Assessment
A blood pressure value of 138/92 is an example of this type of data.
What is objective data?
A tool patients use to help prevent against pneumonia and atelectasis while hospitalized or post-surgery.
What is an incentive spirometry.
A nursing diagnosis for a patient with a stage 4 pressure ulcer.
What is impaired skin integrity?
A tool nurses use to determine the risk for impaired skin integrity.
What is the Braden Scale?
The normal range of this lab is 3.5 to 5 mEq/L. When this lab is out of range the patient is at risk for cardiac rhythm changes that can result in death if not treated.
What is Potassium?
A patient experiences a reaction after a new medication that is a medical emergency in which they experience difficulty breathing and shortness of breath.
What is an anaphylactic reaction?
A patient that is non-ambulatory after surgery is at risk for this due to poor perfusion. Blood pools in their lower extremities.
What is a deep vein thrombosis (DVT)?
A nursing diagnosis for a patient with C. Diff that is having frequent watery stools.
What is imbalanced nutrition?
What is fluid-volume deficit?
What is impaired skin integrity?
What is nutritional deficiency?
This infectious disease process requires the healthcare staff and all family members to wash their hands with soap and water because hand sanitizer is not effective.
What is C. diff?
This lab is used to determine the patient's protein and nutritional status. The range is between 3.5 to 5 g/dL. It is an essential component of fluid balance, responsible for maintaining colloidal oncotic pressure. Low levels of this may indicate malnutrition.
What is Albumin?
This is an early sign of a urinary tract infection.
What is a fever?
This is the priority nursing action for a patient with an oxygen saturation of 86% following the administration of pain medication.
What is administering oxygen?
What is risk for infection?
This is what SBAR stands for.
What is Situation-Background-Assessment-Recomendation?
Labs that are used to assess renal failure with their normal values.
What are BUN (10-20) and Creatinine (0.6-1.6).
This is the second step the nurse should take when performing an assessment of a patient's abdomen after inspection.
What is auscultation?
This is a type of wound that is considered full-thickness skin loss into the subcutaneous tissue.
What is a stage 3 pressure injury?
A nursing diagnosis for a patient with a recent amputation of the left arm following a boating accident.
What is altered body image?
This is another term for healthcare associated infections (HAIs) when a patient acquires a new condition that was not present at the time of admission. (Example: CAUTIs or CLABSIs)
What is a nosocomial infection?
This lab has a normal level of 135-145 mEq/L. This electrolyte assists with nerve impulses and maintaining a proper balance of fluid and minerals. It is the most abundant electrolyte.
What is Sodium?
When this type of bowel sound is identified, the nurse must listen to the patient's abdomen for a full 5 minutes to confirm.
What are absent bowel sound?
This type of healing process (intention) would include a clean incision that evolves into a hairline scar.
What is primary intention?
This is the phase of the nursing process where nurses obtain information from the patient about their current health status.
What is assess?
This medication is contraindicated for patients receiving contrast-dye due to the risk of renal complications and contrast-induced nephropathy.
What is Metformin?
This is when a patient has a pH greater than 7.45, a CO2 WNL, and a HCO3 of greater than 26.
What is Metabolic Alkalosis?