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HUMAN RESPONSE TO A HEALTH CONDITION OR LIFE PROCESS THAT IS HAPPENING AT THE PRESENT TIME
THE SYSTEMATIC AND ONGOING COLLECTION OF COMPREHENSIVE DATA RELEVANT TO A PATIENT HEALTH OR TO THE SITUATION INFLUENCING THEIR HEALTH
NURSING INTERVENTIONS THAT ARE ORDERED BY A PHYSICIAN OR CARRIED OUT UNDER A PHYSICIANS SUPERVISION FOR THE TREATMENT OF A MEDICAL DIAGNOSIS
A CLINICAL JUDGMENT ABOUT THE CLIENTS RESPONSE TO ACTUAL OR POTENTIAL HEALTH CONDITIONS OR NEEDS
EMERGENCY NURSING ASSESSMENT
THE DATA COLLECTION PROCESS THAT OCCURS IN A LIFE THREATENING SITUATION
THE PROCESS OF DETERMINING BOTH THE PROGRESS TOWARDS ATTAINMENT OF THE EXPECTED OUTCOMES AND THE EFFECTIVNESS OF NURSING CARE
FOCUSED HEATH DATA ASSESSMENT
THE PERFORMANCE OF SELECTED PORTIONS OF THE PATIENTS HISTORY AND EXAMINATION PROCESS WHENEVER SPECIFIC CONDITIONS WARRENT THIS ACTION
THE PROCESS OF CARRYING OUT THE PLAN OF CARE WHICH MAY INCLUDE PROVIDING,MONITORING, DELEGATING, COORDINATING, TEACHING, AND/OR COUNSELING
NURSING INTERVENTIONS THAT ARE INICIATED BY THE NURSE AND THAT ADDRESS THE NURSING DIAGNOSIS
MASLOWS HIERARCHY OF NEEDS
A TOOL FOR PRIORITIZING NURSING DIAGNOSIS. ACCORDING TO THIS HIERARCHY A PATIENTS BASIC PHYSICAL NEEDS MUST BE MET BEFORE THEIR SAFETY NEEDS, THEN SOCIAL NEEDS, THEN ESTEEM NEEDS, THEN SELF ACTUALIZATION NEEDS
THE PROTECTION, PROMOTION, AND OPTIMIZATION OF HEALTH AND ABILITIES. THE PREVENTION OF ILLNESS OR INJURY, ALLEVIATION OF SUFFERING THROUGH THE DIAGNOSIS AND TREATMENT OF HUMAN RESPONSE AND ADVOCACY IN THE CARE OF INDIVIDUALS, FAMILIES, COMMUNITIES, AND POULATIONS
A PROCESS FOR THE DELIVERY OF NURSING CARE THAT INVOLVES THE FOLLOWING STEPS- ASSESSMENT,DIAGNOSIS, OUTCOMES IDENTIFICATION, PLANNING, IMMPLEMENTATION, AND EVALUATION
SIGNS OR OBSERVATIONS MADE DIRECTLY BY THE NURSE THAT ARE CAPABLE OF BEING VERIFIED BY SOMEONE ELSE
AN EXAMINATION OF QUALITY INDICATORS SUCH AS NUMBER OF PATIENT FALLS, NUMBER OF PRESSURE ULCERS FORMED, NUMBER OF POST OPERATIVE INFECTIONS, AND NUMBER OF TUBE FEEDER RESIDENTS DEVELOPING ASPIRATION PNEUMONIA
WRITTEN INSTRUCTIONS DESIGNED TO ADDRESS A COMMONLY OCCURING PROBLEM IN AN INSTITUTIONALLY APPROVED MANNER
INSITUTIONALLY APPROVED, PREPRINTED, DETAILED INSTRUCTION ON HOW TO PERFORM SPECIFIC CLINICAL TASKS
THE APPROPRIATENESS OF THE CARE GIVEN AND WHETHER POLICIES AND PROCEEDURES WERE FOLLOWED TO MAXIMIZE PATIENT SAFETY, MINIMIZE MEDICATION ERROR, MINIMIZE INFECTOUS CONTAMINATION, AND ENSURE THAT PATIENTS AND FAMILIES FEEL WELCOME
INSTITUTIONALLY APPROVED PREPRINTED INSTRUCTIONS GOVERNING INTERVENTIONS OR ACTIONS TO BE TAKEN IN THE CARE OF GROUPS OF PATIENTS WITH PARTICULAR PROBLEMS
METHODS THAT FOCUS ON DIAGNOSING SYSTEM PROBLEMS AND SUGGESTING INTERVENTIONS TO ADDRESS THOSE PROBLEMS
THOSE VARIABLES THAT INCREASE A PATIENTS VUNERABILITY TO DEVELOPING AN ACTUAL NURSING DIAGNOSIS
INSTITUTIONALLY AND DEPARTMENTALLY APPROVED INSTRUCTIONS INSTRUCTIONS GRANTING THE NURSE THE AUTHOIRITY TO ACT IN THE ABSENCE OF A PHYSICIAN
