Exam2 Study Guide PDF

Exam2 study guide VITAL SIGNS BODY TEMMPERRAATURE NORMALRANGES nonshivering thermogenesis i...

Exam2 study guide VITAL SIGNS BODY TEMMPERRAATURE NORMALRANGES nonshivering thermogenesis in babies they cant Temperature Shiver produces brow averagerange 360 3800 96.8 100.4 F fat that it metabolized oral tympanic 3700198.6 F for heat rectal 37.5 99.5F conduction Axillary 36.5 97.7 F heat btwtouchingobjects convection Pulse heat by air movement 60 to1006pm Diaphoresis strong regular sweating Pulse oximetry Sp02 Normal 95 Respirations 12 to 20 breaths per min deep regular BloodPressure Heatstroke EnF5ainormalitie notidrysk.in systolic 4120mmHg diastolic 8ommHg delirium coma Pulsepressure 30to 50mmHg 104 F Heat Exhaustion excesswater electrolyte loss environmental heat PULSE never stimulate shivering Temporal Ulnar Pulse Deficit carotid apical iptopi.FI RADIAD APITAL Brachial Posterior Tibial radial DorsalisPedis inefficent contraction of heart that fails to transmit pulse wave  Pe p p PULSE RESSPIRATIONS Rate PNEA BREATHING Tachycardia 1006pm Epned Bradycardia 606pm cessationofrespirations Rhythm Tachypnea 20breaths min rapid Dysthythmia regularlyirregular Bradypnea 12breaths min slow early late irregularlyirregular Depth seenin obesity alcoholism missedbeats deep strength shallow risk of pneumion Bonding fluidvolumedeficit Labored use extramuscles Full Unlabored Normal expected childrennormal 306pm Diminishedorweak Absent dead or infoot circulationout ASSESSMENT off Hyperned labored depth rate Hypoventalation depth rate in002 levels BBLOOD PRRESSURE ex copbpt.notblow.in enoughCO2so the ystolic drive tobreathe S soundscontract PulsePressure goesaway lastolic sounds relax WSttic Diastolic CheyneStokes alternate apnea hyperventalation slow shallow then ypertensionHTN abnormal cardiac Stage 130 1398089mmHg related Stagel 140 90mmHg higher Kussmaul's abnormallydeep regu Heartattack Strokes rate ypotension Keatons of DNA systolic 190mmHg Biots abnormallyshallow2 3bred orthostatic Hypotension then irregular apnea dropBP standuptoo fast fallrisk Neuro related ex strokes SSESSMENT oxygensaturationSp02 direct catheter inartery used in cusettings Normal959 indirect cuff scope hemoglobinboundwithOz in BPCUFF 40 0 by80 0 Peripheralblood big BP 75 0 critical small BP Peripheralperfusion uscultatorygap disappearance ofsound blw first 2nd applyearlobe Noseforhead Korotkoffsounds  PHYSICAL ASSESSMENT it POSITIONS supine iiii nnh lying onback chestabdomen Dorsalrecumbent lyingonbackhands shoulders legsflexed w gap chestabdomen Lithotomy lie on backlegsapart footresting on stand near bed femalegenitalia order head to toe or systematic prone stomach handsunderheadonpillow musculoskeletal cheifcomplaint abnormal ateralrecumbent side one legoverother rectumvag leastinvasive to most kneechest restonknees chest elbowsflexed painful last 3headturned toside palmsnext comparesidessymmetry to head rectum regular Abdomen INSPECT e nutor INSPECT PALPATE AUSOULLIATT Abdu would NSPECT PALPATE PERCUSS PERGUSS Nonverbal warmhands AUSCULTATE PALPATE Whatyouseephysically light deeptouch alsosmelllisten meNl temp texture moisture PERCUSS tender mass fluid sltgl.FIIrFltbdo A tapskin AUSCULTATE tianya.in ifyoupalpate1st you can't air fluidsound bell pitch densertissue quietersound diaphragm pitch uedevers dulloverbon lungs bowel GENERALISSURVEY SKIN Generalappearance behavior inspect oxygenation blue boxygen howtheylook circulation capillaries walk speek EDEMA Hydration skinturgor 10 4 alert or confused FEEDUCT Pallorpale anemia Stnvitasiqmm PAIN ildhsii.byhipiitef PersonPlace alcoholism me situation Ruddy red fever Ishmael erythema red infection Fdeoe.cn again vitiligo melanin not in mmep Tuition how it grows skin Petechide reddotsrash  HAIR SEALP EYES inspect Alopecia hairloss strabismus crosseyed exophthalmos buidging NAILS dirtynailscause thyroidproblem INFECTION inspect ptosis 111 eyedroops streaks lossofnutrients P.E.R.R.LI AA ectropion bottomliddroop clubbing lack of oxygen Pupil equalround outward 180 Heart