Normal ranges
What is the normal heart rate for adults?
60-100 bpm
What are some types of assessments?
Initial, problem-focused (edema), emergency (choking), ongoing reassessment (chronic open wound)
The stage of the interview when you thank the client and summarize key points is the _____
Closing
What are the sources of data?
Primary, secondary, support people, literature
History, physical exam, observation, over-nutrition, under-nutrition, and healthy attachment are all observed in the assessment of ____.
Infants
What is the normal respiration rate for adults?
12-20 breaths per minute
What is assessment? (Definition)
Systematic method of collecting data about a patient for the purpose of determining health status, predicting risks to health & identifying health-promoting activities
What is the first stage of the interview? What does it entail?
Opening: establish rapport, introduce self, explain the purpose
What is salience?
The ability to understand what is more or less important in a clinical setting
This age of children has slow, steady growth, like to talk about hobbies & friends, and appear thin & gangly
School-aged
True or false: As individuals age, their heart beats at a faster rate
False.
x A newborn's heart rate is 100-205 bpm (awake) and as we age the heart beats slower to a normal range of 60-100 bpm
The measurement of head circumference measurement is unique for children ____ and younger
When auscultating the lungs, what are three abnormal sounds you can hear? What do they sound like?
Crackles (air going past fluid), wheeze (bird sounding), stridor (honking noise)
What are the ABCs of prioritization?
Airway, Breathing, Circulation
_______ are talkative. Nurse needs to assess language & cognitive ability. Growth rate slows.
Preschoolers
What is the normal heart rate range for a newborn?
100-205 bpm (awake)
90-160 bpm (asleep)
What are you looking for (inspection) of a respiratory exam?
Respiratory pattern, diaphoresis, anxiety, labored breathing, use of accessory muscles, color of the patient
What is in the body of the interview?
The client answers the nurse's questions and provides information.
Don't rush, be at eye level with the client
What is the purpose of validating data?
Ensure information is complete, ensure that objective & subjective data agree, obtain additional information
In this age group, the growth rate decreases. The nurse needs to assess caloric intake and nutrition (which can be received by the parent if needed)
Toddlers
What are the normal resting pulse rates for infants?
100-180 bpm (awake)
80-160 (asleep)
When checking for pressure ulcers in a dark-skinned client, the skin is ______ after blanching?
Darker
x Dark skin rarely shows the blanch response. Instead, after applying light pressure, look for an area that's darker than the surrounding skin or that's taut, shiny, or indurated (hardened). Early signs of skin damage include induration, bogginess, and increased warmth at the injury site. Over time, the area becomes cooler.
When assessing the abdomen, what order do you go in?
Inspection, auscultation, percussion, palpation
Listen before you "move things around"
In prioritization, what are the four questions a nurse should ask themselves?
What is the most important client need? Which nursing intervention is most important? Which nursing action should be done first? Which response is best?
What are some aspects of assessment for adolescents?
Growth spurts are common, they are beginning puberty, appetite typically increases, peer focused. The nurse should offer privacy