
Cardiac Data -JVD -Apical pulse noting rate & rythm -skin color -edema -homan'sign -CMS -peripheral pulses=quality & strength, compare
Gastrointestinal Data -Abdomen soft/symetrical -diet -nause/vomiting -passing gas/last BM -Bowel sounds,look,listen,feel(4quads)
Geritourinary Data -emptied bladder independently(catheter/patent) -note the urgency,frequency,incontinence,dysuria -note color,clarity,odor,amount
Skin integrity Data -skin warm,dry,intact -note rashes,bruishes,redness -mucous membranes,intact,pink,moist -incision/wound data=wound edges approximated,dressing/drainage,redness,edema,pain & warmth
Activity Data -Normal ROM -note swelling/tenderness -note swelling or tenderness
IV Data -Note site, redness,tenderness,swelling,pain warmth -access device i.e peripheral or central.
Psychosocial Data -coping skills -emotional needs -verbalize feelings/needs -patient and family
Sleep/Rest data -resting/sleeping btw cares -normal sleep habits
Safety Data -Safety is first -note perceptual deficts -oriented -communication barriers -steady on feet -bed in low position,side rails up, bed alarms and restraints.
Glascow coma scale Response to:-Stimuli -Motor -verbal -eye opening -8 or less score towards coma
Posturing a)Decorticate-abnormal flexion.=3pts, worse b)Decerebrate-abnormal extension=2pts, worst
PERRLA -Pupils Equal Round Reactive to Light & Accomodation.
Aphasia difficult expressing oneself or impairment of language ability.
Receptive Aphasia -involves wernicke's area -pt. has difficult understanding when spoken to.
Expressive Aphasia -involves Broca's area -pt. has difficult expressing oneself. Frustrating.
Types of iv solutions a)Isotonic b)Hypotonic c)Hypertonic
Complication of IV therapy a)infection-swelling,pain,redness at site,drainage b)circulatory overload-increased B/P,SOB,bounding pulse,anxiety. c)infiltation-swelling at site,pain,cool skin,decreased infusion rate. d)phlebitis-redness,warmth,pain along vein
complication of IV therapy e)thrombus-swelling,pain,slowed infusion f)pulmonary/air embolism-sudden CP,SOB,anxiety,decreased B/P.
Created by: ondara123