34
Fundamentals
© 37
, Tips for Fundamentals Class
35
nurse in the making
Don’t just memorize, Learn about nursing itself
understand! Ethical principles, theories in nursing,
Fundamentals are truly the foundation scope of practice, and delegation are
just a few of the topics you’ll cover in
on which you build the rest of your nursing
fundamentals class.
knowledge. That’s why understanding
the basics is so important. Knowing this information
Some things just have to be will help you on the NCLEX and
memorized, but in general, understanding once you start working as a nurse!
and connecting the dots will help you far
more than simply memorizing information.
Make the core information stick Build your skills
Remember, fundamentals include lab Fundamentals class is heavily based on
values, vital signs, basic interventions, core nursing skills such as checking vital
and more. You’ll never stop using this signs and administering oxygen.
information as a nurse.
Utilize your simulation labs as a safe
Learn the information in place for learning the proper steps for
fundamentals, and it will continue to each procedure, and continue practicing
expand with each course to come. to improve your skills.
You can find step-by-step
nursing skills in
The Complete
Fundamentals Flashcards!
© 38
, Nursing Documentation
36
nurse in the making
Abbreviations There are many abbreviations, so be sure to follow your facility’s policy on approved abbreviations
AAA Abdominal Aortic Aneurysm CF Cystic Fibrosis ICU Intensive Care Unit PTCA Percutaneous Transluminal Coronary Angioplasty
Abd Abdomen CHF Congestive Heart Failure I&O Intake and Output PVC Premature Ventricular Contraction
Ac Before Meals CKD Chronic Kidney Disease LES Lower Esophageal Sphincter RA Rheumatoid Arthritis
ACLS Advanced Cardiac Life Support C/O Complaining Of LMP Last Menstrual Period RBC Red Blood Cell(s)
AD Admitting Diagnosis COPD Chronic Obstructive Pulmonary Disease LOC Level of Consciousness RN Registered nurse
or Advance Directives CPR Cardiopulmonary Resuscitation LP Lumbar Puncture Rom/R.O.M. Range of Motion
A&D Admission and Discharge C&S Culture and Sensitivity LPN Licensed practical nurse RT Respiratory Therapist or Respiratory Therapy
Ad lib As Desired CVA Cerebrovascular Accident (stroke) LVN Licensed Vocational Nurse SBAR Situation, Background, Assessment,
ADL Activities of Daily Living CVC Central Venous Catheter MAP Mean Arterial Pressure Recommendation
Adm. Administration D/C Discontinue or Discharge MRI Magnetic Resonance Imaging SIADH Syndrome of Inappropriate
AKA Above-the-Knee Amputation D&C Dilatation and Curettage MVA Motor Vehicle Accident Antidiuretic Hormone Secretion
or Alcoholic Ketoacidosis DI Diabetes Insipidus NGT Nasogastric Tube SLE Systemic Lupus Erythematosus
ALL Acute Lymphocytic Leukemia DIC Disseminated Intravascular Coagulation NKA No Known Allergies SOB Shortness of Breath
Amb Ambulation DKA Diabetic Ketoacidosis NPO Nothing by Mouth SSE or S.S.E. Soap Suds Enema
AP or A.P. Appendectomy DM Diabetes Mellitus O2 Oxygen Stat At Once, Immediately
or Anterior/Posterior DVT Deep Vein Thrombosis OA Osteoarthritis STD Sexually Transmitted Disease
AV Atrioventricular DX Diagnosis OB Obstetrics TB Tuberculosis
Bid Twice a Day ECG or EKG Electrocardiogram OOB Out of Bed TIA Transient Ischemic Attack