orpulmonary retractive to light entropion bottomliddroop disease accommodation in eye cornea HEAD arcussenitis bluenalo lookingfor scratch Us SPE symmetry yellow dye TMS Jaw snappingor clicking EARS upright midline Webber Test boneconduction lateralizationofsounds Rhine Test BLACK LUNG bone to air you hearair conduction diameter 1 ratio twiceaslongas bone Breath sounds 0 breathsounds Normal clear 1 missing Ypg'lobe vesicular soft.iow periphery CHEST bronchial loud highhollow percuss bronchioles trached Normal resonance overlungs dull over bronchovesicular combination of bone 3 organs the 2 mediumpitch aventitousBreathsounds Epointof maximumimpulsePMI abnormal midclavicular 5thintercostal crackles bubbly fine medium space coarse Rhonchi coursefluid mucous in larger airways obstruction wheezing pitchinspiratory or exhibatory bottomlobes asthma Pleuralfrictionrub dry rubbing grating lower lateralanteriorsurface  HEART WAASCULLAARR SYSTEM S 52Sounds lubdub absentpulsations may blockage iion Abnormalsounds ssounasiganop.ucenti.in i palpateONEcarotidattime lookingfor 0 thrills 54soundsgallop tennessee murmurs auscultate w BELL listen for bruit clicksrubsdysrhythmids while pthold breath no bruit inspectjugularvein fordistention dehydration VASCULAR SYSTEM Peripheralpulses palpate use doppler Arterial occlusion blockage 5p.si ain Pallor Pulselessness Earesthe Paralysis 9ingnumb ex legpalepallor nofeeling arterialocclusion Arterial insufficiency KNOWDIFFERENCE venousInsufficiency pale worse elevated red when normalcolor or lowered pain artery notworking cyanotic cool to touch NormTemp pulse absentor Norm Pulse Absent mildedema Edema present Thinskin hairgrowth thick skin brownpigment nails lack of oxygen aroundankles MUSCULOSKELETAL AABDOMMENN gait walking displacementof umbilicus shuffling Parkinson http 4a YYtateG nernia distention posturalabnormalities kyphosis flanksbulge fluid Lordosis flanks bulge gas scoliosis Auscultate Range of motion 4quads grademusclestrength hyperactive diarreah 0 muscle contraction hypoactive constipationblockage 1 trace muscle contract listen min eachquad 2 Full ROM gravity Normalactivebowels5.35 min 3 FullRomagaisntgravity alpate 4 Romagaisntsomeresitan deep rebound 5 Romagaisntfullresistan  MENTAL EMOTIONAL MUSCULOSKELETAL AAOX4 coordination fingers person placetimesituation G touch nose w arms 9 lethargic each finger touch thumb Pt notmoving can'tdofor self but show Balance signs ofbeing alertthroughstimuli Romberg Glasgowcomascale stand 1 foot determine level of consciense walk heel to toe evaluation of neurological status score the better less than 8 intubate intellectual Function ReceptiveAphasia usually a chimers cannotunderstand written verbal dementia pt's expressive Aphasia understandswritten verbal cannot write or speak appropriately cannotexpress self CRANIAL NERVES 1 olfactory smell 11OpticSnellen Rosenbaum 111Oculomotor 6cardinalfield of gaze IV Trochlear 6cardinal field ofgaze V Trigmeninal facesensations cornealreflex palpatetemplesclenchjaw V1 Abducens 6 cardinalgaze VII Facial facialexpressions taste front tongue vill Vestibulocochlear WhisperWeber Rhine ix Glossopharyngeal taste back tonguegag Vagus speech Ah symmetrical soft palate rise 1 Spinalaccessory shouldershrug turn head with resistance 11 Hypoglossal stick out tongue move 1 pressagaisnt cheek REFLEXES cutaneous Babinski test toes curl Normal toes out abnormal Normalinbabies though  SENSORY ALTERATIONS read'sPsychoanalyticmodel Erikson'sTheory of Psychosocial of Personalitydevelopment development oralstage birth 12.18m trust vs Mistrust birth 12.18m analstage12.18m 3yr AutonomyvsShamedoubt 18m 3yr phallic orOedipalstage 3 byr Iniative vs Guilt 3 6yr Latencystage 6 12yr industryvs Inferiority 6 12yr Genitialstage Puberty Adulthood Identity vs Roleconfusion puberty Intimacy vs Isolation YoungAdult eachstageischaracterizedby sexual Generativity vs SelfabsorptionMiddleAdu Pleasure in parts of body Adultpersonality Integrity vs despair OlderAdult is result of how an individualresolvesconflict b w sources