Types of Assessment - Answers comprehensive, episodic or problem-focused, emergency
comprehensive assessment - Answers (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 - Answers based on the patient's health issues, involves
one or two body systems. smaller scope, but more in depth
What is the nursing process? - Answers 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 - Answers involves life threatening or unstable situation, traumatic
injury, uses ABCDE
ABCDE - Answers airway, breathing, circulation, disability, and exposure
ADPIE - Answers assessment of patient, nursing diagnosis, planning care, implementing and
then evaluating patients status
implementation - Answers collaboration with other team members, involvement of patient and
family, actually doing the phase
evaluation - Answers how effective is nursing care and each phases affects the other
nursing diagnosis vs medical diagnosis - Answers medical focuses on diagnosis and treatment
of disease whereas nursing focuses on the human response to actual or potential health
problems
assessment - Answers establish baseline, review history, physical assessment
diagnosis - Answers clustering of data to make a judgement or statement about the patient's
difficulties or condition
Nanda diagnosis for nursing - Answers 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 - Answers 120/80
normal range of pulse - Answers 60-100 bpm
scale of pulse strength - Answers 0-4+
scale of 0 pulse - Answers non palpable or absent
, 1+ of pulse - Answers weak, diminished, and barely palpable
2+ of pulse - Answers normal, expected
3+ of pulse - Answers Full, increased
4+ of pulse - Answers Bounding
normal oral temperature range - Answers 97.7-99.5 F
normal range for Temporal range - Answers 98.7-100.5 F
five ways to take temperature - Answers oral, axillary, rectal, tympanic, and temporal
normal respirations - Answers 12-20
normal O2 saturation - Answers 95-100%
Pain scale - Answers 1-10
COLDERR - Answers characteristic, onset, location, duration, exacerbation, relief, radiation
6 stages of infection cycles - Answers infectious agent, reservoir, portal of exit, means of
transmission, portal of entry, susceptible host
infectious agent - Answers bacteria, viruses, and fungi
reservoir - Answers 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 - Answers 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 - Answers 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 - Answers point at which organisms enter a new host, same as exit route...
urinary, respiratory, and gastrointestinal tracts
susceptible host - Answers 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
- Answers immunizations and screen healthcare staff
nursing interventions to break chain of infection between infectious agent and reservoir -
Answers hand hygiene, sterilization, antibiotic/antimicrobials