EVALUATION OF PATIENT OUTCOMES PRIOR TO DISCHARGE OF THE PATIENT FROM THE HOSPITAL OR PRIOR TO A CASE BEING CLOSED IN A COMMUNITY SETTING
TIME-LAPSED NURSING ASSESSMENT
A REPEATED ASSESSMENT OBTAINED TO COMPARE DATA COLLECTED AT ONE OR MORE POINTS IN TIME WITH BASELINE DATA
Identify and explain the six components of the nursing process.
The six components of the nursing process include assessment, diagnosis, outcomes
identification, planning, implementation, and evaluation. Assessment refers to a
systematic and ongoing collection of comprehensive data relevant to a patient's health or
to the situation or ambience influencing the patient's health. Diagnosis is a clinical
judgment about the client's response to actual or potential health conditions or needs.
The diagnosis provides the basis for determination of a plan of care to achieve expected
outcomes. Expected care outcomes are individualized according to the patient's
presenting needs or diagnoses or to the situation in which the patient is found. To
achieve expected outcomes, the registered nurse develops a plan of care and prescribes
strategies designed to achieve the expected outcomes. This plan of care is also
diagnostic-specific. Implementation may include any or all of these activities: providing,
monitoring, delegating, coordinating, teaching, and counseling. Evaluation is the process
of determining both the client's progress toward the attaining of expected outcomes and
the effectiveness of nursing care.
Explain the American Nurses Association (ANA) standards of professional performance.
The American Nurses Association Social Policy Statement includes ten standards of
professional performance that include eithics, education, evidence bassed practice and research, quality of practice, communication, leadership,collaberation, professional practice evaluation, resource utilization, enviromental health
The ethical principles underlying nursing practice are
1. Do no harm.
2. Benefit others.
3. Be loyal to the patients, the profession, and self.
4. Be truthful.
5. Promote social justice.
6. Discern ethical issues that relate to the changing context of health care.
7. Respect the autonomy of the patient and the nurse.
Performing selected portions of the history and examination is called a focused health
data assessment. A focused health data assessment is performed when patient complains
of a new or changed symptom; new or changed sign occurs; laboratory, telemetry,
electrocardiogram, or X ray results indicate a change in the patient's health status; new or
changed nursing diagnosis is being considered; or particular diagnosis requires the
frequent assessment of repeated measures, monitoring, or vigilance. Focused
assessments are one of the primary tools by which nurses nurture and sustain life, initiate
vigilance and surveillance methods, and contribute to the success of the health care team.
An emergency nursing assessment refers to the data collection process that occurs in a
life-threatening situation. A time-lapsed nursing assessment is a repeated assessment
obtained to compare data collected at one or more points in time with baseline data.