BKA Below-the-Knee Amputation ED Emergency Department OR Operating Room Tid Three Times a Day
BLS Basic Life Support EENT Eye, Ears, Nose, and Throat Ortho Orthopedics TPN Total Parenteral Nutrition
BM Bowel Movement ETT Endotracheal Tube OT Occupational Therapist T&S Type and Screen
BP Blood Pressure FBS Fasting Blood Sugar or Occupational Therapy TURP Transurethral Resection of the Prostate
BPH Benign Prostatic Hyperplasia Fx Fracture Pc After Meals UA Urinalysis
BUN Blood Urea Nitrogen GI Gastrointestinal PFT Pulmonary Function Test UAP Unlicensed assistive personnel
BX Biopsy Gtt or G.T.T. Glucose Tolerance Test PLT Platelets US Ultrasound
CABG Coronary Artery Bypass Graft HOB Head of Bed PRBC Packed Red Blood Cells UTI Urinary Tract Infection
CAD Coronary Artery Disease HR Heart Rate Pre-op Before Surgery VS Vital Signs
CBC Complete Blood Count HS Bedtime Prn or p.r.n. As Needed WBC White Blood Count
CCU Cardiac Care Unit/Coronary Care Unit Hx History PT Physical Therapist or Physical Therapy WNL Within Normal Limits
can be cannot
e prove
The Nursing Process
proven
Objective Data subjective Data
“A Delicious PIE” Unbiased facts:
things you can see, Opinions
hear, feel, auscultate,
1 ASSESS
or biases
and measure
• Gather information
Objective think subjective think
• Verify that the information
collected is clear & accurate Observe what the
Examples:
patient says
5 EVALUATE 2 DIAGNOSE
• Vital signs
(except for pain) examples:
• Determine the outcome of the goals • Interpret the • Blood pressure, • Pain level
information collected respiratory rate, • Past history
• Evaluate the patient's compliance heart rate, oxygen
& emotions
• Document the patient's response to pain • Identify & prioritize the problem • Bleeding
• Modify & assess the need for changes through a nursing diagnosis • Vomiting
(be sure it's NANDA-approved)
Set
4 IMPLEMENT 3 PLAN Specific
SMART Goals:
• Reach those goals through • Set goals to solve
performing the nursing actions
measurable
the problem
• Implement the goals set Achievable
• Prioritize the
above in the planning stage outcomes of care Relevant
time frame
© 39
Fundamentals
© 37
, Tips for Fundamentals Class
35
nurse in the making
Don’t just memorize, Learn about nursing itself
understand! Ethical principles, theories in nursing,
Fundamentals are truly the foundation scope of practice, and delegation are
just a few of the topics you’ll cover in
on which you build the rest of your nursing
fundamentals class.
knowledge. That’s why understanding
the basics is so important. Knowing this information
Some things just have to be will help you on the NCLEX and
memorized, but in general, understanding once you start working as a nurse!
and connecting the dots will help you far
more than simply memorizing information.
Make the core information stick Build your skills
Remember, fundamentals include lab Fundamentals class is heavily based on
values, vital signs, basic interventions, core nursing skills such as checking vital
and more. You’ll never stop using this signs and administering oxygen.
information as a nurse.
Utilize your simulation labs as a safe
Learn the information in place for learning the proper steps for
fundamentals, and it will continue to each procedure, and continue practicing
expand with each course to come. to improve your skills.
You can find step-by-step
nursing skills in
The Complete
Fundamentals Flashcards!
