NURS 6011 Exam 2 Study Guide
Steps in Nursing Process (again) - ADPIE
Nursing process (ADPIE): systemic problem-solving approach to identifying and treating human responses to
actual or potential health difficulties
o Serves as a framework for providing individualized care to individuals, families and communities
o Patient centered; focuses on solving problems and enhancing strengths
o Applicable to patients in all stages of life span and in all settings
Assess: complete and accurate health assessment to promote health at highest level
Diagnose: clustering of data to make judgement or statement about patient’s difficulty or condition
o Use diagnostic reasoning and critical thinking
o Identify actual or potential problems
Plan: determining resources, targeting nursing interventions, and writing plan of care
o Nursing care plan requires you to analyze the individual patient and their needs to provide
individualized and holistic care
o Communicate care plan verbally and document it in their chart
Implement: nursing interventions are any treatment, based upon clinical judgement and knowledge, that a
nurse performs to enhance patient outcomes
o Be aware of the standards of care within the agency where I work (they define expected practices,
like taking vital signs every 8 hrs)
o Types of nursing interventions: assessment, education, supervision, coordination, referral, support,
therapeutic communication, and technical skills
Evaluate: judgement of the effectiveness of nursing care in meeting the goals and outcomes
o Based on patient’s responses to interventions
o Purpose: make judgements about patient’s progress, analyze effectiveness of nursing care, review
potential areas for collaboration with and referral to other health care professionals, and monitor
quality of nursing care and its effect on patient
o Assess the promotion of and barriers to goal attainment; goals may be completely or partially met,
or completely unmet
o Use interviewing skills for subjective data collection and physical assessment skills for objective data
collection
What are normal Vital Signs (again)?
*Not going to ask what the average range is for a particular age group
Recognize key concepts; the older the person is, the lower their HR is and vice versa, the younger they are, the
higher their HR is
, Know: if an adult has a HR of 120 beats/min, they’re tachycardic
If a baby has a HR of 120 beats/min, you wouldn’t be too concerned
What is the point of nursing diagnoses?
Clustering data to make a judgement or statement about patient’s actual or potential health difficulties or
conditions
Provides the basis for selection of nursing interventions to achieve outcomes
Measuring Intake and Outputs
Instruct patient and family about the need for a record of all fluids entering body and all fluid output
o Explain rationale and instructions for how patient can help keep measurements accurate
o May need to remind patient each morning
Use patient’s care plan to communicate to other nursing personnel about measuring fluid I/O
Post sign in patient’s room and bedside form for recording I/O
Record I/O totals for each 8 hr shirt and total each 24 hrs
o If nurse suspects large diff btwn I/O, notify PCP
Intake: all fluids and foods that are liquid at room temp (orally and intravenously)
o Foods, fluids, meds, IV fluids
Output: anything liquid that comes out of patient
o Urine, feces, emesis (vomit), drainage from tubes or wound
o If not measurable, document it on output record (heavy perspiration when patient’s clothing or bed
linens are soaked; hyperventilation- water vapor loss, record rate/depth of respirations)
What is the difference between interstitial fluid, intracellular fluid, extracellular fluid, intravascular fluid?
Intracellular fluid (ICF): fluid within the cell; ~70% total body water or 40% of adult’s body weight
Extracellular fluid (ECF): fluid outside the cells; ~30% of total body water or 20% of adult body weight
o Intravascular fluid (plasma): liquid component of blood
o Interstitial fluid: surrounds tissue cells, includes lymph
How do you measure acid-base balance?