Data is initially collected upon admission of a patient to a hospital or extended care
facility or upon a first encounter with a patient in a home or primary care setting. This is
called assessment data. An initial assessment includes a nursing history
demographic information to obtain when assessing patient
Name, address, phone numbers, persons to contact in an emergency, age,
sex, marital/family status, occupation, religious preference, health insurance,
and health care providers (primary care and/or specialists)
What information should you obtain when getting the Presenting
Onset (When did the problem begin? Suddenly? Gradually?)
Precipitating factors (What were you doing when the problem began?)
Description (How would you describe it?)
Location (Where is the pain, discomfort, difficulty? Does it radiate?)
Duration (How long did it last?)
Timing (Is the problem continuous, intermittent, occasional?)
Frequency (How often has it occurred in the past hour, day, week,
Intensity or severity (On a scale of 1-10, in which 1 is the least amount
of discomfort/pain and 10 is the greatest amount of discomfort/pain you
can tolerate, how severe would you say your pain is? [Note that
children and some adults may not be able to translate their discomfort
into numerical values. In such cases, the nurse may quote the exact
words of the patient or ask the patient if it is slight, moderate, severe, or
Associated signs or symptoms (Do you experience any other difficulties
or problems when the problem occurs? For example, nausea and
vomiting commonly occur in the presence of a migraine headache. Or,
shortness of breath may occur with angina or the pain of myocardial
Factors associated with its worsening (Have you noticed anything that
makes the problem worse for you? For example, light worsens
migraine pain; exercise worsens angina.)
Factors associated with its relief (Is there anything you do that helps
relieve the problem?)
history information to obtain includes
Allergies; past illnesses/hospitalizations, including childhood;
immunizations, including childhood; accidents/injuries; surgeries;
medications (prescribed/over-the-counter/food supplements); abuse (as child
or as adult, domestic or other)
Distinguish between primary, secondary, objective, and subjective data.
Data that the nurse derives directly from interaction with the patient is called primary
data and is either subjective or objective data. Subjective data relies on a conscious
patient providing a narrative statement or report, such as, "I feel nauseated." Signs or
observations made directly by the nurse that are capable of being verified by another are
called objective data. Thus, cyanosis is a sign that a nurse observes that can be
objectively verified by another. Data derived from all other sources is called secondary
data. Sources of secondary data are the patient's family and friends; other nurses and
health professionals on the patient's health care team; the clinical record, including
laboratory reports and reports of the results of diagnostic procedures; and relevant
literature (such as published protocols, standards, guidelines, classification manuals,
reference manuals, or articles) related to the patient's condition.
Explain how to validate and properly document data
Only valid data is documented. For data to be valid, it must be accurate, complete, and
factual. It is critical that data be accurate. Modifiers such as small, medium, and large
may be used only when a more accurate measure is unavailable. When measurements are
used, such as blood pressure measurement, care must be taken to avoid errors. To
increase the accuracy of data, quantify or specify observations when possible. For
example, when obtaining information about appetite, quantify the amount eaten, such as
"The patient ate 50 percent (or 25 percent, 75 percent, or 100 percent, whichever is most
accurate) of the food served." Another way of accurately recording appetite is to specify the precise foods eaten, such as one bowl of cereal, two pieces of toast, and a glass (240
ml) of milk. Relevant interview data must be recorded completely. Documentation must
be factual. Recording "slept well" is an assumption that may or may not be factual. For
example, if the patient required observation at two-hour intervals only, then the nurse
does not know if the patient slept well throughout the night. In this case, the nurse only
knows that the patient was sleeping at the time the observations were made.
Prioritize nursing diagnoses according to Maslow's hierarchy of needs
Some diagnoses have a higher priority than others and must be addressed before
diagnoses with a lower priority. For example, a patient's ineffective breathing pattern
must be addressed before a patient's body image disturbance is addressed. According to
Maslow's hierarchy, physical needs are the most basic of needs. These are the needs
most immediately concerned with survival, e.g., oxygen, circulation of blood, water,
food, and sleep. Those needs directed to maintaining threatened safety have the next
highest priority. Examples of these diagnoses include risk for injury, risk for aspiration,
and risk for violence directed toward self or others. After physical and safety needs have
been met, treatments that address diagnoses that center on love and belonging have the
next highest priority. Examples of these needs include risk for loneliness, impaired social
interaction, or altered parenting. Self-esteem needs represent the fourth level in
Maslow's hierarchy of needs. Related nursing diagnoses are self-esteem disturbance,
chronic low self-esteem, and situational low self-esteem. Self-actualization represents
the fifth and last level of needs in Maslow's hierarchy. Diagnoses that address the human
spirit operate on this level. These diagnoses include risk for spiritual distress and
potential for enhanced spiritual well-being.
