West Coast University: NURS 100 Midterm Study Guide Latest updated 2022/2023,100%CORRECT
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Course
NURS 100
Institution
NURS 100
West Coast University: NURS 100 Midterm Study Guide Latest updated 2022/2023
1. Fall prevention:
- Patients are at risk for falls (dementia, Alzheimer’s, confusion, vision, HISTORY OF FALLS) Indications for risk for falls: yellow nametag, yellow signs. Patient safety #1
- When patient starts t...
west coast university nurs 100 midterm study guide latest updated 20222023
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West Coast University: NURS 100 Midterm Study Guide Latest
updated 2022/2023
1.Fall prevention:
- Patients are at risk for falls (dementia, Alzheimer’s, confusion, vision,
HISTORY OF FALLS) Indications for risk for falls: yellow nametag, yellow
signs. Patient safety #1
- When patient starts to fall, SLOWLY let them slide on the floor, close to
you.
2.Occult blood: test to see hidden blood in the stool (can send specimen
stool to lab to see if there is blood in the stool)
- Black stool indicates: iron consumption or food/medication
3.Nursing DX for sleep disorders or lack of sleep:
- Insomnia (inability to sleep)
- Sleep apnea (when sleeping, there is absence of breath. Use specific
CPAP machine to help you breath while asleep)
- Narcolepsy (can fall asleep anywhere)
- Sleep deprivation (lack of sleep)
4.Physical assessment:
(Why: to create plan of care)
*DOCUMENT EVERYTHING*
- Neurological system:
Visual assessment (look @ patients color, breathing pattern, face, posture
(brain stem abnormalities))
Introduce yourself
Determine LOC (x4= patient is alert/oriented (0-4))
- person (aware who they are?)
- event (where they are?)
- situation (who is the president of the USA?)
- time frame (what day is today? Or what
time is it?) Asking for patient’s identification, check for
level of consciousness
Pupils: Cranial nerve III (Oculomotor) responsible for pupil size and certain
movement of the eye (Brisk= rapid response where the pupils
constricts/dilates fast)
Cranial nerves
This study source was downloaded by 100000802531269 from CourseHero.com on 03-25-2023 16:42:37 GMT -05:00
, Masses on the head (Ex: bumps/ lumps)
Speech: Check for verbal communication, clear speech, and how they
respond (Ex. Stoke (slurred))
Vital signs & medical histories
- Eyes: First assessment
PERRLA (Pupils, Equal, Round, Reactive, to Light, Accommodation)
- Penlight (pupils will constrict and dilating)
This study source was downloaded by 100000802531269 from CourseHero.com on 03-25-2023 16:42:37 GMT -05:00
, - alter pupils: drugs, alcohol, stroke, brain damage
Cranial nerve: III (Oculomotor) responsible for pupil size and certain
movement of the eye
- Mouth & Tongue & Neck & Ears & Nose:
“AAHHH” checking if the Uvula wiggles (one of the cranial
nerves) moisture, don’t want it to be too dry
Teeth, missing tooth
tongue for any open
sores PINK tongue=
normal
NORSE & EARS: Check for any abnormal drainage,
objects NECK: check Lymph nodes
- Lungs:
Check for patients color, chest raising, respiration, O2 saturation, ask for
shortness of breathe
Listen to 6 anterior and 8 posterior (last 2 will be in the last two lower lobes)
Abnormal sounds= adventitious
Crackles = high pitched, sound like rice crispy (snap crackle
pop) can be heard with patients with pneumonia
Rhonchi = low pitched, sounds like SNORING; can be
heard with patients with COPD
Wheezing = musical; asthma patients
Stridor = see it more on children (choking)
- Heart:
Aortic, Pulmonic, ERB’s point, Tricuspid, Mitral (All People Enjoy Time
Magazine) Listening for LUB-DUB
S1 = Tricuspid & Mitral valves closing
(LUB) S2 = Aortic & Pulmonic valves
closing (DUB)
Aortic: 2nd Right ICS
Pulmonic: 2nd Left
ICS ERB’s: 3rd Left
This study source was downloaded by 100000802531269 from CourseHero.com on 03-25-2023 16:42:37 GMT -05:00
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