Assessment
Assessed by lifting and releasing a fold of skin on the forearm or sternum of an adult, or on the abdomen of an infant, to verify that it returns quickly into place.
What is skin turgor?
For adults, SBP>130 and/or DBP>80 for two assessments at least 2 weeks apart.
What is hypertension?
Acid-base disorder that results from opioid toxicity.
What is respiratory acidosis?
Patient education for this elimination abnormality includes increased fiber and water consumption and activity.
What is constipation?
The first step in the nursing process; involves collecting data from a variety of sources that is needed to care for patients.
What is assessment?
Tapping the patient’s skin with short, sharp strokes. An abnormal sound implies that an organ or area is possibly compromised with another substance, such as air, blood, or other bodily fluids.
What is percussion?
Medications that increase the diameter of blood vessels; ex. Nitroglycerin.
What are vasodilators?
Breathing triggered by a decrease in CO2. Results in an increase in hydrogen ions.
What is hypoventilation?
Painful urination.
What is dysuria?
Developed during the second step in the nursing process and is "the nurse’s clinical judgment about a client’s response to actual or potential health conditions or needs" (ANA, 2022).
What is a nursing diagnosis?
Serous fluid-filled lesion smaller than 1 cm. Examples: Blister, herpes simplex, varicella
What is a vesicle?
Post-op patients and those with decreased mobility are at risk for this blockage or collapse of alveoli.
What is atelectasis?
H2CO3
What is carbonic acid?
Daily oral hydration goal unless contraindicated.
What is 2 to 3 L.
In this step of the nursing process, nurses use clinical judgment to determine whether short- and long-term goals were met and desired outcomes were achieved.
What is evaluation?
Flexing the foot and toes upward.
What is dorsiflexion?
The mechanical process of movement of O2 and CO2 into and out of the blood stream.
What is ventilation?
ABG result: pH 7.31, pCO2 40, HCO3 19
What is metabolic acidosis?
Urinary diversion in which the surgeon attaches one or both ureters via a stoma to the surface of the abdominal wall.
What is an urostomy?
A patient's plan of care is developed during this step in the nursing process.
What is planning?
Movement of a body part so the ventral (front) surface faces down.
What is pronation?
Increase the diameter of the bronchi and bronchioles improving oxygenation.
What are bronchodilators?
ABG result: pH 7.50, PaCO2 28, HCO3 24
What is respiratory alkalosis?
Bowel control is achieved by this age.
What is 3 years old?
The tasks of this stage of the nursing process are derived from evidence-based practice and may be independent, dependent, or collaborative requiring direct or indirect nursing care.
What is implementation?