Formulate patient goals and expected outcomes.
Outcomes should be individualized according to the patient's presenting needs or
diagnoses or to the situation in which the patient is found. The nurse should devise
expected outcomes that involve the patient and the patient's family; are culturallysensitive; take into account associated risks, benefits, and costs; have an appropriate time
frame; are ethical and consistent with the patient's values and belief system; are able to
be modified when the patient's condition changes; and can be documented as measurable
Patient goals are patient-centered, future-oriented, and action/direction-oriented. Because
goals are patient-centered, they are always expressed in terms of patient goals to be
achieved and not in terms of the nurse's work goals. Because patient goals are future
oriented, they are expressed in the future tense, most often using the verb "will."
Because goals are action oriented, verbs that express an action or a behavior, such as
achieve, maintain, walk, and cough, are used to refer to these goals.
Identify and develop appropriate nursing orders
Nursing orders (or strategies) are used to achieve patient outcomes once they have been
identified. The orders need to be individualized for the patient; developed in conjunction
with the patient; be diagnostic-specific with a set of strategies written for each diagnosis;
provide for continuity of care; include a pathway or a timeline for goal achievement;
prioritize diagnoses and strategies appropriately; available for communication with and
use by other members of the health care team; take economic impacts into consideration;
rely on standardized language; and be written precisely.
Distinguish between dependent, independent, and collaborative nursing interventions
Nursing interventions may be independent or nurse-initiated when they address nursing
diagnoses. Examples of independent interventions include repositioning a patient in bed
who is at risk of impaired skin integrity or who has an ineffective breathing pattern.
Dependent interventions are ordered by a physician or carried out under a physician's
supervision for the treatment of a medical diagnosis. Administration of medication is an
example of a dependent nursing intervention. Collaborative interventions are those
developed in conjunction with other health professionals such as physicians, social
workers, and other nurses. For example, physicians treat medical diagnoses, and each
medical diagnosis is associated with certain disease complications.
Distinguish between delegating authority to assistive personnel and retaining
responsibility for tasks delegated.
While a registered nurse may delegate care (such as morning care) to assistive personnel
(licensed practical nurses and unlicensed nursing assistants), the registered nurse remains
accountable for the outcome of that care. While a registered nurse may assign tasks (such
as vital sign measurement) to assistive personnel, the registered nurse cannot assign
responsibility for those tasks to the assistive personnel. The responsibility remains with
the professional nurse.
Develop expected and evaluate obtained outcomes that are diagnostic-specific
The nurse should continually evaluate progress toward the attainment of outcomes and
revise the diagnosis, outcomes, and plan of care as needed. The status of progress in
achieving the expected outcomes should be communicated appropriately to the patient,
the patient's family, and other providers involved in care of the patient.
A PATIENT ADMITTED WITH THE DIAGNOSIS OF PNEUMONIA NEEDS A FOCUSED ASSESSMENT AT LEAST EVERY TWO HOURS UNTIL THE CONDITION BEGINS TO IMPROVE. IDENTIFY THE STEPS IN THAT ASSESSMENT
VITAL SIGNS: BLOOD PRESSURE, HEART RATE, RESPIRATORY RATE, TEMPERATURE
COMFORT OR DISTRESS, ASK THE PATIENT ABOUT ANY IMPROVEMENT OR DECLINE, BE SPECIFIC ABOUT BREATHING COUGHING SHORTNESS OF BREATH FATIGUE AND ANXIETY. ASK ABOUT SPUTUM COLOR PRODUCTION AND HEMOPTYSIS. IF SPUTUM IS AVAILABLE OVSERVE COLOR, AMT,CONSISTANCY. EMPTY CUP SO THE NEXT TWO HOURS CAN BE OBSERVED.
