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Subjective data
Data obtained from the patient verbally
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Objective data
Information obtained through the senses and hands on physical examination
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Four elements of malpractice
Duty, Breach of duty, Causation, Injury
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Five components of nursing process
Assessment (data collection), Nursing diagnosis, Planning, Implementation, Evaluation
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Medical asepsis vs surgical asepsis
- Medical=practice of reducing the number of organisms present or reducing the risk of transmission of organisms
- Surgical=practice of prepaaring and handing materials in a way that prevents the patient's exposure to living microorganisms
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Six parts of the chain of infection
- Causative agent
- Reservoir
- Portal of exit
- Mode of transfer
- Portal of entry
- Susceptible host
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5th vital sign must show
location, intensity, character, frequency, and duration
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Kussmaul's respirations
Fast, deep respirations
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Biot's respirations
Fast, deep respirations with abrupt pauses
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Cheyne-Stokes
Respirations become faster and deeper, the slower and shallower with a period of apnea
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Crackles
(Rales)-abnormal nonmusical sounds heard during inspiration (hair between the fingers next to the ears)
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Rhonchi
Continuous dry, rattling sounds caused by partial obstruction
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Stertor
Snoring sound produced when patients are unable to cough up secretions from the tranchea or bronchi
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Stridor
Crowing sound on inspiration caused by obstruction of the upper air passages as occurs in croup or laryngitis
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Wheeze
Whistling sound of air forced past a partial obstruction as found in asthma or emphysema
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Four areas to listen for heart
Aortic, Pulmonic, Tricuspid, Mitral
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Where is the apex of the heart?
FIfth intercostal space at the midclavicular line
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Nine pulse points
Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Postterior tibial, Dorsalis pedis
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Where do you hear S1 (lub)?
Apex (mitral)
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Where do you hear S2 (dub)?
Aortic area
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NAPNES standards for LPNs
- Professional behaviors
- COmmunication
- Assessment
- Caring
- Planning and interventions
- Managing
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Edema standards
- +1 up to 1/4 inch
- +2 1/4 to 1/2
- +3 1/2 to 1 inch
- +4 > 1inch
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Nursing diagnosis
- Problem + etiology+signs+symptoms
- Subjective
- Objective
- Assessment
- Planning
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BP numbers
- Normal <120 and <80
- Prehypertension 120-139 or 80-89
- Hypertension 1 140-159 or 90-99
- Hypertension 2 >160 or >100
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Vitals in aging
- T=lower normal temp
- P=may be irregular
- R=may rise as decreases in vital capacity and respiratory reserve occur
- BP=rises slightly because arteries tend to harden with age
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Kussmaul's respirations may be in people with
diabetic acidosis and renal failure
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Host may be susceptible by virtue of
age, state of health, broken skin
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