of pleasures mandatesreality individualsneedtoaccomplish a Particular taskbeforesuccessfully sensoryalterations mastering thestage Progressing to th visual sight olfactory smell next one eachtaskframed w opposing auditory near gustatory taste conflicts tasksoncemastered are tactile touch kinesthetic 879igyotpapqfitipsmegyg.pt challenged 3tested againduringnew situations or at times of conflict sensory deficit a deficit in the normalfunction of sensoryreceptionorperception PATIENT IN PAIN 1 pmnpy n sensoryDeprivation State in which stimulation toone or more ofsensesislacking produce monotony boredom 3Types 1 reducedsensoryinput deficitfrom hearing or vision loss 2 eliminationofpatternsormeaningfrominput exposure to strange environments symptom aiesimilar mmFa in nusion severeerectroiyt imbalance or influence of psychotropicdrugs sensoryoverload ex motherhood state wherestimulation to one or more ofthesenses is so excessive the braindisregards ordoesnotmeaningfully respond to stimuli symptoms racethoughts scattered attention actors influencingsensoryFunction elderly sensory alterationsdiagnosis Age hearingloss start at30 risk for injury difficulty w balancespatial risk for fall orientation coordination Age60 impairedverbalcommunicat impairedsocialization globalaphasia impairedmobility inability to understand language self care deficit or communicate verbally COMFORT PPAIN PAINN subjective actual potentialtissue damage TYPES OF PAIN athologicalPain acutepain afterhealing Serves nopurpose identifiablecause lastlessthan 3months limited tissue damage Treatment analgesics Gatecontroltheory painbroughttotolerable level rubbinginjury Painreduced Chronicpain prevent painfromreaching recurrent last longer than 3months brain migraines arthritis lower backpain uncertainduration copingstyle disease internal loci you have control Idopathic over your own pain chronicpain that can't be identified Drs don ex yougiveyourself even know they give you the run around tylenol Nociceptive external loci others areresponsible pain caused by an observableactivity in for seeing about pt'spain nervoussystem in response to stimulus ex nurses Dr giving tissue damage medications Superficialsomatic arisefromsubcutaneo tissues localized sunburns wounds Yuffering w overbalizing Deepsomatic arisefrommuscles complaint tendonsjointsbones inside body internal Low health literacy localizeddiffuseradiating causes barrier's to optimalpain Aon throb t.mg 99kMatie19kyesniteegarder gygettingstabbed bone  g n y ne d visceralPain arisefromorgans inabdomen Acutepain implementations chest Pelvis inresponseto meds nerve blocks inflammation stretching Physicaltherapy other ischemia nonpharmacological modities Poorlylocalized appendicitis pancreatitis Chronicpain implementations Referredpain opioids physical Patientsayspainis located in spot that is Occupationaltherapy image distant from the stimulus initial problem hur guided 3invasiveprocedures along w paininanotherrelatedbodypart psychological cognitive liverdiseasepain felt in Neck shoulder emotional socialaspect painstroke neuro but entire right side nur approaches acupuncture radiating massageyoga taichi paingoesbeyond injurysite causingpainto spiritually another bodypart radiate pain travels Nonpharmalogical kidneystones relaxation sciaticNerves distraction BreakthroughPain cutaneous patientstable baseline then randomlyget stimulation of the skin 10 10 Pain interventions herbal MED ADMMIN ONSET chrondrotin glucosamine TIMMES for arthritis remove cause ofpain Vs meds 0 15 mins to work repositioning IM meds 30 mins to work therapy D O Meds I hour to work Analgesics Nonopioidsopioidsadjuvants opioids Nonopiods moderate severe pain Mild moderatepain acute cancer pain tylenol goal is to reduce INTENSITY of Safest DoesNot work on pain to get at TOLERABLE level inflammation short term 3 5 days NSAIDS risk respiratorydepression ibuprofen treats inflammation Nausea vommitting side effects causes gastrointestinal irritation Nalaxone Narcan overdose NOT recommended in older pts Older adults fall risks