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