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NCLEX-LPN: Nursing Basics
Terms in this set (61)
Patient is placed flat on back
Patient is in a side lying position partially on abdomen.
Used when administering enemas or suppositories.
A device placed over the bed to aid the patient in positions changes, transfers or performing upper-extremity exercises
Patient is positioned by lowering HOB below the feet causing a shift of intravascular volume from the lower extremity and abdomen to the upper body.
Done for patients w/severe hypotension an or shock.
HOB is elevated to 45-60 degrees, pillow is placed under knees to keep them slightly flexed.
Improves ventilation and also chest tube drainage.
HOB is 30 degrees
HOB is 90 degrees
Patient's body alignment is in a lateral position at about 30 degrees.
Used when turning patients to avoid pressure ulcers.
Prevents supine vena cava syndrome and increases uterine and renal perfusion during pregnancy.
While pt. is in a supine position. A rolled up towel is placed slightly underneath each hip preventing external rotation of the hips.
Ankle-Foot Orthotic Device (AFO)
Aides in keeping pt. in anatomical position, prevents "foot drop" dorsiflexion of the ankle (can be debilitating and cause gait abnormalities.
Patient is positioned lying face down. Pillow is placed under legs to promote dorsiflextion.
Thin pillow is placed to prevent hyperextension of the neck.
What are the Vital signs?
Blood Pressure - 120/80
Pulse - 60-100 BPM
Respiratory Rate - 12-20/minute
Oxygen Saturation - (95-100%)
Pain (pain scale 1-10)
Respiration vs Ventilation
R: Bodies ability to move oxygen into the blood and into the cells, at the same time removing CO2 from the body.
V: the movement of air/gas in and out of the lungs (respiratory rate)
The measure of force exerted on the artery walls when the heart contracts and blood is pushed out from the ventricles.
It is important to use the right size cuff or readings will be altered.
the high pressure, range (90-120mmHg) caused by the heart contracting and blood being pushed into the aorta.
the low pressure, range (60-80mmHg) measures the amount of continous pressure on the artery walls after contraction of the heart and the ventricles relax.
Measurement of bodies ability to diffuse and perfuse read by an LED light reflected form the hemoglobin molecules.
Patient with nail polish, hypothermia, vasoconstriction, peripheral edema, or abnormal hgb levels will produce an inaccurate reading.
Pain -universal sym in compartment syn
Paresthesia- pins and needles sensation
Pulse- diff in rate/quality
Pallor- color of extremity
Pressure- rise = compartment syndrome
Paralysis- sensation/mobility of limb
First sign of an impending problem, "pins and needles" sensation may include numbness or tingling as a result of inadequate circulation, nerve damage or compartment syndrome.
Refers to the color of the extremity along w/temp assessed against unaffected side.
Capillary refill return in 3 secs.
Pulse (nerovasc asses.)
compared to unaffected extremity for diff in rate and quality.
Diminished or absent distal to the injury may indicate vascular dysfunction.
Insufficiency should be reported to provider immediately.
Paralysis (nerovasc asses.)
Partial of full loss of sensation or function may be a late sign of neurovascular damage.
Inability to move limb distal to the injury may indicate compartment syndrome or significant muscle and nerve damage.
Pain (nerovasc asses.)
the universal symptom in compartment syndrome, related to edema, movement of bone fragments, or muscle spasms; increases as the pressure in the compartment rises.
Increase may indicate compartment syndrome and is related to swelling w/in the cavity.
Depending on severity could result in a feeling of sensation in the extremity or cause severe pain.
Glasco Coma Scale
Score of 3 - 15 (15 = alert 8 or > = coma)
Motor Response (Glasco Coma Scale)
1-6 points total
6= Normal, obeys movement commands
5= Movement in response to pain
4= Withdrawals in response to pain
3= Flextion in respose to pain (decorticate post. "curling to the spine")
2= Extension in response to pain (decerebate post. "curling away from spine")
1= no response
Eye Opening (Glasco Coma Scale)
Rated 1-4 points
4= spontaneous - w/blinking at baseline
3= verbal stimuli, command, speech
2= to painful stimuli(not applied to face)
1= no response/does not open
Verbal Response (Glasco Coma Scale)
Rated 1-5 points
5= able to converse (oriented: time, place, person)
4= converse, some words are slurred/sluggish (may be disoriented)
3= pt. thinks he is speaking; not understandable
2= speak in sounds or grunts
1= completely mute even with painful stimulus
LOC Assessment (Glasco Coma Scale)
LOC: Descriptive terms to Glascow Coma Scale
Conscious, Confused, Delirious Somnolent, Obtunded, Stuporous
Normal attentive orientated to place and mind.
Impaired or slowed thinking; disoriented
Disoriented, restless, clear deficit in attention; possible hallucinations and delusions.