ALWAYS MONITOR PT ON OPIOIDS Adjuvants developedto treat conditions not AALLS related to pain but also has analgesic properties managing neuropathicpain SHORTTERM tricyclic antidepressants reduce pain intensity w anticonvulsants meds corticosteroids antiemetics LONG TERM coping strategies to manage chronicreoccurring pain w NONPharmacologicalapproach PAAITTENT EDUGATION cognitivelearning Affective learning individual gains info to further expressfeelings emotions to develop intelectual abilities mental develop values attitudes 3 belief capacities understanding thinking needed towardimproving health process W BLOOMS TAXONOMMY W N AAFFECTIVE LEARNING mn remember frommemory recieving engaged willing to understand interpreting summarizing getinto Apply carryout implenting responding active participation Analyze breakingdowninfo how valuing worth value added skill it relates organizing value system characterizing acting responding internalization EACH METHOD mn TEACH METHODD We discussion one on one role playing lecture Discussion group question answer Discussion one on one role play discovery independentProjectcomputerassisted sychomotor learning development of manual physicalskills such as learninghowto walk or type on a computer PSYCHOMOTORLEARNING fundamental skills movement behavior perception skillsrelatedtobodilymovement guidedresponse learn by instructor demonstrate mechanism confidence in skill more steps than guided complex overt response smoothmotorskill done adaption developed modify if need origination use of existingskills to solve problems EACH METHOD mn demonstration practice return demonstration independentprojects games PSYCHOSOCIAL ADAPTATION STAGES Denial disbelief 2 Anger Notprepared to deal w problem Listen eye contact teach present attempt to educate turns to tense reassure family that anger anger is NORMAL Provideonly info pt absolutely still not ready to face future requires 4 Resolution Bargaining encourage expressed feelings introduce reality set aside formaldiscussiontime speak present tense ready to learn unwilling toacceptlimitations HEALTH LITERACY NW Acceptance cognitive social skills that determinethe recognizes reality ability of individuals togainaccess to focusedteaching on future understand use info in waysto promote skills knowledge maintain good healt motivated Mitch Pilate'Messions  1 COMMUNICATION Process of interaction b w people in which symbols are usedto createexchange 3 interpret messages about ideas emotions States of mind Thearpeuticcommunication ELEMENTS mutuality referent motivates personto talk Holistic view understanding another occurs w in a healingrelationship message content of communication sender persondeliveringmessag connotativemeanings reciever persongettingmessage word meaningschangedepending on who channels used to send recieve you are talking to message ex if youspeakit ex nurses serious means the nature of the illness whilefamily fledia c mdehssdiafemsehnadehieci.ve says it means neardeath from the reciever INDICATES IFRECIEVER UNDERSTOOD MESSAGE reinteraction phase interpersonalvariables factors beforemeeting pt that influencecommunication ex gettingreport looking at perception cultural medicalrecords painanxiety understanding rientation Phase Environment setting of the Nurse pt meets set the tonefor the interaction as nurses we have relationship Pt test nurse competence to create the environment for comitment clarify roles observe effective communication hospital workingphase are distracting Scary for Nurse Pt work together encouragept People give info collaborate take action termination phase end relationship evaluate outcomes separate pt by relinquishing care Situation bedside shift report sentinel events BBACKGROUNLY Assessment seriousunexpected events that occur duringepisodes of care Recommendation Jehovah's witness do not accept blood products  DOCUMENTATION Written account of pertinentpatient data clinical decisions interventions 3 Patient responses in a health record electronichealthrecord GUIDELINES individual's lifetime