Nurs 111 - Unit 1

Front 1

Nursing Process

Back 1

A D P I E

Hint 1

Approach to Identify, diagnose, and treatment of responses to illnesses

Front 2

Assessment

Back 2

Deliberate and systematic collection of data to determine a patient’s current and past health status, functional status, and present and past coping patterns

Hint 2

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

Front 3

Diagnosis

Back 3

Nursing Diagnosis is a clinical judgment/description about individual, family, or community response to an actual and potential health problem or life process

Hint 3

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

Front 4

Planning

Back 4

Identify a set of Patient Goals, expected outcomes, prescribe nursing interventions and set priorities for a patient

Hint 4

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’

Front 5

Implementation

Back 5

Describes the performance of a nursing intervention (any treatment, based on clinical judgment that a nurse performs to enhance patient outcomes)

Hint 5

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’

Front 6

Evaluation

Back 6

examination of events to see if expected outcome occurred.

Hint 6

Collection of data to determine if you met the criteria or standards, interpring your findings, summarizing and documenting findings, and revising the care plan

Front 7

Types of Data

Back 7

Complete
Episodic
Follow Up
Emergency database

Front 8

Eight Attributes for Symptom Analysis

Back 8

PQRST

Hint 8

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

Front 9

Methods of Physical Examination

Back 9

Palpation
Percussion
Auscultation

Front 10

Palpation

Back 10

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

Front 11

Percussion

Back 11

striking using a stationary hand and striking hand
Resonant
Hyperresonant
Tympany
Dull - over organs
Flat - over bone

Dense sounds = over air
Empty sounds = clear

Front 12

Auscultation

Back 12

Diaphragm = high pitch noises.
Best for breath, lungs and bowel sounds

Bell = low pitch sounds
Best for vascular sounds and certain heart conditions

Front 13

Types of Data

Back 13

Subjective = Symptom (what patient says)
Objective = Sign (data, labs, observable characteristics)

Front 14

Types of Interviews

Back 14

Directed : Nurse directs interview. Use of close ended questions

Indirect: Patient directs. Use of open ended questions

Front 15

Temperature

Back 15

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

Hint 15

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

Front 16

Fever

Back 16

persistent high temp.
One episode of a high temp reading is not a fever it is an elevated temp

Hint 16

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!

Front 17

BMI

Back 17

BMI = weight(lbs) x 703
_____________________
Height (inches) squared

Need to know how to calculate BMI

Hint 17

Underweight < 18.5
Normal BMI 18.5 – 24.9
Overweight 25 – 29.9
Obsese > 40

Front 18

Respirations

Back 18

Ratio of pulse rate to respiration 4:1

Normal rate for age group adult 10-20

Front 19

Pulse

Back 19

Normal rate for age group adult 60-100

Front 20

Bradycardia

Back 20

under 60 (athletes are consistently lower because the muscle is more conditioned so one contraction is more efficient for distributing blood efficiently)

Front 21

Tachycardia

Back 21

over 100

Front 22

Pre-hyper tension

Back 22

120 -139
_________
80-89

Front 23

Hypertension

Back 23

>160
_________
100

Hint 23

As noted in class we do not need to know stage 1 or 2 hyper tension. Just pre hypertensive and hypertension

Front 24

BP (too small cuff or too large?)

Back 24

Too small of a cuff- reading too high
Too large of a cuff- reading too low

Front 25

Kartkoff Sounds

Back 25

1. Tapping

Ausculatory Gap

2. Swooshing
3. Knocking
4. Abrupt muffling
5. Silence

Front 26

Orthostatic hypotension

Back 26

low BP from sitting or standing

Hint 26

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

Front 27

Neurological Levels of Consciousness

Back 27

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

Hint 27

Oriented to
1. Time
2. Place
3. Familiar Person
4. Self

Front 28

Neurological Levels of Consciousness

Alert

Back 28

awake, easily aroused

Hint 28

Oriented to
1. Time
2. Place
3. Familiar Person
4. Self

Front 29

Neurological Levels of Consciousness

Lethargic

Back 29

not fully alert, drifts off when not stimulated

Hint 29

Oriented to
1. Time
2. Place
3. Familiar Person
4. Self

Front 30

Neurological Levels of Consciousness

Obtunded

Back 30

sleeps most times, difficult to arouse

Hint 30

Oriented to
1. Time
2. Place
3. Familiar Person
4. Self

Front 31

Neurological Levels of Consciousness

Stupor

Back 31

need persistent loud noise or pain arousal responds to stimuli

Hint 31

Oriented to
1. Time
2. Place
3. Familiar Person
4. Self