NUR 155 SIMPLIFID AND BRIEF
NOTES FOR REVISION
Assessing
To establish a database about the client's
response to health concerns or illness
and the ability to manage health care
needs
Diagnosing
To identify client strengths and health
problems that can be prevented
or resolved by collaborative and
independent nursing interventions
To develop a list of nursing and
collaborative problems
Planning
To develop an individualized care plan
that specifies client goals/desired out-
comes, and related nursing interventions
Implementing
To assist the client to meet desired goals/
outcomes; promote wellness; prevent
,illness and disease; restore health; and
facilitate coping with altered functioning
Evaluating
To determine whether to continue,
modify, or terminate the plan of care
Nursing ABC's
airway, breathing, circulation
Maslows level 1: physiologic needs
oxygen, food, water, sex, rest, physical activity; physiologic
needs are highest priority
Maslows level 2: safety and security needs
both physical and emotional components; being protected from
potential or actual harm
Maslows level 3: love and belonging needs
understanding and acceptance of others in both giving and
receiving love; feeling of belonging; unmet needs produce
loneliness and isolation
Maslows level 4: self-esteem needs
Need for a person to feel good about oneself, to feel pride and a
sense of accomplishment and to believe that others also
respect and appreciate those accomplishments
-Positive self-esteem facilitates the person's confidence and
independence
, Maslows level 5: Self-Actualization
acceptance of self and others as they are; each lower level must
be met; focus of interest on problems outside oneself; respect
for all people; focus on strengths and possibilities vs problems
Macule
flat, colored spot on the skin ex- birthmark
papule
small, solid, raised lesion on surface of the skin - less then 1cm
ex- wart, acne
plaque
a solid mass greater than 1 cm in diameter and limited to the
surface of the skin ex- psoriasis, rubeola
nodule
solid, round or oval elevated lesion 1 cm or more in diameter
ex- squamous cell carcinoma
pustule
elevation of skin containing pus ex- acne
Vesicle/Bulla
circumscribed, round or oval thin translucent mass vesicles less
than 0.5 cm Example 2nd degree burns and herpes simplex
cyst
sac containing fluid
NOTES FOR REVISION
Assessing
To establish a database about the client's
response to health concerns or illness
and the ability to manage health care
needs
Diagnosing
To identify client strengths and health
problems that can be prevented
or resolved by collaborative and
independent nursing interventions
To develop a list of nursing and
collaborative problems
Planning
To develop an individualized care plan
that specifies client goals/desired out-
comes, and related nursing interventions
Implementing
To assist the client to meet desired goals/
outcomes; promote wellness; prevent
,illness and disease; restore health; and
facilitate coping with altered functioning
Evaluating
To determine whether to continue,
modify, or terminate the plan of care
Nursing ABC's
airway, breathing, circulation
Maslows level 1: physiologic needs
oxygen, food, water, sex, rest, physical activity; physiologic
needs are highest priority
Maslows level 2: safety and security needs
both physical and emotional components; being protected from
potential or actual harm
Maslows level 3: love and belonging needs
understanding and acceptance of others in both giving and
receiving love; feeling of belonging; unmet needs produce
loneliness and isolation
Maslows level 4: self-esteem needs
Need for a person to feel good about oneself, to feel pride and a
sense of accomplishment and to believe that others also
respect and appreciate those accomplishments
-Positive self-esteem facilitates the person's confidence and
independence
, Maslows level 5: Self-Actualization
acceptance of self and others as they are; each lower level must
be met; focus of interest on problems outside oneself; respect
for all people; focus on strengths and possibilities vs problems
Macule
flat, colored spot on the skin ex- birthmark
papule
small, solid, raised lesion on surface of the skin - less then 1cm
ex- wart, acne
plaque
a solid mass greater than 1 cm in diameter and limited to the
surface of the skin ex- psoriasis, rubeola
nodule
solid, round or oval elevated lesion 1 cm or more in diameter
ex- squamous cell carcinoma
pustule
elevation of skin containing pus ex- acne
Vesicle/Bulla
circumscribed, round or oval thin translucent mass vesicles less
than 0.5 cm Example 2nd degree burns and herpes simplex
cyst
sac containing fluid
