AN midterm
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Determining sterility | sterile to sterile=sterile sterile to clean=contaminated sterile to contaminated=contaminated sterile to questionable=contaminated
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| Breaking the chain of infection? | Hand washing.
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| Techniques of Assessment | a)inspection b)Auscultation c)palpation d)percussion e)look,listen & feel
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| General "once over" | LOC, distress, appearance and posture
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| Neurological Data | LOC, orientation, behavior and speech
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| Vital signs | Temp, respiratory rate, pulse, and B/P
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| Pain | Description, location, rating(o-10 scale)and provide comfort measures.
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| Respiratory data | -note respiratory pattern -lung sounds -oxygen use
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| Lung souds | -clear,wheezes,crackles,rhonchi -note location,timing,clear/w coughing -compare side to side
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| Oxygen use | -oximeter reading amount of used vs room air method of delivery insentive spirometer
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| Cardiac Data | -JVD -Apical pulse noting rate & rythm -skin color -edema -homan'sign -CMS -peripheral pulses=quality & strength, compare
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| Gastrointestinal Data | -Abdomen soft/symetrical -diet -nause/vomiting -passing gas/last BM -Bowel sounds,look,listen,feel(4quads)
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| Geritourinary Data | -emptied bladder independently(catheter/patent) -note the urgency,frequency,incontinence,dysuria -note color,clarity,odor,amount
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| 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
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| Activity Data | -Normal ROM -note swelling/tenderness -note swelling or tenderness
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| IV Data | -Note site, redness,tenderness,swelling,pain warmth -access device i.e peripheral or central.
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| Psychosocial Data | -coping skills -emotional needs -verbalize feelings/needs -patient and family
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| Sleep/Rest data | -resting/sleeping btw cares -normal sleep habits
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| 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.
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| Glascow coma scale | Response to:-Stimuli -Motor -verbal -eye opening -8 or less score towards coma
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| Posturing | a)Decorticate-abnormal flexion.=3pts, worse b)Decerebrate-abnormal extension=2pts, worst
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| PERRLA | -Pupils Equal Round Reactive to Light & Accomodation.
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| Aphasia | difficult expressing oneself or impairment of language ability.
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| Receptive Aphasia | -involves wernicke's area -pt. has difficult understanding when spoken to.
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| Expressive Aphasia | -involves Broca's area -pt. has difficult expressing oneself. Frustrating.
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| Types of iv solutions | a)Isotonic b)Hypotonic c)Hypertonic
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| 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
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| complication of IV therapy | e)thrombus-swelling,pain,slowed infusion
f)pulmonary/air embolism-sudden CP,SOB,anxiety,decreased B/P.
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Created by:
ondara123
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