NURS 6001 EXAM 1 Latest update/100% verified
Types of Assessment
comprehensive, episodic or problem-focused, emergency
comprehensive assessment
(initial) results in baseline data for problem identification and care planning, time
consuming, complete, all aspects of preventive health/physical disease
episodic/problem-focused assessment
based on the patient's health issues, involves one or two body systems. smaller scope,
but more in depth
What is the nursing process?
systematic problem-solving approach to identifying and treating human responses to
actual or potential health difficulties. patient centered and focuses on problem solving
and inhaling strengths. uses ADPIE
emergency assessment
involves life threatening or unstable situation, traumatic injury, uses ABCDE
ABCDE
airway, breathing, circulation, disability, and exposure
ADPIE
assessment of patient, nursing diagnosis, planning care, implementing and then
evaluating patients status
implementation
collaboration with other team members, involvement of patient and family, actually
doing the phase
evaluation
how effective is nursing care and each phases affects the other
nursing diagnosis vs medical diagnosis
medical focuses on diagnosis and treatment of disease whereas nursing focuses on the
human response to actual or potential health problems
assessment
establish baseline, review history, physical assessment
diagnosis
clustering of data to make a judgement or statement about the patient's difficulties or
condition
Nanda diagnosis for nursing
a clinical judgement about individual, family, or community responses to actual or
potential health difficulties/life processes. Provides the basis for selection of nursing
interventions to achieve outcomes for which the nurse is accountable
Normal range of blood pressure
120/80
normal range of pulse
60-100 bpm
scale of pulse strength
0-4+
scale of 0 pulse
non palpable or absent
, 1+ of pulse
weak, diminished, and barely palpable
2+ of pulse
normal, expected
3+ of pulse
Full, increased
4+ of pulse
Bounding
normal oral temperature range
97.7-99.5 F
normal range for Temporal range
98.7-100.5 F
five ways to take temperature
oral, axillary, rectal, tympanic, and temporal
normal respirations
12-20
normal O2 saturation
95-100%
Pain scale
1-10
COLDERR
characteristic, onset, location, duration, exacerbation, relief, radiation
6 stages of infection cycles
infectious agent, reservoir, portal of exit, means of transmission, portal of entry,
susceptible host
infectious agent
bacteria, viruses, and fungi
reservoir
place for growth and multiplication of microorganisms is the natural habitat of the
organism (other people, animals, soil, food, water, milk and inanimate objects)
portal of exit
point of escape for the organism from the reservoir (respiratory, gastrointestinal, and
genitourinary tracts, as well as breaks in the skin and blood and tissue
means of transmission
how an organism is transmitted from its reservoir, through touching, kissing, sexual
intercourse, contaminated instrument, blood, food, water, or inanimate objects, vectors
like mosquitos, ticks, and lice
portal of entry
point at which organisms enter a new host, same as exit route... urinary, respiratory,
and gastrointestinal tracts
susceptible host
source that is acceptable for microorganisms that overcome any resistance mounted by
the host's defenses
nursing interventions to break chain of infection between susceptible host and
infectious agent
immunizations and screen healthcare staff
Types of Assessment
comprehensive, episodic or problem-focused, emergency
comprehensive assessment
(initial) results in baseline data for problem identification and care planning, time
consuming, complete, all aspects of preventive health/physical disease
episodic/problem-focused assessment
based on the patient's health issues, involves one or two body systems. smaller scope,
but more in depth
What is the nursing process?
systematic problem-solving approach to identifying and treating human responses to
actual or potential health difficulties. patient centered and focuses on problem solving
and inhaling strengths. uses ADPIE
emergency assessment
involves life threatening or unstable situation, traumatic injury, uses ABCDE
ABCDE
airway, breathing, circulation, disability, and exposure
ADPIE
assessment of patient, nursing diagnosis, planning care, implementing and then
evaluating patients status
implementation
collaboration with other team members, involvement of patient and family, actually
doing the phase
evaluation
how effective is nursing care and each phases affects the other
nursing diagnosis vs medical diagnosis
medical focuses on diagnosis and treatment of disease whereas nursing focuses on the
human response to actual or potential health problems
assessment
establish baseline, review history, physical assessment
diagnosis
clustering of data to make a judgement or statement about the patient's difficulties or
condition
Nanda diagnosis for nursing
a clinical judgement about individual, family, or community responses to actual or
potential health difficulties/life processes. Provides the basis for selection of nursing
interventions to achieve outcomes for which the nurse is accountable
Normal range of blood pressure
120/80
normal range of pulse
60-100 bpm
scale of pulse strength
0-4+
scale of 0 pulse
non palpable or absent
, 1+ of pulse
weak, diminished, and barely palpable
2+ of pulse
normal, expected
3+ of pulse
Full, increased
4+ of pulse
Bounding
normal oral temperature range
97.7-99.5 F
normal range for Temporal range
98.7-100.5 F
five ways to take temperature
oral, axillary, rectal, tympanic, and temporal
normal respirations
12-20
normal O2 saturation
95-100%
Pain scale
1-10
COLDERR
characteristic, onset, location, duration, exacerbation, relief, radiation
6 stages of infection cycles
infectious agent, reservoir, portal of exit, means of transmission, portal of entry,
susceptible host
infectious agent
bacteria, viruses, and fungi
reservoir
place for growth and multiplication of microorganisms is the natural habitat of the
organism (other people, animals, soil, food, water, milk and inanimate objects)
portal of exit
point of escape for the organism from the reservoir (respiratory, gastrointestinal, and
genitourinary tracts, as well as breaks in the skin and blood and tissue
means of transmission
how an organism is transmitted from its reservoir, through touching, kissing, sexual
intercourse, contaminated instrument, blood, food, water, or inanimate objects, vectors
like mosquitos, ticks, and lice
portal of entry
point at which organisms enter a new host, same as exit route... urinary, respiratory,
and gastrointestinal tracts
susceptible host
source that is acceptable for microorganisms that overcome any resistance mounted by
the host's defenses
nursing interventions to break chain of infection between susceptible host and
infectious agent
immunizations and screen healthcare staff
