General, Safety and Skin
Risk for pressure injury
What does the Braden Scale measure?
Person, Place and Time
What 3 things are questioned with orientation?
Normal range of respirations for adults
What is 12-20 breaths per minute?
4 quadrants
CWMS
What is included in the neurovascular assessment?
Hydration level
What does the skin turgor indicate?
Unconscious most of the time with response only to painful stimuli
What is stuporous?
Nothing by mouth
What is NPO?
Amount of blood flow to the tissues
What is capillary refill?
A yellowing of the white sclera of the eye
What is jaundice?
Pain that is short term and dissipates after the injury is healed
What is acute pain?
Lung sounds heard over the trachea
What are bronchial sounds?
Misdirection of oral secretions into the lower respiratory tract
What is aspiration?
Accumulation of fluid in the interstitial space
What is edema?
Collection of information to formulate nursing diagnoses that require nursing care
What is a head to toe assessment?
Location, duration and onset
What are 3 of the factors included in a pain assessment?
Sound made by backflow of blood through valves not closing completely
What is a murmur?
Inspection, Auscultation, Percussion, Palpation
In what order should you do an abdominal assessment?
Simulate normal muscle contraction and venous compression
What are SCD's
A 9 factor scale with scores ranging from 0-77
What is the Hester Davis Scale/Fall Assessment Tool?
Meditation, massage, ice and humor
What are some non-pharmacologic methods to treat pain?
2nd intercostal space, left side
Where would you listen to the pulmonic valve?
Laxatives, diuretics, antibiotics and opioids
What are medications that can affect elimination?
Surgery, pregnancy and immobility
What are risk factors for DVT development?