Block 2

Nursing Process (describe)
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Terms in this set (28)
Nursing Process (describe)
Assessment-gathering information
Diagnosis-Identify the patient's problems
Planning- Set goals of care and desired outcomes and identify appropriate nursing actions.
Implementation-Perform the nursing actions
Evaluation-Determine if goals and expected outcomes are achieved
subjective data
verbal description of their health problems. Includes: feelings, perceptions, and self-reported symptoms.
objective data
findings resulting from using the 5 senses
Cultural competent care
removing bias and judgment while implementing norms to provide transcultural patient-centered care.
needed in documentation
Legal documentation, reimbursement, research, education, and communication.
acceptable ranges for vital signs (adult)
temp,pulse,pulse oximetry(spo2),respirations, blood pressure
temp-36 to 38 celcius (96.8 to 100.4 F)
oral temp- 37 C (98.6 F)
rectal temp- 37.5 C 99.5 F)
Axillary 36.5 C (97.7 F)

Pulse- 60-100/ min

Sp02 greater than or equal to 95%

respirations- 12-20

bp- anything lower than 120/80
Healthcare disparities
particular type of health difference that is closely linked with social, economic, and/ or environmental disadvantage" (limit these)
Social determinants
Age
○ Race
○ Ethnicity
○ Socioeconomic status
○ Access to nutritious food
○ Transportation resources
○ Religion
○ Sexual Orientation
○ Level of education
■ Literacy level
○ Disability (physical and cognitive
○ Geographical location (e.g. access to health care)
Marginalized groups
Sexual orientation, people of color, people who mentally or physically challenged, people who are not college educated are more likely to have poor health outcomes and die at an earlier age because of a complex interaction between individual genetics and behaviors; public and health policy; community and environmental factors; and quality of health care
PQRSTU
Provocative or palliative (what makes it better or worse)
Quality or quantity, (type of pain)
Region or radiation, (location
Severity scale, (pain scale)
Timing, (duration, when first start)
Understanding (effect of pain)
painPain is always what the patient says it isGeneral SurveyWhen a patient enters an exam room, observe his/ her walk and general appearance and be attentive to his/ her behavior and dress. A general survey, or appraisal of the patient's presentation and behavior provides information about characteristics of an illness, and the patient's ability to function independently, body image, emotional state, recent changes in weight, and developmental status.PERRLAEye assessment is part of the neurological assessment as well ● P: Pupils ● E: Equal ● R: Round ● R: Reactive ● L: Light ● A: AccommodatingPhases of the InterviewAgenda-(Setting an agenda/ orientation)Focus on the patient's goals, preferences, and concerns, NOT your personal agenda. Working Phase-Interview (Working phase/ Collecting Data), Open-ended questions, Direct Closed-Ended Questions(for the problem), Back Channeling (Reinforce your interest) Termination-Summarize your discussion and let your patient know when the interview is coming to an endSBARSituation-describes the situation to md Background-happened in the past Assessment-thingg seen objective and subjective Recommendation-what the patient needsMental statusfirst action, Alert: Are their eyes open and looking at you? Orientation questions: ● Who are you? ● Where are you? ● What day is it today (Month, day, and year) ● Why are you here today?External ear:○ Have the patient sit comfortable, inspect the size, shape, symmetry, landmarks, position, and color of the auricle. ■ Normally equal size and level w/ each other ■ The upper point attachment is in a straight line with the lateral canthus, or corner of the eye ■ Position of the auricle is almost vertical ○ Palpate the auricles for texture, tenderness, and skin lesions. ■ Normally, smooth, and without lesions ○ Inspect the opening of the ear canal for size and presence of discharge ○ Who assesses the internal ear? ■ Health care providerAnatomy of the mouth■ Upper molars normally rest directly on the lower molars, and the incisors slightly over-ride the lower incisors. A symmetrical smile reveals normal facial nerve function. ■ Observe the position and alignment of the teeth. ○ Test for swallowing ■ Prevent aspiration ○ Where the uvula sits ○ Soft palate and hard palate ■ Have the patient extend the head backward, holding the mouth open to inspect the hard and soft palates ● Hard palate: located anteriorly and dome shaped ● Soft palate: located posteriorly toward the pharynx. Pink and smooth. ○ Observe the palates for color, shape, texture, and extra bony prominences, or defects ○ Pink moist and hydratedNailsTransparent, rounded. Nails reflect a person's general health, state of nutrition, occupation, and habits of self-care The semilunar whitish area at the base of the nail bed is called the lunula from which the nail plate grows. ● Inspect the nail bed for color, length, symmetry, cleanliness, and configuration. Assess the thickness and shape of the nail, its texture, the angle between the nail and the nail bed. Angle of nail bed should should be 160 degreesInhalation and exhalationKnow the points ○ Bronchial: trunk-Loud, high, and hollow ■ Inspire: Shorter ■ Expire: Longer X 3-2 ○ Bronchovesicular: Branch-Medium, blowing sound ■ Inspire= Expire ○ Vescular: Little branches- Soft, low pitched ■ Inspire: Longer X 3 ■ Expire: ShorterOrthostatic vital signssupine→ sitting → standing ○ Same arm each time Obtain BP readings within 3 min.Abdomen Assessment-Inspection (round/ flat/ non distended) Auscultate(active bowel sounds), and palpation (soft non-tender) -Listen for 2-20 seconds in each quadrant starting from the RLQ → RUQ → LUQ → LLQ ■ Listen for gurgling sounds (we want to hear active bowel sounds heard throughout all 4 quadrants) -IF you do not hear anything, you have to know the assessment of that abnormal ○ Assess each quadrant for a total of 5 mins (4 quadrants and middle)Menstral cycle for BSEMenstrual hx: BSE should be done on the 4th-7th menstrual cycle or any time after her menstruation has endedBreast examination and techniques:-Vertical Up-and-Down - Concentric Circles(clockwise) - wedging( in and out) ○ Palpate with a consistent patternGCS (glasgow):-Best motor, verbal, and eye response -Normal score of glasgow coma scale = 15 -Lowest score you can ever get from a GCS scale is 3, NOT 0!Female External Genitalia Assessment:-Warnings (Touch inner thigh) -Lithotomy position -Internal Genitalia(Cannot be performed by nurses) -External Genitalia Pubic hair growth and distribution Labia majora Labia minora Thumb and index finger Clitoris Urethral orifice Vaginal orifice HymenMale External Genitalia Assessmentinspect the shaft- Palpate the shaft between the thumb and first two fingers to detect localized areas of hardness or tenderness. prepuce (foreskin)- pull down after assessing urethral meatus and check for smegma corona(head of penis) /glans /urethral meatus(urethral opening)- compress the glans between the thumb and index finger, this opens the urethral meatus for inspection of lesions, edema and inflammation. Normally, the opening is glistening and pink without discharge. testicles- left testicle is lower than the right. Inspect the size, shape, and symmetry of the scrotum while observing for lesions or edema. Gently lift the scrotum to view the posterior surface.MMSE (Mini Mental State Examination)-A score of 20 to 24 suggests mild dementia, 13 to 20 suggests moderate dementia, and less than 12 indicates severe dementia.