231 Exam 1 Study Guide .docx - NU 231 Fundamentals of Nursing Exam 1 Study Guide Week 1 1 Define the nursing process a What is it Framework you approach

231 Exam 1 Study Guide .docx - NU 231 Fundamentals of...

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NU 231 Fundamentals of Nursing Exam 1 Study Guide Week 1 [01/16/20] 1. Define the nursing process. i. Medical vs. Nursing Assessments 1. Medical assessments target data pointing to pathologic conditions 2. Nursing assessments focus on the patient’s response to health problems ii. Types of Assessment 1. Focused Assessment - Performed by the nurse to collect data about the specific problem 2. Emergency Assessment - Performed by the nurse to gather data about a life-threatening problem 3. Time-Lapsed Assessment - Performed by the nurse to collect data about current health status of patient iii. Objective Data vs. Subjective Data 1. Objective data a. Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them b. For example, elevated temperature, skin moisture, vomiting 2. Subjective data a. Information perceived only by the affected person b. For example, pain experience, feeling dizzy, feeling anxious c. Not only perceived by person, but also part of personal medical history d. 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 Data 1. Patient 2. Family and significant others 3. Patient records 4. Consultations b. Diagnosis - analyzing patient data to identify patient strengths and problems i. Nurses can only use the diagnosis approved by NANDA ii. Medical vs. Nursing diagnosis 1. Nursing diagnosis: Describes patient problems nurses can treat independently 2. Medical diagnosis: Describes problems for which the physician directs the primary treatment 3. 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 ways iii. Formulation of Nursing Diagnoses 1. Problem —identify what is unhealthy about patient, comes from approved NANDA list 2. 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 Diagnoses 1. High priority: greatest threat to patient well-being a. ABC – Airway Breathing Circulation
NU 231 Fundamentals of Nursing Exam 1 Study Guide 2. Medium priority: nonthreatening diagnoses 3. Low priority: diagnoses not specifically related to current health problem c. Plan - specifying patient outcomes and related nursing interventions i. You establish priorities first ii. Select evidence-based nursing interventions 1. Research 2. Standards of care 3. Guidelines in unit iii. Communicate plan of care, can change as patient’s condition changes iv.

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