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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.
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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.
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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.
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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.
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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.
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nursing process
systematic, rational method of planning and providing individualized nursing care.
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initial assessment
performed within specified time after admission
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problem-focused assessment
ongoing process integrated with nursing care
-
emergency assessment
during any physiological or psychological crisis
-
time lapses reassessment
several months after initial assessment
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Subjective data
- AKA symptoms, verified only by the person affected
- "i feel weak all over"
- "i feel sick to my stomach"
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Objective data
- AKA signs can be seen
- BP 90/50
- Resp. 20
- Abdomen distended
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mydriasas
enlarged pupils
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miosis
constricted pupils
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nystagmus
rapid involuntary rhythmic eye movement
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otoscope
instrument for examining the interior of the ear
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Low set ears are associated with:
Down syndrome
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Straighten ear canal of an adult by pulling the pinna:
up and back
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adventitious breath sounds
occur when air passes through narrowed airways or airways filled with fluid or when pleural linings are inflamed.
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vesicular
soft-intensity, low pitched "gentle sighing sound created by air moving through smaller airways
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Broncho-vesicular
moderate intensity and moderate pitched blowing sounds created by air moving through larger airway
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bronchial (tubular)
high pitched, loud, harsh sounds created by air moving through the trachea
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crackles
fine, short, interrupted crackling sounds
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gurgles
continuous, low pitched, coarse, gurgling, harsh, louder sounds
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friction rub
superficial grating or creaking sounds heard during inspiration and expiration.
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wheeze
continuous, high pitched, squeaky musical sounds.
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S1 occurs when:
"lub" AV vales close
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S2 Occurs when:
"dub"semilunar valves close
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What is bruit?
A blowing or swishing sound, suggest's occlusive artery disease.
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What is bradycardia?
HR under 60 bpm.
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What is tachycardia?
HR over 100 bpm.
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Organs in RUQ
- liver
- gallbladder
- duodenum
- Hepatic flexure of colon
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Organs in LUQ
- stomach
- spleen
- pancreas
- left adrenal gland
- splenic flexure of colon
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Organs in LLQ
sigmoid colon
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active bowel sounds occur:
about every 5 to 20 seconds
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atrophy
a decrease in size
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hypertrophy
an increase in size
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