Data Collect/Interview
This is used to data cluster and identify problems
What is assessment data?
While collecting a health history the nurse asks COLDSPA questions to obtain a thorough history of present health concern. The question that should be asked related to the "A" is
What is "Are there associated factors and how does it affect you?"
When completing an entry on a nurses note the student nurse should line over to avoid any spaces and sign with_________.
What is First initial, last name, SN
This scale can be used to determine a risk for skin integrity impairment.
What is Braden scale?
This term is used to describe a blue/gray hue resulting from low oxygen (hypoxia).
What is cyanosis?
This type of assessment is done only once and is the baseline for all future assessments.
What is initial assessment? or What is comprehensive health history and physical exam?
This type of data is collected during the review of systems.
What is subjective data?
This order of assessments is used when completing the physical exam of any body section EXCEPT the abdomen.
What is inspect, palpate, percuss, and auscultate?
What is jaundice?
This term is used to describe a white or gray color caused by decreased blood flow.
What is ongoing assessment? or What is partial assessment?
When evaluating a patient for long term care placement this assessment could be used to assess IADLs (Instrumental Activities of Daily Living).
What is Lawton?
The sound heard when percussing muscle or bone (very dense) would be described as:
What is flat or flatness?
Term used to describe a primary lesion that is elevated and is > 1 cm in diameter and is solid.
What is plaque?
This term is used to describe a clear fluid filled primary lesion measuring <0.5 cm.
What is vesicle?
This type of data is obtained during the health history.
What is subjective data?
The term describing level of consciousness for a patient who is only able to moan and not fully arouse with painful stimulation.
What is stuporous?
Hand placement used during deep palpation (2.5-5 cm) of organs.
What is dominant hand on skin and nondominant hand on top?
This term would be used to describe the CONFIGURATION of urticaria (hives) as it begins to run together as the patient scratches.
What is confluent?
Term used to describe the lesion of a patient taking a blood thinner that develops a large 5 mm macular purple/blue lesion after hitting the siderail.
What is ecchymosis?
This communication technique is often employed after asking a patient for a description that they are completely unable to provide.
What is laundry list?
Name AT LEAST 3 safety considerations to follow during the physical examination.
What is: 1. Follow standard precautions 2. ID patient 3. Ask about allergies 4. Raise bed during exam and lower it after 5. Rail up on your side, and down on the opposite side ?
Name AT LEAST 3 observable (objective) signs of pain.
1. dilated pupils 2. decreased cognitive function 3. Increased HR/BP 4. Increase respiratory rate and sputum retention 5. decreased gastric motility and intestinal motility 6. urinary retention 7. hyperglycemia 8. depressed immune response 9. muscle spasm, decreased mobility
An area is discovered on the heel that is clearly the result of excessive pressure. There is visible muscle and tendon. This would be categorized as________
When documenting the measurements of a wound this order would be used.
What is LXWXD, then tunneling and undermining.