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AN midterm
| Question | Answer |
|---|---|
| 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
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