NU 231 Fundamentals of Nursing Exam 1 Study GuideWeek 1 [01/16/20]1. Define the nursing process.i.Medical vs. Nursing Assessments1.Medical assessmentstarget data pointing to pathologic conditions2.Nursing assessmentsfocus on the patient’s response to health problemsii.Types of Assessment 1.Focused Assessment- Performed by the nurse to collect data about the specific problem2.Emergency Assessment- Performed by the nurse to gather data about a life-threateningproblem3.Time-Lapsed Assessment- Performed by the nurse to collect data about current health status of patientiii.Objective Data vs. Subjective Data1.Objective dataa.Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing themb.For example, elevated temperature, skin moisture, vomiting2.Subjective dataa.Information perceived only by the affected personb.For example, pain experience, feeling dizzy, feeling anxiousc.Not only perceived by person, but also part of personal medical historyd.For example, a patient may say I have high BP but the you take it and it is within the normal range iv.Sources of Data1.Patient2.Family and significant others3.Patient records4.Consultationsb.Diagnosis- analyzing patient data to identify patient strengths and problemsi.Nurses can only use the diagnosis approved by NANDAii.Medical vs. Nursing diagnosis 1.Nursing diagnosis:Describes patient problems nurses can treat independently2.Medical diagnosis: Describesproblems for which the physician directs the primary treatment3.Can be interchangeable (pain is both nursing and medical) 4.Patients can have same medical diagnosis of congestive heart failure but have several different nursing diagnosis because they show condition is many different waysiii.Formulation of Nursing Diagnoses1.Problem—identify what is unhealthy about patient, comes from approved NANDA list2.Etiology—identify factors maintaining the unhealthy state (cause)3.Defining characteristics—identify the subjective and objective data that signal existence of a problem iv.Prioritizing Nursing Diagnoses1.High priority: greatest threat to patient well-beinga.ABC – Airway Breathing Circulation
NU 231 Fundamentals of Nursing Exam 1 Study Guide2.Medium priority: nonthreatening diagnoses3.Low priority: diagnoses not specifically related to current health problemc.Plan - specifying patient outcomes and related nursing interventions i.You establish prioritiesfirstii.Select evidence-basednursing interventions 1.Research 2.Standards of care 3.Guidelines in unitiii.Communicate plan of care, can change as patient’s condition changesiv.