documentation
what is a medication administration record?
contains information about the medications that have been prescribed for the client
what is SBAR?
a format for handoff report- situation, background, assessment, recommendation
bubbling, cracking, popping. soft, high pitched and very brief sounds, usually heard during inspiration. (pneumonia, bronchitis, emphysema)
crackles (rales)
normal respiration rate
12-20 /min
how are i&o's totaled
by shift and every 24hrs
the type and site of injection
allows you to observe important aspects of client care; outgoing nurse introduces you to the client; ensure continuity of care , team collaboration, and communication
characteristics of rhonchi
coarse, snoring, continuous low pitched sounds heard during inspiration and expiration, may clear with coughing (bronchitis, emphysema, narrowed airways, fibrotic lungs)
what meds can cause slower, deep respirations
CNS depressants, morphine, general anesthetics
what site is the most accurate representation of core temperature
temporal
how do you fix incorrect documentation?
draw a line through incorrect documentation and initial it so that other healthcare providers can see the error and avoid it.
how to ensure confidentiality
Maintain confidentiality; do not provide written or verbal information to anyone not involved in the direct care of the client without consent Ensure confidentiality and privacy (log out of computers and close the screen when done) - Use privacy filters
- Create a secure password and change it at regular intervals
- Do not share your personal username or password with anyone
- Do not leave client data displayed on the screen where others can see it
- Do not leave the computer unattended after you have logged on
- Do not leave portable devices unattended in public locations
- Never access client health record that you have no professional reason to view
what causes friction rub?
pleuritis
normal infant RR
40-60 breathes/min
how do you convert a centigrade to F
multiply the centigrade temp by 9/5 and + 32
all verbal orders and prescriptions must be countersigned by the provider within ____ hours.
24
face to face oral report
characteristics and causes of stridor
(medical emergency) high pitched, continuous honking sounds heard throughout the respiratory cycle but most prominent on inspiration. acute respiratory distress, foreign body in airway, epiglottis
for every 1 degree F the temp rises, the RR may increase up to ____ breathes/in
4
what is orthostatic hypotension
drop in systolic BP from lying/sitting/standing of 20 mmHg or more
when you chart a patients symptom, what else do you have to document?
what you did about it and how the patient responded
narrative charting
tracks clients changing health status and progress towards their goal
provides info on pts. care, status, activities, nursing interventions, psychosocial context, and response to treatment
what are some normal breath sounds?
bronchial/tubular, bronchovesicular, vesicular
factors that influence respirations
developmental level, exercise, pain, stress, smoking, fever, hemoglobin, disease, medications, position
name all of the pulse points
apical(apex of heart);radial(wrist);brachial(elbow);carotid(neck);temporal(temple); dorsalis pedis(top of foot); posterior tibial(inner ankle); popliteal (behind knee)