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29 Cards in this Set
- Front
- Back
single most effective way to prevent spread of infection |
hand hygiene |
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how to wash hands |
rub hands for 15-30 seconds to remove soil/ dead skin cells rinse hands 15-30 seconds with water flowing towards finger tips, dry from finger tips to wrist turn off faucet with paper towel, not hands |
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When should you wash hands |
before/ after meeting patient/ patient contact when ever you put on or take off gloves before passing medicine after you sneeze before you eat |
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4 components of conducting a health assessment |
1. inspection- looking over patient (sight, hearing, smell) 2. palpation (touching) (light (1cm), moderate (2-3 cm), deep (4 cm or more)) 3. percussion (to determine how dense material or organ is beneath what you are percussing) (louder over air, soft over solid, moderate over liquid) -three types- direct, blunt, indirect (flicking a finger against another finger that is pressed firmly against skin) 4. auscultation (uses stethoscope) - has bell (smaller end, low pitched sounds) and diaphragm (bigger end- picks up high pitched sound best) Typical order, but different for abdominal assessment |
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gastric sounds |
tympany (gastric bubble)- loud musical drum like sound, high pitched hyperresonance (emphysema)-booming quality over lungs resonance (normal lungs)- less than hyperressonance, but same sound over lung dullness (liver)- dull, short lived sound flatness (muscle)- dead sound, very short, very dull |
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How to hold stethoscope |
hold between second and third fingers |
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General survey |
vital signs, height and weight module, observations |
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acute pain |
rapid onset, varies with intensity, protective in nature (warns you of injury or potential for it) |
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chronic |
intermittent or persistent, long standing pain, interferes with ability to function |
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acute on chronic |
chronic pain and then acute exaccerbated pain. acute pain is treated first |
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remission and exacerbation |
remission- no symptoms exacerbation- when symptoms come back and maybe get worse |
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cutaneous or superficial pain |
skin, paper cut, tend to be pretty painful due to nerve endings right there |
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somatic pain |
tendons, ligaments, nerves, vessels, bones diffuse pain, scattered |
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visceral pain |
originating from body organs, poorly localized, |
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referred pain |
perceived in an area that is distant from where the injury is myocardial infraction |
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neuropathic pain |
injury to peripheral or central nerves pain from neck from compression of vertebrae, pain may also be in areas innervated by vertebrae |
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intractable pain |
can't get down to goal of pain aggreed upon with the patient |
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psychogenic pain |
no physical cause of pain, but has psychological origin |
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is response to pain sympathetic or parasympathetic |
sympathetic, unless for very sustained |
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psychological responses |
withdrawn, anxious, fearful, angry, tired, depressed etc. |
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COLD ERA mnemonic to assess pain |
Character of the complaint/ pain Onset of the symptom Location of the complaint Duration of the problem Exacerbated by what Relieved by what Associated symptoms problem |
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OLD CARTs mnemonic to assess pain |
Onset Location Duration Character Aggravating factors/ associated symptoms Relieving factors Temporal factors Severity |
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other pain assessment tools |
Wong Baker FACES Pain Rating Scale 0-10 numeric visual analogue scale abbey pain scale |
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Wong Baker FACES scale |
language barrier, can't read, old adults, young children. point to smiley faces, has multiple languages, talks about how much pain is interfering with function (concentration) |
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numeric scale |
10 being most 0 being fine has a color scale on the chart |
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visual analog scale |
mark where their pain is on a scale, a little bit vague and harder to interpret because their isn't anything quantible from it |
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abbey pain scale |
dementia patients who can't verbalize are they vocalizing if they are having pain- give them a number based on what it is is there a change in body languages/ facial expressions behavior changes physiological changes (sympathetic nervous system) physical changes |
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TENS |
transcutaneous electrical nerve stimulation alternative to using an analgesic |
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4 different NANDA diagnosis for pain |
acute postoperative, pain (name site) (leg pain), pain, chronic pain |