Unit 3A
data described to the nurse
can be verified only by the patient
Examples: pain, itching, dizziness
What is subjective data?
adults 60-100
infants 120-160
What are normal pulse rates?
occurs when drug levels exceed the therapeutic range
may occur secondary to overdose or drug accumulation
Includes appreciating, accepting, and respecting all individuals’ cultural influences, beliefs, customs, and values.
A necessity in nursing to provide the best care possible.
Includes positive and open communication between clients and nurses along with open feedback.
What is cultural competence?
FiO2 = 35%-50%
Flow rate = 6-12 L/min
*contraindicated for COPD
What is simple facemask?
good, better, appears, seems, apparently, lots in documentation
What are words to avoid in documentation?
drop after a position change
typically lying/sitting to standing
What is orthostatic hypotension?
unpredictable responses to medications in which a patient can overreact or underreact to medication or has a different than normal reaction
example: Benadryl causing agitation and hyperactivity instead of drowsiness
What is an idiosyncratic reaction?
denial, anger, bargaining, depression, acceptance
What are Kubler-Ross's Stages of Grief?
FiO2 = 60%-75%
Flow rate = 6-11 L/min
Reservoir bag should be at least one third to one half full on inspiration
Adjust flow rate to keep reservoir bag inflated
What is partial rebreather mask
Date collected during a physical exam or by testing
can be observed/perceived by others observing the same client
examples: weight, height, temperature, labs
What is objective data?
classification of pain in bones, joints, muscles, skin or connective tissue
What is somatic pain?
results when the combination of two drugs is greater than the effect that would be expected if the individual effects of the two drugs acting alone were added together
What is a synergistic effect?
Beliefs on death:
This age group has no concept
believe reversible/temporary
asleep
What is infant - 5 years?
Right Task
Right Circumstances
Right Person
Right Direction/Communication
Right Supervision/Evaluation
What are the five rights of delegation?
*remember stable vs unstable, in scope vs out of scope, predictable outcome vs unpredictable
Remember to ________, _______ and then _________ for abdominal assessment.
What is inspect, auscultate, and then palpate
radiates or felt in another area away from source of injury
What is referred pain?
desirable response to the medication
What is therapeutic effect?
Beliefs on death:
death is final, believe something they did is r/t death
What is ages 5-9?
allows nurses to attend to situations in the proper sequence, without jeopardizing patient care
*remember high priority first (ABC)
Adults 12-20 per minute
Infants 30-60 per minute
What are normal respiratory rates?
pain that occurs in addition to the pain being managed by the mainstay analgesic
What is breakthrough pain?
unfavorable physiological response to an allergen to which a person has been previously exposed and has developed antibodies
What is an allergic reaction?
End of life
an irregular respiratory rate fluctuating between several quick breaths and periods of apnea
What are Cheyne-Stokes respirations?
Do not "_________" these:
activities that require nursing judgement
steps of the nursing process
teaching
What is delegate?