vital signs
What is the normal range for a heart rate
60-100BPM
What is the B in SBAR
Background- pertinent and brief information related to the situation
What is protective isolation
Positive pressure room with HEPA filtration
Mask for everyone in room or living room
Hand Washing
Infections watch
No live plants or flowers, fruit, etc
what makes it easier to get subjective data
physical setting, nurse behavior, how questions are asked, open ended questions
How do you assess older adults
louder, slower, less medical words
what is orthostatic hypotension
Low BP when you stand up. Measure in laying, sitting, standing and bp drops
What does DAR stand for
Data
Action
Response
Incubation - time from exposure to show of symptoms
Prodromal- When you start to feel bad. MOST INFECTIOUS
Illness- when the person shows apparent symptoms of infection disease
Decline- Start feeling better. Bodies immune system works
example nursing diagnosis
related to, as evidenced by
direct percussion
Strike a finger or hand directly against the patient's body.
Evaluate adult sinus by directly tapping finger on sinus.
what is core body temperature
36.5° to 37.5° C (97.6° to 99.6° F)
what is a handoff
A standardized process for handoffs helps nurses deliver safe, effective care
what does it mean if something is medical
everything is clean techniques
what happens during the implementation step of a nursing care plan
Initiation of appropriate interventions
Clinical pathways, protocols, and standing orders
what is the bimanual technique
uses both hands, one anterior and one posterior, to entrap an organ or mass between fingertips to assess size and shape.
What is an auscultatory gap
Also known as the silent gap, is a period of diminished or absent Korotkoff sounds during the manual measurement of blood pressure.
What is general survey
Overall impression of the patient
Physical-age, race, gender, ethnicity
Body structure
Mobility (gait, ROM)
Behavior (facial expression)
Mood/affect (cooperative, present)
Speech, dress, hygiene
airborne precautions
Negative pressure room, N95, mask, gown, gloves, eyewear
explain each step of COLDSPA
CHARACTER- what type of pain
ONSET- when did it start
LOCATION- where is it
DURATION- how long
SEVERITY-do ur pain scale
PATTERN- what makes it better or worse
ASSOCIATED FACTORS - do you have fever or other symptoms
Light palpation
accomplished by pressing to a depth of approximately 1 cm, used to assess skin, pulsations, and tenderness.
What is the order of vital signs
temp- pulse rate, respirations, BP
Give an example COLDSPA
O
L
D
S
P
A
what illnesses require droplet precautions
Mumps, rubella, pneumonia, flu
what makes it easier to get subjective data from a patient
physical setting, nursing diagnosis, questions asked, how the questions are asked, personality of nurse and patient
Order of health assessment
Inspection, Auscultation, Palpation, Percussion