GRADED
1. Promote health
2. To Treat human responses to Health or illness
3. To advocate for individuals, families, communities, and populations
4. To prevent illness
4 broad goals of nursing according to American nurses Association
Primary Prevention
Strategies aimed at preventing problems ex. Health posters on the awarness of sepsis
secondary prevention
early diagnoses, prompt treatment ex. breast cancer screening
Tiertiary prevention
preventing complications of existing disease, promoting highest health level possible
ex. managing insulin levels or regularly examining for edema
Assessment
Diagnosis
outcomes
planning
implementation
evaluation
A D (O) P I E
Comprehensive Nursing Assessment
complete health history and physical assessment performed
Annually for outpatients
upon hospital/long term care admission
Focused nursing Assessment
occurs in all settings, smaller in scope but increased depth for specific issues
Emergency Nursing Assessment
life-threatening or unstable situation ABCDE
Airway
breathing
circulation
disability
exposure
Emergency Nursing assessment mnemonic
Functional Assessment
focuses on functional patterns all humans share
head to toe assessment
Most organized framework for health assessment
Body systems approach
Framework for health assessment
, organizational for documentation communication
promotes critical thinking
Onset
location
duration
characteristics
alleviating factors
relieving factors
Timing
Severity
Pain and System Assessment
Oldcarts
Square male
Circle Female
X Death
Genogram legend
Inspection
observing patient visually for general appearance or specific details and is the first step
of general survey
only technique used for every body part and body system
Palpation
clinical touching of specific body areas to assess characteristics (texture, temp,
moisture, size, shape, vibration, tenderness, pain, edema)
Percussion
tapping technique with hands to determine condition of solid or air-filled body areas
Finger pads
finding pulses, lymph nodes, small lumps, skin texture, edema
ascultation
Using a stethoscope to assessment movement of air or fluid within specific body
systems
hand hygiene
Most important transmission prevention strategy
Normal Lungs
Resonant Percussion Tone
Normal Abdomen
Tympanic Percussion Tone
Suibjective
objective
assessment
Plan
intervention
evaluation
Record nursing activities during a shift
SOAPIE