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A comprehensive review of the nursing process, covering essential steps such as assessment, diagnosis, planning, implementation, and evaluation. It includes key concepts like nanda-i, gordon's functional health patterns, and various assessment techniques including inspection, palpation, percussion, and auscultation. The material also details physical examination procedures, vital sign assessment, and neurological assessments using the glasgow coma scale. Additionally, it covers skin lesion assessment, cranial nerve examinations, and respiratory and cardiovascular assessments, making it a valuable resource for nursing students. The document concludes with information on muscle strength testing and learning domains.
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5 steps of the nursing process Assessment Diagnosis Planning Implementation Evaluation 3 types of nursing diagnosis actual, risk, health promotion NANDA-I a professional nursing organization that provides standardized language to identify patient problems and plan customized care
Planning (nursing process) prioritizing nursing diagnosis set goals NOC outcome identification colderrra character, onset, location, duration, exacerbation, relief, radiation, rate, accompanying signs and symptoms Gordon's Functional Health Patterns Health perception-health management pattern Nutritional-metabolic pattern Elimination pattern Activity-exercise pattern Sleep-rest pattern Cognitive-perceptual pattern Self-perception-self-concept pattern Roles-relationships pattern Sexuality-reproductive pattern Coping-stress tolerance pattern
3 phases of patient interview Orientation, working, termination whiipp wash hands introduce identify privacy painful procedure Bell of stethoscope low pitched sounds, heart murmur Diaphragm of stethoscope high pitched sounds, lungs apical pulse pulse taken with a stethoscope and near the apex of the heart peripheral pulses radial, brachial, posterior tibial, dorsalis pedis
pulse deficit difference between the apical and radial pulse rates hypercapnia excessive carbon dioxide in the blood hypoxemia decreased level of oxygen in the blood Eupena normal breathing apnea absence of breathing
dorsal recumbent lying on back, knees flexed and apart Fowler's position sitting position lithotomy position lying on back with legs raised and feet in stirrups Sims position lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back knee-chest position patient is lying face down with the hips bent so that the knees and chest rest on the table
Turgor Elasticity of the skin crepitation crackling sound pallor paleness erythema redness purpura the appearance of multiple purple discolorations on the skin caused by bleeding underneath the skin
Papule/Plaque Solid, elevated lesion nodule a small lump, deeper than dermis tumor solid mass that extends into subcutaneous tissue Vesicle/Bulla Fluid filled superficial, elevated pustule elevation of skin containing pus wheal raised red skin lesion due to interstitial fluid
burrow ringworm cyst sac containing fluid hirsutism excessive body hair alopecia hair loss pruritus itching
hydrocephalus accumulation of fluid in the spaces of the brain strabismus crossed eyes diplopia double vision ptosis drooping of eyelid cataracts lens of the eye is cloudy nystagmus Involuntary rapid eye movements
purulent containing pus cerumen ear wax Weber test test for sensorineural hearing loss Rinne test test for conductive hearing loss Romberg test used to evaluate cerebellar function and balance
cranial nerve V Trigeminal cranial nerve VI Abducens cranial nerve VII Facial cranial nerve VIII acoustic cranial nerve IX Glossopharyngeal
cranial nerve X Vagus cranial nerve XI accessory cranial nerve XII Hypoglossal Obtunded aroused by pain Stuporous aroused by pain, never fully awake bruit
low pitch, blowing, soft amp atelectasis collapsed lung adventitious breath sounds abnormal breath sounds crackles (rales) abnormal, heard at lung bases, Rhonchi Rattling noise of mucous in the lungs wheezes continuous high-pitched whistling sounds, constricted airway
stridor strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx pleural friction rub continuous, dry grating sound caused by inflammation of pleural surfaces and loss of lubricating pleural fluid cardiac murmurs blowing or swishing sounds heard in systole or diastole thrill palpable vibration on the chest wall accompanying severe heart murmur tortuosity bending twisting
