Question | Answer |
Making rounds | You visit each resident BRIEFLY to see if they have IMMEDIATE needs. |
Planning involves | -what you are going to do.
-How you are going to do it.
-When you are going to do it. |
Procrastination | Putting off doing something till some other time. |
Objective Observation | FACTS observed |
Subjective Observation | JUDGMENTS based on personal feelings. |
Principles of Charting | -All entries signed 1st initial last name & title.
-When a error is made a single line may be drawn through the entry. |
2.2 pounds in each? | Kilogram |
TPR | Temperature, Pulse & Resporation |
Normal body Temperature | 98.6 F |
Individualized Health car plan is a | Legal requirment |
Factors that increase the body temperature | -Infections
-Shivering
-physical activity & exercise
-warm external environment
-dehydration |
Factors the decrease the body temperature | -stroke
-Colder external environment
-Age
-Drugs such as asperion or acetaminophen |
Medical lift to weigh a resident make sure | the open part of the hook is away from the resident |
Oral | in the mouth |
Rectal | In the rectum |
Before taking temperature | -ask if they had anything to drink
-ask if they smoked
-if so wait 20 min |
When taking temperature you must remain in the mouth for | 2-3min |
When taking rectal temperature | -Glove
-Lubricate & insert 1 in
-hold 3 min
-Never leave alone |
Axillary | Armpit |
When taking temperature axillary | -Dry arm pit
-hold 10min |
Normal Oral temperature | 98.6 Degrees F |
Normal Rectal Temperature | 99.6 degrees F |
Normal Axillary Temperature | 97.6 degrees F |
Not normal Oral Temperature | 100 degrees F |
Not normal Rectal Temperature | 101 degrees F |
Not normal Axillary | 99 degrees F |
Pulse | how fast the heart is beating |
The radial pulse is found | in the wrist |
Report to charge nurse if beats are below in above | below 60 above 90 |
Normal pulse for different ages | -Childhood 80-115
-Adult 72-80
-Later 60-70 |
Apical Pulse | measurement of the heart beats at the apex of the heart. |
Never use what when taking a pulse | your thumb |
Respiration | the process of inhaling and exhaling. breathing in and out once |
Normal adult breath at what rate? | 16-20 times per min |
Cheyene-Stroke | -breathing is slow & shallow
-Respiration becomes faster & deeper
-slows & becomes shallow again
-breathing may stop completely for 10 sec & begin the same pattern again. |
Steps for measuring respiration | -hold wrist as if you were talking the pulse.
-One rise & fall in one count
-If you can't see the chest rise & fall, cross the arms over the chest & feel it rise & fall
-Count for 1 min |
Systolic Pressure | Pressure when the heart is contracting. |
Diastolic pressure | Pressure when the heart is relaxed |
Hypertension | High blood pressure |
Sphygmanometer | Formal name for blood pressure cuff |
Blood pressure cuff | wrap snug & smoothly around the arm about 1 in above the elbow with the arrows pointing at the brachial pulse |
120/80=systolic/diastolic= | work/rest or relax=100-140/60-90 |
Anatomical position | the left side is always your right. it will always be opposite for you. |
Metastasize | Spread to other parts of the body through blood and lymphatic vessels |
Cancers 7 warning signs (Caution) | -Change in bowel or badder habits
-a sore that doesn't heal
-unusual bleeding or discharge
-thickening or lump in breast or elsewhere
-Indigestion or difficult swallowing
-Obvious changes in wart or mole
-Nagging cough or hoarseness |
The sensory system consists of (TEENS) | T-tongue E-eyes E-Ears N-Nose S-Skin |
Presbyopia | Small print at arms length. Cure is Glasses |
Contaract | the lens becomes cloudy to the point of complete blindness. The only cure is surgery. Looking through glasses covered with Vaseline |
Glaucoma | Pressure within eyes. Symptoms are pain over the eyes at night. Usually treated with eye drops. Individuals describe "halos" around lights & tunnel vision |