OBJECTIVE DATA TO OBSERVE WITH DX OF PNEUMONIA
INSPEC CIRCUMORAL COLOR, QUALITY AND DEPTH OF RESPIRATIONS, CHEST EXCURSION, INTERCOSTAL AND SUPRACLAVICULAR MOVEMENT, WATCHING FOR RETRACTION
PALPATATION- CHECK OR FREMITIUS
PERCUSION- CHECK FOR DULNESS AND COMPARE LUNG FIELDS. ESPECIALLY NOTE A DIFFERENT PITCH AT LEVEL OF RIGHT LOWER LOBE
AUSCULTATION- ANY AUDIBLE WHEEZING? AUSCULTATE TRACHEA AND BRONCHIAL AREAS
HOW DOES A FOCUSED ASSESSMENT AFFECT THE PATIENTS NURSING DIAGNOSIS
DIAGNOSIS MAY STAY THE SAME. DIAGNOSIS MAY IMPROVE OR WORSEN, OR NEW DIAGNOSES MAY BE ADDED
INVOLVES SELECTING OUTCOMES THAT ARE OUTCOME IDENTIFICATION IS FRAMED AS PATIENT GOALS. BOTH THE PATIENT GOALS AND OUTCOMES ARE SPECIFIC TO THE NURSING DIAGNOSIS UNDER CONSIDERATION
PLANNING INVOLVES PRESCRIBING STRATAGIES DESIGNED TO ACHIEVE THE EXPECTED OUTCOMES. THESE STRATAGIES ARE ALSO DIAGNOSIS SPECIFIC
ON WHAT BASIS WOULD YOU ASSIGN TASK TO A NURSING ASSISTANT AND A LPN
ASSIGN ACTIVITIES OF DAILY LIVING TO NURSING ASSISTANTS AND ASSIGN PROCEEDURES FOR WHICH THE PRACTICAL NURSE IS EDUCATED
HOW DO YOU EVALUATE OUTCOMES
COMPARE THE EXPECTED AND THE ATTAINED OUTCOMES. IF THE EXPECTED OUTCOME WERE ATTAINED THIS IS IDEAL. HOWEVER IF THEY ARE NOT CHECK THE ACCURACY OF THE MEASURES. IF THE MEASURES WERE ACCURATE, REACESS THE PATIENT. CONSIDER THE EFFECTIVNESS OF THE INTERVENTION AND CHANGE OR ADJUST TO OBTAIN THE DESIRED OUTCOME. INDIVIDUALIZE FOR EACH PATIENT.
A model of health, wellness, and illness that views health as adaptation to the physical and social world in which a person lives and disease as maladaptation to this world.
The flight or fight response, which is the first portion of the
response-based stress model and is mediated by the sympatheticnervous system.
Listening to sounds emitted from the patient's heart, arteries, respiratory tract, or intestinal tract, typically through use of a stethoscope.
A process by which the body learns to bring autonomic nervous system responses under its control.
A model of health, wellness, and illness that narrowly defines health as the absence of disease.
A form of imagery that involves the creation of realistic images that are physically and physiologically correct.
The second phase of the alarm reaction, during which the
physiologic changes that occurred during the shock phase reverse themselves.
END STATE IMAGERY
A form of imagery that involves picturing the final state of a process or situation.
A model of health, wellness, and illness that focuses on health as well-being, self-fulfillment, and self-actualization
The final phase of the response-based stress model, which occurs if the resistance phase is unsuccessful; during this phase, the body either rests and recovers, or death occurs.
general adaptation syndrome (GAS)
The bodily response to stress that involves the adrenal and lymphatic structures and the gastrointestinal tract.
local adaptation syndrome (LAS)
A bodily response to stress that involves only one organ acting alone.