First look at ph, then either co2 or bicarb (hco3)
Low pH (acidosis), high CO2 respiratory acidosis
o Hypoventilation CO2 trapped/retained in lungs
High pH (alkalosis), low CO2 respiratory alkalosis
o Hyperventilation blowing off too much CO2
o High fever, sepsis
Low ph, high hco3 metabolic acidosis
o Excess acid - diabetic ketoacidosis
High ph, high hco3 metabolic alkalosis
o Excess base (diuretics) or loss of acid (vomiting); kidney failure
Compensation: normal ph but co2 or hco3 are up/down, body is compensating
Be able to assess fluid volume excess vs. fluid volume deficit
Fluid volume excess
Steps in Nursing Process (again) - ADPIE
Nursing process (ADPIE): systemic problem-solving approach to identifying and treating human responses to
actual or potential health difficulties
o Serves as a framework for providing individualized care to individuals, families and communities
o Patient centered; focuses on solving problems and enhancing strengths
o Applicable to patients in all stages of life span and in all settings
Assess: complete and accurate health assessment to promote health at highest level
Diagnose: clustering of data to make judgement or statement about patient’s difficulty or condition
o Use diagnostic reasoning and critical thinking
o Identify actual or potential problems
Plan: determining resources, targeting nursing interventions, and writing plan of care
o Nursing care plan requires you to analyze the individual patient and their needs to provide
individualized and holistic care
o Communicate care plan verbally and document it in their chart
Implement: nursing interventions are any treatment, based upon clinical judgement and knowledge, that a
nurse performs to enhance patient outcomes
o Be aware of the standards of care within the agency where I work (they define expected practices,
like taking vital signs every 8 hrs)
o Types of nursing interventions: assessment, education, supervision, coordination, referral, support,
therapeutic communication, and technical skills
Evaluate: judgement of the effectiveness of nursing care in meeting the goals and outcomes
o Based on patient’s responses to interventions
o Purpose: make judgements about patient’s progress, analyze effectiveness of nursing care, review
potential areas for collaboration with and referral to other health care professionals, and monitor
quality of nursing care and its effect on patient
o Assess the promotion of and barriers to goal attainment; goals may be completely or partially met,
or completely unmet
o Use interviewing skills for subjective data collection and physical assessment skills for objective data
collection
What are normal Vital Signs (again)?
*Not going to ask what the average range is for a particular age group
Recognize key concepts; the older the person is, the lower their HR is and vice versa, the younger they are, the
higher their HR is
, Know: if an adult has a HR of 120 beats/min, they’re tachycardic
If a baby has a HR of 120 beats/min, you wouldn’t be too concerned
What is the point of nursing diagnoses?
Clustering data to make a judgement or statement about patient’s actual or potential health difficulties or
conditions
Provides the basis for selection of nursing interventions to achieve outcomes
Measuring Intake and Outputs
Instruct patient and family about the need for a record of all fluids entering body and all fluid output
o Explain rationale and instructions for how patient can help keep measurements accurate
o May need to remind patient each morning
Use patient’s care plan to communicate to other nursing personnel about measuring fluid I/O
Post sign in patient’s room and bedside form for recording I/O
Record I/O totals for each 8 hr shirt and total each 24 hrs
o If nurse suspects large diff btwn I/O, notify PCP
Intake: all fluids and foods that are liquid at room temp (orally and intravenously)
o Foods, fluids, meds, IV fluids
Output: anything liquid that comes out of patient
o Urine, feces, emesis (vomit), drainage from tubes or wound
o If not measurable, document it on output record (heavy perspiration when patient’s clothing or bed
linens are soaked; hyperventilation- water vapor loss, record rate/depth of respirations)
What is the difference between interstitial fluid, intracellular fluid, extracellular fluid, intravascular fluid?
Intracellular fluid (ICF): fluid within the cell; ~70% total body water or 40% of adult’s body weight
Extracellular fluid (ECF): fluid outside the cells; ~30% of total body water or 20% of adult body weight
o Intravascular fluid (plasma): liquid component of blood
o Interstitial fluid: surrounds tissue cells, includes lymph
How do you measure acid-base balance?
First look at ph, then either co2 or bicarb (hco3)
Low pH (acidosis), high CO2 respiratory acidosis
o Hypoventilation CO2 trapped/retained in lungs
High pH (alkalosis), low CO2 respiratory alkalosis
o Hyperventilation blowing off too much CO2
o High fever, sepsis
Low ph, high hco3 metabolic acidosis
o Excess acid - diabetic ketoacidosis
High ph, high hco3 metabolic alkalosis
o Excess base (diuretics) or loss of acid (vomiting); kidney failure
Compensation: normal ph but co2 or hco3 are up/down, body is compensating
Be able to assess fluid volume excess vs. fluid volume deficit
Fluid volume excess