computerized Do NOT enter personalopinoins record both displayed printed correct all errors record Documentdiscussions with providers that you feel needs clarification electronic medical record regarding an order Pt's record w in an integrated Avoid usinggeneralized emptyphases health care info systemfor an such as status unchanged or had individual visit to a health care goodday providers office or for an individual Begin each entry with date time admission to an acutecaresetting DO NOT erase or scratch out errors made that allows for seamlessdocumentation while documenting of the progression of care DONOT leave blank spaces or lines in a written nurse's progress note use black ink ONLY Appropriate use of Abbreviations Joint commission requires that health care agenciesdevelop a list of standard abbreviations symbols actual acronymsto be used by all members avoid appears seems or of healthcare whendocumenting apparently DONOTUSE List use when inputingsubjective data current MilitaryTime timelyentriesrequiredfor Accurate vitals measurements Painassessment avoidunnecessarywords Admin of meds ex Thefactthattheptis Preparationfordiagnostictests watchingTVis necessary orsurgery change in ptstatus treatment organized who was notified concise clear to thepoint Admissiontransfer D c or complexsituations death Application of critical thinking Pt response to treatment clinical judgment or intervention ocusedchartingDAR used to reportproblems addresspt What to document for Normal findings concerns signs symptoms condition nursing diagnosis behaviorsignificant Normal withindefinedlimits event or change in condition WithinNormalLimits Allexceptions change instatus needs a Subjective narrative note concerning anysignificant indicator of the pt'scondition changein Djective Assessmentf status any subsequentinterventions the patient'sresponse Plan Telephone order TO ordergivenoverphoneto an RN orLPN verbalorder vo includes Date time ordergivenfaceto face to an RN called or LPN who called do not input V0 into the EHR info was givento who in urgentoremergent situations info given inforecieved Incidentreport an incident is anything that is notconsistant with pt routine expected care of a pt or the standard procedures in place is NOT part of healthrecord anything that leads to injury or poses document objectivedescriptionof risks for pt such as near miss what happened whatyouobserved and the snow upactions taken Near Miss Do NOTlabel as an incident incidents in which a pt is exposedto hazard near miss or sentinel event in the situations w potential to cause harm but health care record DoNOTreferent didn't m ACUITY RATING Determines thehoursofcare of staff required CriticalPathways for a givengroup of pt every shift or every24hrs interprofessionalcareplansthat based on interventionssuch as identify pt problems key intervention IV Therapy andexpectedoutcomes w in an Woundcare established time frame Ambulationassistance variances Health Informatics Technology unexpectedoutcomes interventions use ofinformationsystems notspecified w in a critical other info technology torecord pathway monitor deliver ptcare to Positive Ptmakesprogressfaster perform managerial organize than expected functions in health care Negative Ptdevelopspulmonarycomplications aftersurgery requiringoxygen clinicalinformationsystem therapy monitoring large computerizeddatabase managementsystem that is use healthcareinformationsystem to access pt dataneededto plan computer hardware softwarededicatedto implement evaluate care the collection storage processing retrieval 3communication of pt care info in a healthcare clinical decisionsupportsystem agency aids supports clinical decision making Nursing clinical into system incorporates the principles of nursing Nursing informatics informatics tosupport the work that nurses integrates nursing science doby facilitating documentation of nursing computer science 3 into science process activities Offering resources for to manage communicate data managing nursing care delivery info knowledge Wisdom in nursing practices