© 38
, Nursing Documentation
36
nurse in the making
Abbreviations There are many abbreviations, so be sure to follow your facility’s policy on approved abbreviations
AAA Abdominal Aortic Aneurysm CF Cystic Fibrosis ICU Intensive Care Unit PTCA Percutaneous Transluminal Coronary Angioplasty
Abd Abdomen CHF Congestive Heart Failure I&O Intake and Output PVC Premature Ventricular Contraction
Ac Before Meals CKD Chronic Kidney Disease LES Lower Esophageal Sphincter RA Rheumatoid Arthritis
ACLS Advanced Cardiac Life Support C/O Complaining Of LMP Last Menstrual Period RBC Red Blood Cell(s)
AD Admitting Diagnosis COPD Chronic Obstructive Pulmonary Disease LOC Level of Consciousness RN Registered nurse
or Advance Directives CPR Cardiopulmonary Resuscitation LP Lumbar Puncture Rom/R.O.M. Range of Motion
A&D Admission and Discharge C&S Culture and Sensitivity LPN Licensed practical nurse RT Respiratory Therapist or Respiratory Therapy
Ad lib As Desired CVA Cerebrovascular Accident (stroke) LVN Licensed Vocational Nurse SBAR Situation, Background, Assessment,
ADL Activities of Daily Living CVC Central Venous Catheter MAP Mean Arterial Pressure Recommendation
Adm. Administration D/C Discontinue or Discharge MRI Magnetic Resonance Imaging SIADH Syndrome of Inappropriate
AKA Above-the-Knee Amputation D&C Dilatation and Curettage MVA Motor Vehicle Accident Antidiuretic Hormone Secretion
or Alcoholic Ketoacidosis DI Diabetes Insipidus NGT Nasogastric Tube SLE Systemic Lupus Erythematosus
ALL Acute Lymphocytic Leukemia DIC Disseminated Intravascular Coagulation NKA No Known Allergies SOB Shortness of Breath
Amb Ambulation DKA Diabetic Ketoacidosis NPO Nothing by Mouth SSE or S.S.E. Soap Suds Enema
AP or A.P. Appendectomy DM Diabetes Mellitus O2 Oxygen Stat At Once, Immediately
or Anterior/Posterior DVT Deep Vein Thrombosis OA Osteoarthritis STD Sexually Transmitted Disease
AV Atrioventricular DX Diagnosis OB Obstetrics TB Tuberculosis
Bid Twice a Day ECG or EKG Electrocardiogram OOB Out of Bed TIA Transient Ischemic Attack
BKA Below-the-Knee Amputation ED Emergency Department OR Operating Room Tid Three Times a Day
BLS Basic Life Support EENT Eye, Ears, Nose, and Throat Ortho Orthopedics TPN Total Parenteral Nutrition
BM Bowel Movement ETT Endotracheal Tube OT Occupational Therapist T&S Type and Screen
BP Blood Pressure FBS Fasting Blood Sugar or Occupational Therapy TURP Transurethral Resection of the Prostate
BPH Benign Prostatic Hyperplasia Fx Fracture Pc After Meals UA Urinalysis
BUN Blood Urea Nitrogen GI Gastrointestinal PFT Pulmonary Function Test UAP Unlicensed assistive personnel
BX Biopsy Gtt or G.T.T. Glucose Tolerance Test PLT Platelets US Ultrasound
CABG Coronary Artery Bypass Graft HOB Head of Bed PRBC Packed Red Blood Cells UTI Urinary Tract Infection
CAD Coronary Artery Disease HR Heart Rate Pre-op Before Surgery VS Vital Signs
CBC Complete Blood Count HS Bedtime Prn or p.r.n. As Needed WBC White Blood Count
CCU Cardiac Care Unit/Coronary Care Unit Hx History PT Physical Therapist or Physical Therapy WNL Within Normal Limits
can be cannot
e prove
The Nursing Process
proven
Objective Data subjective Data
“A Delicious PIE” Unbiased facts:
things you can see, Opinions
hear, feel, auscultate,
1 ASSESS
or biases
and measure
• Gather information
Objective think subjective think
• Verify that the information
collected is clear & accurate Observe what the
Examples:
patient says
5 EVALUATE 2 DIAGNOSE
• Vital signs
(except for pain) examples:
• Determine the outcome of the goals • Interpret the • Blood pressure, • Pain level
information collected respiratory rate, • Past history
• Evaluate the patient's compliance heart rate, oxygen
& emotions
• Document the patient's response to pain • Identify & prioritize the problem • Bleeding
• Modify & assess the need for changes through a nursing diagnosis • Vomiting
(be sure it's NANDA-approved)
Set
4 IMPLEMENT 3 PLAN Specific
SMART Goals:
• Reach those goals through • Set goals to solve
performing the nursing actions
measurable
the problem
• Implement the goals set Achievable
• Prioritize the
above in the planning stage outcomes of care Relevant
time frame
© 39
