Assessment Data
The patient states he is feeling chills. This is _______ type of data.
Subjective
The nurse knows to use these types of questions to obtain more information from a patient than a yes or no answer.
Open-ended questions
Includes a bell and a diaphram for listening to low-pitched and high-pitched sounds.
Stethescope
A heart rate of 39 beats per minute for a normal adult.
Bradycardia
The best person to measure the intensity of a patient's pain.
The patient.
Rapid shallow breathing.
Tachypnea
Data gathered that is measurable and quantifiable.
Objective
This re-assessment is performed by the nurse to compare a patient’s current status to baseline data obtained earlier and will guide revisions in the care plan.
An on-going or time-lapsed assessement.
Assessment technique that uses vibration from tapping to detect tissue density
Percussion
Key times when the nurse should obtain vital signs.
New symptoms, after or before medications, when VS order is placed by the medical team, when patient arrives to the unit, or changes locations.
Increased pain will result in these changes to vital signs.
Increased BP, increased HR, maybe increased RR, maybe decreased Oxygen saturation.
Sweat cools the body and can lead to insensible water loss and dehydration.
Evaporation
The normal range in heart rate for a 6 year-old child.
65 - 130 beats per minute
A screening assessment either on the phone or in person to determine the extent and severity of patient problems and recommend appropriate follow-up.
Triage assesment
Known commonly as a blood pressure cuff.
Sphygmomanometer
Best site for the most accurate core temperature
Rectal
The pain scale in which the child is asked to select the face that "shows how much you hurt?"
Faces pain scale - revised (FPS-R)
Normal systolic blood pressure for an infant
85 mm Hg
Obtaining a family history, the nurse collects this type of data.
Subjective
Three things the nurse will assess during a neurological exam.
A & O x 3, numbness, tingling, trembling, seizures, dizziness, changes in vision, taste or smell, substance use, balance, coordination, bilateral strength, cognitive abilities, memory, cranial nerves.
Pain lasting longer than 4 months.
Chronic pain
Normal adult temporal temperature range in Fahrenheit.
98.7 - 100.5 degrees
Pain that originates in one part of the body and is perceived in an area distant to that part.
Referred pain
For a patient who is A + O x 1 who would the nurse ask about past medical history?
A family member, close friend, guardian, or health proxy.
This is a non-verbal communication practice of the nurse at the bedside to promote equality and engagement of the patient.
Sit at the patients eye level
The five types of assessment
1) Initial, 2) triage, 3)focused, 4) emergency, 5) time-lapse
A neurological assessment tool that includes the rating of patient eye, motor and verbal responses.
Glasgow Coma Scale
Error in measurement that occurs when the BP cuff is too large for the patient.
Blood pressure measurement will be lower than actual.
The 3 main terms used by the nurse to describe subjective pain characteristics.
Quality, Severity & Periodicity (or timing)
An apical-radial pulse deficit indicates this serious nursing concern.
Blood flow is not adequately reaching the peripheral arm and hand.