Unit 1

  1. Assessing
    • Collect Data
    • Organize Data 
    • Validate Data
    • &
    • Document Data
    • Purpose: To establish a database about the clients response to health concerns or illness and the ability to manage health care needs.
  2. Diagnosing
    • Analyze data
    • Identify health problems, risk & strengths
    • Formulate diagnostic statements
    • Purpose: To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions. To develop a list of nursing and collaborate problems.
  3. Planning
    • Prioritize problems/diagnoses
    • Formulate goals/desired outcomes
    • Select nursing interventions
    • Write nursing interventions
    • Purpose: To develop an individualized care plan that specifies client goals/desired outcomes, and related nursing interventions.
  4. Implementing
    • Reassess the client
    • Determine the nurses need for assistance
    • Implement the nursing interventions
    • Supervise delegated care
    • Document nursing activities
    • Purpose: To assist the client to meet desired goals/outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning.
  5. Evaluating
    • Collect data related to outcomes
    • Compare data with outcomes
    • Relate nursing actions to clients goals/outcomes
    • Draw conclusions about problem status
    • Continue, modify, or terminate the clients care plan
    • Purpose: To determine whether to continue, modify or terminate the plan of care.
  6. nursing process
    systematic, rational method of planning and providing individualized nursing care.
  7. initial assessment
    performed within specified time after admission
  8. problem-focused assessment
    ongoing process integrated with nursing care
  9. emergency assessment
    during any physiological or psychological crisis
  10. time lapses reassessment
    several months after initial assessment
  11. Subjective data
    • AKA symptoms, verified only by the person affected
    • "i feel weak all over"
    • "i feel sick to my stomach"
  12. Objective data
    • AKA signs can be seen
    • BP 90/50
    • Resp. 20
    • Abdomen distended
  13. mydriasas
    enlarged pupils
  14. miosis
    constricted pupils
  15. strabismus
  16. nystagmus
    rapid involuntary rhythmic eye movement
  17. otoscope
    instrument for examining the interior of the ear
  18. Low set ears are associated with:
    Down syndrome
  19. Straighten ear canal of an adult by pulling the pinna:
    up and back
  20. adventitious breath sounds
    occur when air passes through narrowed airways or airways filled with fluid or when pleural linings are inflamed.
  21. vesicular
    soft-intensity, low pitched "gentle sighing sound created by air moving through smaller airways
  22. Broncho-vesicular
    moderate intensity and moderate pitched blowing sounds created by air moving through larger airway
  23. bronchial (tubular)
    high pitched, loud, harsh sounds created by air moving through the trachea
  24. crackles
    fine, short, interrupted crackling sounds
  25. gurgles
    continuous, low pitched, coarse, gurgling, harsh, louder sounds
  26. friction rub
    superficial grating or creaking sounds heard during inspiration and expiration.
  27. wheeze
    continuous, high pitched, squeaky musical sounds.
  28. S1 occurs when:
    "lub" AV vales close
  29. S2 Occurs when:
    "dub"semilunar valves close
  30. What is bruit?
    A blowing or swishing sound, suggest's occlusive artery disease.
  31. What is bradycardia?
    HR under 60 bpm.
  32. What is tachycardia?
    HR over 100 bpm.
  33. Organs in RUQ
    • liver
    • gallbladder
    • duodenum
    • Hepatic flexure of colon
  34. Organs in LUQ
    • stomach
    • spleen
    • pancreas
    • left adrenal gland
    • splenic flexure of colon
  35. Organs in RLQ
    • cecum
    • appendix
  36. Organs in LLQ
    sigmoid colon
  37. active bowel sounds occur:
    about every 5 to 20 seconds
  38. atrophy
    a decrease in size
  39. hypertrophy
    an increase in size
Card Set
Unit 1
Nursing Essentials