Touching the patient with the pads of the fingers to detect
vibrations or discriminating changes in texture or consistency.
A stress-reducing technique in which the patient progressively tenses and relaxes each muscle group, concentrating on the differences between feelings of tension and feelings of relaxation.
The phase of the response-based stress model during which the body attempts to cope with the stressor.
response-based stress model
The model of stress and adaptation in which stress is considered to be a response.
role performance model
A model of health, wellness, and illness that views health in functional terms; here, if a person can function, he or she is healthy
The first phase of the alarm reaction, during which epinephrine and cortisone are released and the body prepares itself for flight or fight.
stimulus-based stress model
The model of stress and adaptation in which stress is defined as a stimulus.
The forces or stimuli that impinge upon an individual; also, an individual's response to these forces.
A form of imagery that involves picturing an abstract situation in order to symbolically represent a real-life situation.
Restoring, maintaining, and maximizing health and optimizing functioning in the later stages of illness or disease.
transaction-based model of stress
The model of stress and adaptation in which a person's response to an environmental stimulus is either blocked or facilitated by a variety of factors, such as the sensitivity of the person to stress and the person's vulnerability at any one point in time.
EXAMPLE OF COMPENSATING
A STUDENT WHO DOES POOR WITH DRAMA MAY OVER COMPENSATE BY EXCELLING IN DEBATE
ASSUMING AND ACCEPTING THE VALUES OR NORMS OF OTHERS AS THEIR OWN. EXAMPLE: A TWO YEAR OLD TEACHING YOUNGER SIBBLING TO SAY PLEASE AND THANK YOU.
FAILING TO ASSUME ONES RESPONSIBILITY . EXAMPLE: THE SLEEPY DRIVER THAT SAYS I WASNT ASLEEP I WAS JUST
How do you assess the Olfactory Nerve one
Occlude one nostril and ask patient to inhale through other nostril. Repeat with other nostril.
Ask patient to smell and identify familiar smells (coffee, vanilla, peppermint).
How do you assess the Optic Nerve two?
Snellen Test (for far sight) and Rosenbaum Test (for near sight).
Also test for pupil constriction using your pen light.
How do you assess the Oculomotor Nerve three
Test pupil constriction using your pen light.
Ask patient to raise and lower eyelids
(open and close eyes).
looking down is controlled by oculomotor nerve
How do you assess the Trochlear Nerve four
Administer the Convergence Test.
(Ask patient to follow your pen with their eyes as you move it toward their nose and then down.)
looking up and out
How do you assess the Trigeminal Nerve five
Ask patient to clench jaw.
Use fingertip or penlight to lightly stroke forehead and cheeks and ask patient to identify where on their face they are being touched.
How do you assess the Abducens Nerve six
Administer the Six Cardinal Gazes.
looking outward with eyes
How do you assess the Facial Nerve seven
inspect the symmetrical alighnment of face, mouth, and lips, first while pt at rest and then while attempting to smile or whistle. while inspecting for symmetry close eyes tightly
How do you assess the Auditory Nerve eight
Whisper Test: Ask patient to cover left ear. Stand to right of patient, out of view, about a foot away, and whisper. Have patient repeat what you said. Same for other ear.
Administer Weber and Rinne tests
ask patient if they have had any ringing dizziness vertigo nausea or vomiting
How do you assess the Glossopharyngeal Nerve nine
Ask patient to open their mouth and say, "Ahh," and use the depressor to test their gag reflex by stroking the posterior 2/3 of their tongue or give pt something to taste something
Note the ability to swallow.
How do you assess the Vagus Nerve ten
Note patient's ability to speak and swallow.
(Often can be observed throughout interview and when assessing the Glossopharyngeal Nerve.)
How do you assess the Spinal Accessory Nerve eleven?
Ask the patient to shrug their shoulders. Then push down on their shoulders and have them shrug against resistance.
Ask the patient to turn their head to the left and to the right. Then push against their cheek while they turn against resistance.
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