NVN52 Week 2

Content, Timing, Format, Accountability, Confidentiality

Public health activities (disease outbreaks, infection control, stats r/t dangerous probs with drugs/medical equip)

Law enforcement and judicial proceedings (Prosecution of crime, id victims of crime or disasters, subpoena)

Deceased (coroners, med examiners, funeral directors, organ donations, death from potential crime)

ONLY under medical emergent situations, where the physician, PA, NP finds it impossible to write the order due to the nature of the situation.

• Subjective
• Objective
• Assessment
• Plan

Used in Problem-Oriented Medical Records

SOAPE, SOAPIE, SOAPIER

(Intervention, evaluation, response)

specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge into nursing practice

restraints, anticoagulants, antibiotics, narcotics

• Data
• Action
• Response

It is used in Focus Charting

• Crisis: Fever returns to normal suddenly
• Lysis: Fever returns to normal gradually

False. Aspirin should also NOT be given to children and teens with chickenpox or influenza because of a possible association of Reye's syndrome

Sinoatrial (SA) node. Aka pacemaker.

Parasympathetic stimulation -> vagus nerve= decreased <3 rate

sympathetic stimulation= increased <3 rate

• S: between 120's and 130's
• D: in the 80's

• S: between the 140's and 150's
• D: In the 90's

• S: greater than 160
• D: greater than 100

The sounds the nurse listens for when taking manual BP

The insertion of the rectal thermometer can stimulate the vagus nerve, which can DECREASE heart rate.

It is normal to have a 5-10mm Hg difference in systolic readings for each arm. The nurse should use the highest reading.

The condition where a pt who is experiencing dyspnea can breathe easier in an upright or sitting position

40% the limb to be used

Peripheral vascular disease

A coarse rattling sound, somewhat like snoring. Usually caused by secretion in a bronchial airway

Biographical data, reason for visit, history of present health concern, medical history, family history, lifestyle

• Change in bowl/bladder habits
• A sore that does not heal
• Unusual bleeding or discharge
• Thickening or lump in breast or elsewhere
• Indigestion or difficulty swallowing
• Obvious change in wart/mole
• Nagging cough or hoarseness

Shape, Size, consistency, surface, mobility, tenderness, pulsatile

Primary: Lesions from previously normal skin

Secondary: Changes in primary lesions

To test extraocular movements

noisy, strenuous respirations

• 0         no pulse
• 1+       thready
• 2+       weak
• 3+       normal
• 4+       bounding

Inspection, palpation, percussion, ascultation

In abd assessment it is inspection, ascultation, percussion, palpation. This is because palpation and percussion stimulate bowl movements.

To ascultate low pitch sounds like a heart murmurs. The diaphram is for high ptiched sounds like a normal heart sound

bubbling or popping sounds

Senile keratosis

senile lentigines

Used to assess for bone conduction of sound. The sound is normally heard in both ears, or it is localized at the center of the head.

Pts with conductive hearing loss(tympanic/ossicles) hear the sound best in the affected ear

If the sounds is heard better in the ear w/out a problem, it indicates damage to the inner ear or a nerve disorder.

Used to compare bone and air conduction. Hearing air conduction is usually grater than bone conduction. If the hearing loss is conductive, sound of bone conduction will be the same or greater than air conduction

• Normal: AC>BC
• Conduction loss: AC<=BC