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31 Cards in this Set

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Nursing Process
A D P I E
Approach to Identify, diagnose, and treatment of responses to illnesses
Assessment
Deliberate and systematic collection of data to determine a patient’s current and past health status, functional status, and present and past coping patterns
establishes base of data including Subjective(what the patient says), Objective Data(measurable data, i.e. lab results) , health history,

Nursing Process of Assessment: Collect Data
• Interview
• Health History
• Physical Exam
• Functional Assesment
Consultation
Diagnosis
Nursing Diagnosis is a clinical judgment/description about individual, family, or community response to an actual and potential health problem or life process
EX: Acute pain related to surgical wound as evidence by patient verbalizing pain of 8 on 10 scale

NANDA Diagnosis
Activity intolerance
Noncompliance
Nausea
Constipation

Nursing Diagnosis must include a Related Factor: I.e. Activity intolerance related to pain as evidenced by a pain scale indicated at 8 out 0f 10

Systematic, deliberate collection of data
Nursing v.s Medical diagnosis
Planning
Identify a set of Patient Goals, expected outcomes, prescribe nursing interventions and set priorities for a patient
Goals and Outcomes should be measurable, time limited (this will occur within 3hrs or days, etc), realistic and mutual factors

Goals should be measurable and quantative. i.e. “Patient will b describe three benefits from progressive exercise”

Expected Outcome is a specific measurable change in patient’s status that you would expect to occur in response to nursing care. Again, this is measurable.
i.e. “ambulate patient in hall 3 times a day’
Implementation
Describes the performance of a nursing intervention (any treatment, based on clinical judgment that a nurse performs to enhance patient outcomes)
Direct Care Interventions: treatments performed through interactions with patients
• ADLS
• Lifesaving measures
• Controlling for adverse reactions
• Counseling, teaching,
• Preventative measures
Indirect Care Interventions: treatments performed away from but on behalf of patient
• Giving report to next shift
• Delegate the right tasks, get referrals to PT,etc

EX: if the diagnosis is ‘activity’ intolerance the intervention is ‘body mechanics and exercise promotion’
Evaluation
examination of events to see if expected outcome occurred.
Collection of data to determine if you met the criteria or standards, interpring your findings, summarizing and documenting findings, and revising the care plan
Types of Data
Complete
Episodic
Follow Up
Emergency database
Eight Attributes for Symptom Analysis
PQRST
Provokes and Pallative : when did you notice? What makes it better?
Quality and Quantity: How does it look? How bad is it?
Region: Where?
Severity: intensity?
Timing: onset, duration, frequency
Methods of Physical Examination
Palpation
Percussion
Auscultation
Palpation
use of finger pads to asses skin

Light Palpation assesses moisture, texture

Deep Palpation assesses organ borders

Texture
Rigidity
Temp
Crepition
Moisture
Presence of mass or lump
Organ Size and location
Prescence of tenderness or pain
Swelling
Vibration
Percussion
striking using a stationary hand and striking hand
Resonant
Hyperresonant
Tympany
Dull - over organs
Flat - over bone

Dense sounds = over air
Empty sounds = clear
Auscultation
Diaphragm = high pitch noises.
Best for breath, lungs and bowel sounds

Bell = low pitch sounds
Best for vascular sounds and certain heart conditions
Types of Data
Subjective = Symptom (what patient says)
Objective = Sign (data, labs, observable characteristics)
Types of Interviews
Directed : Nurse directs interview. Use of close ended questions

Indirect: Patient directs. Use of open ended questions
Temperature
Influences on temp
Diurnal cycle (patterns of activity or behavior that follow day-night cycles, i.e, breakfast, lunch, dinner schedules)
Menstrual cycle
Exercise
Age
Routes of temp measurement
Oral
Electronic Thermometer
Most accurate method of temp taking is

Axillary temp--- when you document temp, document the actual temp … write 98.6 but you read it in your head as adding a degree b/c skin temp

Rectal for ped is the most accurate method of temp taking
Tmpyanic reads low, if it reads high
Fever
persistent high temp.
One episode of a high temp reading is not a fever it is an elevated temp
Hyperthermia = fever
Hypothermia – prolonged exposure to cold, or purposefully induced to lower body’s oxygen requirements during heart surgery, neurosurgery or gastrointestinal hemorrhage. This comes up in NCLEX questions all the time!
BMI
BMI = weight(lbs) x 703
_____________________
Height (inches) squared

Need to know how to calculate BMI
Underweight < 18.5
Normal BMI 18.5 – 24.9
Overweight 25 – 29.9
Obsese > 40

Respirations
Ratio of pulse rate to respiration 4:1

Normal rate for age group adult 10-20
Pulse
Normal rate for age group adult 60-100
Bradycardia
under 60 (athletes are consistently lower because the muscle is more conditioned so one contraction is more efficient for distributing blood efficiently)
Tachycardia
over 100
Pre-hyper tension
120 -139
_________
80-89
Hypertension
>160
_________
100
As noted in class we do not need to know stage 1 or 2 hyper tension. Just pre hypertensive and hypertension
BP (too small cuff or too large?)
Too small of a cuff- reading too high
Too large of a cuff- reading too low
Kartkoff Sounds
1. Tapping

Ausculatory Gap

2. Swooshing
3. Knocking
4. Abrupt muffling
5. Silence
Orthostatic hypotension
low BP from sitting or standing
Lying- rest for 2-3 minutes
Sitting, standing

Normal – less than 10mm Hg drop in systolic value or pulse increase more than 20bpm
Abnormal – more than a 20mm Hg drop in systolic value or pulse increase more than 20 bpm
Abrupt peripheral vasodilatation
Neurological Levels of Consciousness
Alert = awake, easily aroused
Lethargic = not fully alert, drifts off when not stimulated
Obtunded = sleeps most times, difficult to arouse
Stupor = need persistent loud noise or pain arousal responds to stimuli
Oriented to
1. Time
2. Place
3. Familiar Person
4. Self
Neurological Levels of Consciousness

Alert
awake, easily aroused
Oriented to
1. Time
2. Place
3. Familiar Person
4. Self
Neurological Levels of Consciousness

Lethargic
not fully alert, drifts off when not stimulated
Oriented to
1. Time
2. Place
3. Familiar Person
4. Self
Neurological Levels of Consciousness

Obtunded
sleeps most times, difficult to arouse
Oriented to
1. Time
2. Place
3. Familiar Person
4. Self
Neurological Levels of Consciousness

Stupor
need persistent loud noise or pain arousal responds to stimuli
Oriented to
1. Time
2. Place
3. Familiar Person
4. Self