Excessive drowsiness: little response to external stimuli
Decreased alertness, slowed motor response; sleepiness
Sleep like state, little or no activity, responds only to pain
No response to stimuli, cannot be aroused; no gag reflex or pupil response to light.
Maslow's Hierarchy of Needs
Safety and security
Love and belonging
Oxygen, water, nutrition, elimination, sleep, homeostasis, sex, and shelter
Safety and Security
Bodily system working together and keeping one safe, and other systems such as law, stability, order, property and freedom of fear.
the ability to avoid harm or injury creates the feeling of comfort.
Love and Belonging
Friendship, Family, and companionship. Needs are for giving and receiving love to create satisfactory interpersonal relationships.
Self-esteem, Self-respect confidence, respect of others, respect by others, achievement, desires prestige from accomplishments.
Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts.
Fulfillment can not be met until previous needs have been mastered.
Nurse collects data about patient.
Will encompass physical findings, psychological, cultural, social, family, and nursing Hx as well as accessing medical record and obtaining diagnostic results.
Formed nursing assessment, developed by NANDA and is prioritized based on Maslow's Hierarchy of Needs.
Individualized care plan is developed setting realistic goals.
Setting priorities of nursing diagnosis according to Moslow's Needs.
Outcomes of planning should be measurable, and include a time frame.
Prioritized plans are carried out, involve pt. and family in active care.
Therapeutic communication is key for communication during this step.
Part of nursing process where nurse determines if pt. has met the goals in plan of care.
If goals are not met nursing process starts over again.
Include reasons why goals were not met and modifications to the plan of care to ensure new goals are met.
Onset - When did pain start?
Provoking/Palliative - What makes pain better/worse?
Quality - Can you describe your pain?
Radiation - Where is pain/does it spread
Severity - On a scale 0-10, rate pain
Timing - When does pain occur?
Nursing Considerations for Pain Assessment
Subjective Findings - what pt. states they feel
Objective Findings - what is seen, heard, and measured.
Reassessment of Pain - reassessment of pain after intervention has been implemented
Types of Pain
Acute Pain - limited in duration and will resolve once tissue damage has healed.
Has an identifiable cause.
Chronic Pain - Pain that last longer than 6 months, usually require higher than normal doses to control pain.
60 -100 BPM
Palpable sensation that can be felt when the heart contracts.
Common areas to palpate: radial, carotid, and femoral arteries.
If there is a dysrhythmia or weak pulse check apical pulse.
5 Rights of Delegation
Task: RN delegates task to CNA
Circumstance: pt. must be stable
Person: qualified person, correct pt.
Direction/Communication: explain task
Supervision/Evaluation: provide feedback and thank for assistance
Manifested by air moving through narrowed airways.
Heard at the end of inspiration and beginning of expiration.
Heard throughout lung, typically upon auscultation, usually high pitched and continuous.
High pitch wheezes = disease in smaller air ways
Low pitch wheezes = disease of ;arger airways.
Manifested by air moving through fluid or mucous
Can be fine or course heard more commonly with inspiration than expiration.
Heard at lower lobes of the lungs, imply accumulation of fluid secretions or exudate with in airways and edema in the pulmonary tissue.
Sound like pouring water out of a bottle or ripping open velcro.
Sign of respiratory distress syndrome, early heart failure, asthma, and pulmonary edema.
Indicates presence of mucous.
Sound like salt heated on a frying pan or the rolling of hair between ones fingers next to your ear.
Indicate presence of fluid or non-viscous secretion
Manifested by obstructions of the larger airways resulting from increased secretions
Low pitched rumbling or snoring sound Heard prominently near the trachea and bronchi, loudest at expiration.
Signs of COPD, cystic fibrosis, chronic bronchitis, and pneumonia .
Pleural Friction Rub
Manifested by inflammation of pleural causing pleural spaces moving and rubbing against each other.
Characterized as a dry rubbing or squeaking sound like rubbing a ballon with your finger.
Heard over the anterior lateral lung like a creaking, grating sound.
Pneumonia, pleurisy, and pulmonary infarct irritate & inflame pleura
Tuberculosis Skin Mantoux Test (PPD)
Intradermal Injection, 15* angle, dorsal side of pt's. forearm.
(+) result manifested by delayed hypersensitivity cell mediated response
Immunosupressed >/= 5mm (organ
transplant, HIV, corticosteriod therapy)
High Risk >/10mm (chronic diseases, IV drug users, and recent immigrants from countries w/high prevalence of disease
Low Risk >/= 15mm
Instruct pt. not to itch or cover test site
Interpretation read in 48-72 hrs
(+) TB test requires chest x-ray; confirms Dx or rules out false positive.
Confirmative Dx is by sputum culture
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