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Types of Assessment - Answer✅✅comprehensive, episodic or problem-focused,
emergency
comprehensive assessment - Answer✅✅(initial) results in baseline data for
problem identification and care planning, time consuming, complete, all aspects of
preventive health/physical disease
episodic/problem-focused assessment - Answer✅✅based on the patient's health
issues, involves one or two body systems. smaller scope, but more in depth
What is the nursing process? - Answer✅✅systematic problem-solving approach to
identifying and treating human responses to actual or potential health difficulties.
patient centered and focuses on problem solving and inhaling strengths. uses ADPIE
emergency assessment - Answer✅✅involves life threatening or unstable situation,
traumatic injury, uses ABCDE
ABCDE - Answer✅✅airway, breathing, circulation, disability, and exposure
, ADPIE - Answer✅✅assessment of patient, nursing diagnosis, planning care,
implementing and then evaluating patients status
implementation - Answer✅✅collaboration with other team members, involvement
of patient and family, actually doing the phase
evaluation - Answer✅✅how effective is nursing care and each phases affects the
other
nursing diagnosis vs medical diagnosis - Answer✅✅medical focuses on diagnosis
and treatment of disease whereas nursing focuses on the human response to actual
or potential health problems
assessment - Answer✅✅establish baseline, review history, physical assessment
diagnosis - Answer✅✅clustering of data to make a judgement or statement about
the patient's difficulties or condition
Nanda diagnosis for nursing - Answer✅✅a clinical judgement about individual,
family, or community responses to actual or potential health difficulties/life
processes. Provides the basis for selection of nursing interventions to achieve
outcomes for which the nurse is accountable
Normal range of blood pressure - Answer✅✅120/80
normal range of pulse - Answer✅✅60-100 bpm
scale of pulse strength - Answer✅✅0-4+
scale of 0 pulse - Answer✅✅non palpable or absent
1+ of pulse - Answer✅✅weak, diminished, and barely palpable
2+ of pulse - Answer✅✅normal, expected
3+ of pulse - Answer✅✅Full, increased
4+ of pulse - Answer✅✅Bounding
normal oral temperature range - Answer✅✅97.7-99.5 F
normal range for Temporal range - Answer✅✅98.7-100.5 F
five ways to take temperature - Answer✅✅oral, axillary, rectal, tympanic, and
temporal
, normal respirations - Answer✅✅12-20
normal O2 saturation - Answer✅✅95-100%
Pain scale - Answer✅✅1-10
COLDERR - Answer✅✅characteristic, onset, location, duration, exacerbation, relief,
radiation
6 stages of infection cycles - Answer✅✅infectious agent, reservoir, portal of exit,
means of transmission, portal of entry, susceptible host
infectious agent - Answer✅✅bacteria, viruses, and fungi
reservoir - Answer✅✅place for growth and multiplication of microorganisms is the
natural habitat of the organism (other people, animals, soil, food, water, milk and
inanimate objects)
portal of exit - Answer✅✅point of escape for the organism from the reservoir
(respiratory, gastrointestinal, and genitourinary tracts, as well as breaks in the skin
and blood and tissue
means of transmission - Answer✅✅how an organism is transmitted from its
reservoir, through touching, kissing, sexual intercourse, contaminated instrument,
blood, food, water, or inanimate objects, vectors like mosquitos, ticks, and lice
portal of entry - Answer✅✅point at which organisms enter a new host, same as
exit route... urinary, respiratory, and gastrointestinal tracts
susceptible host - Answer✅✅source that is acceptable for microorganisms that
overcome any resistance mounted by the host's defenses
nursing interventions to break chain of infection between susceptible host and
infectious agent - Answer✅✅immunizations and screen healthcare staff
nursing interventions to break chain of infection between infectious agent and
reservoir - Answer✅✅hand hygiene, sterilization, antibiotic/antimicrobials
nursing interventions to break chain of infection between reservoir and portal of
exit from reservoir - Answer✅✅transmission-based precautions, sterilization or use
of disposable supplies
nursing interventions to break chain of infection between portal of exit from
reservoir and means of transmission - Answer✅✅dry intact dressing, hand hygiene,
wear gloves if contact with body fluids, cover nose and mouth when sneezing