Assessment Finding (Most Common) PDF

**Assessment Finding (Most Common)** Abdominal pain Alteration of comfort: pain -------------------------------------- ---------------------------------------------------- Low oxygen supply Impaired gas exchange Amnesia...

**Assessment Finding (Most Common)** Abdominal pain Alteration of comfort: pain -------------------------------------- ---------------------------------------------------- Low oxygen supply Impaired gas exchange Amnesia Altered though process Aloness Social isolation Anemia Activity intolerance Antisocial Violence Anxiety disorder Anxiety ARDS Impaired gas exchange Arthritis Alteration in comfort Battered wife/gf Violence Bedridden Diversional activity deficit Burn Fluid volume excess Carbon monoxide poisoning Impaired gas exchange Child Abuse Violence Constipation Altered bowel elimination pattern Cough Ineffective airway clearance Crackle, fluid Fluid volume excess Crisis Ineffective individual coping Cyanosis Ineffective airway clearance Decrease muscle strength Physical mobility Decrease urine output (normal: 30μL) Fluid volume deficit Delusion Altered thought process Deteriorating Hopelessness Diarrhea Fluid volume deficit Disoriented Altered thought process Dizzy Risk for fall/injury Dry skin Fluid volume deficit Emotional tension Anxiety Fatigue Activity intolerance Fear of rejection Self-esteem disturbance/body image disturbance Hallucination Altered thought process Hard stool Altered bowel elimination pattern Hemorrhage Fluid volume deficit Hypoxia Impaired gas exchange Ideas of reference Altered thought process Immobility Impaired physical mobility Jugular vein distention Lack of control Powerlessness Lack of interest in learning Knowledge deficit Lack of initiative Hopelessness Limited ROM Impaired physical mobility Leukopenia Risk of injury Long term hospitalization Diversional activity deficit Manic Violence Missing body part Body image disturbance/self-esteem Neuromascular paralysis Ineffective breathing pattern Negative feelings Body image/self-esteem disturbance GBS Ineffective breathing pattern Panic Violence Passive Powerless Poor self-esteem Ineffective individual coping Pulmonary edema Ineffective airway clearance Restlessness Anxiety Retractions in breathing Ineffective breathing pattern Seizure Risk for injury Shortness of breath Ineffective breathing pattern Steroids Fluid volume excess Altered bowel elimination Suicidal Violence Tracheobronchial section Ineffective airway clearance Tracheobronchial obstruction Ineffective airway clearance Vertigo Risk for injury Body weakness Activity tolerance Fever Altered thermoregulation/hyperythermia/hypothermia Pain Alteration of comfort **B. Nursing Theorist** Florence Nightingale Environmental Theory -- manipulation of environment to promote wellness ----------------------- ------------------------------------------------------------------------- Hildegard Psychodynamic theory -- 4 phases of nurse-patient relationship Virginia Henderson 14 Nursing need theory Faye Bella 21 nursing problems Callista Roy Adaptation model Dorothea Orem Self-care theory Lydia Hall 3C's (Care, Core, Cure) Martha Rogers Unitary Human Beings Eugene King Goal Attainment Theory Betty Newman System Model Ida Orlando Nursing Care Process Jean Watson Philosophy and Caring Theory Madeleine Leininger Transcultural Nursing Theory Patricia Benner Novice to expert Joyce Travelbee Human to Human RS Model Margaret Newman Health Katherine Kolcaba Comfort Theory Rosemarie Rizzo Parse Human Becoming Theory Ernestine Wiedenbach Clinical Theory **Common Laws of Nursing Practice** PN RA 9137 : Act of providing more nursing RA 2808 : True nursing act PRC 223 (1973) : RA 6425 : Dangerous Drug Act RA 6675 : Generic Act RA 7305 : Magna Cart of Public Health Workers PHC LOY 949 Legal Basis of Primary Healthcare RA 8353 : Anti-rape law RA 7160 : Local Government Code RA 7610 : Anti Child Abuse RAPD 996 : Compulsory Immunization **Ethics** **Nursing ethics** -- system of principle governing conduct of nurses **Code of ethics** -- essential characteristics of profession **Principle of Double Effect** \- ethically beneficial \- physically harmful 1\. Act must not be contradicting to ones commitment to God & neighbour 2\. Intention must be to achieve the beneficial effects and avoid harmful effects 3\. Beneficial effects must be greater 4\. Beneficial effect must follow from the action for at least immediately harmful effect **Principles of Professional Communication** \- Sharing information which is needed to obtain \- Refrain from lying \- Good communication requires trust (establish rapport) \- Share info within the healthcare team **Principles of dignity** \- Intergrated satisfaction of innate need of person as a whole \- self actualization in connection to God and **Principles of totality** \- every person must presence his/her function \- lower functions are never sacrificed unless to pressure the whole functioning of the person **Nursing Process** \- Lydia Hall (first to use in 1955) \- systematize method that directs the both nurse-client to determine the need for nursing GOSH G -- Goal oriented O -- Organized S -- Systematic H -- Humanistic **Assessment** \- Systematic & continuous collection of data \- Activities : collection, validation, organization, analysis & recording/documentation of data \- Types: \- subjective (symptoms): described by the patient (pain) \- objective (signs): observed & measured (VS) \- Sources: \- patient (primary data) \- medical records, SO, chart (secondary) **Methods of collecting data** \- interview \- observation (5 senses & equipment/instruments) **Nursing Dx** Format: PES (problem, etiology, ssx) \- activities: data clustering, identify gaps Types: \- actual: problem is present \- potential: problem may arise \- possible: problem may be present wellness: low-higher level of wellness Prioritization: ABC, Maslow, Safety **Planning** \- identifying beforehand \- priority setting \- set goals, follow SMART **Implementing** \- requirements: know therapeutic use of self, have knowledge, technical skills, and attitude types: independent, dependent, collaborative **Evaluate** \- measure client achieveness \- determine which goals are met \- reassess if not met **Health Assessment** **Nursing health history** -- structured interview designed to collect data to have detailed health record \- components: \- biographic data \- chief complaint: why patient sought consultation \- history of present illness \- usual health status \- past health history \- all previous illness, hospitalizations, immunization, surgery \- family history \- reveals risk factors for illness \- review of system \- lifestyle (diet, personal habits) \- social data \- family relationship \- ethic affixations \- education/economic status \- psychological \- reveals emotional status \- GORDONS \- physical examination \- should be conducted cephalo (head to toe) \- bring all materials with you before physical examination \- provide privacy \- determine level of consciousness methods of examination (abdomen): E&P: IPPA -- generally APP -- abdomen: except -- AAA, wilm's & tumor of kidney Position: recumbent RLQ, RUQ, LUQ, LLQ Chest exam: sitting position Back: standing **Directional Terms** Superior: upper Inferior: lower Anterior: front Dorsal: back Medial: Lateral: far from you Intermediate: between 2 surfaces Ipsilateral: same side Contralateral: opposite side Proximal: near the attachment Distal: further the attachment Superficial: surface Supination: downward rotation Parietal: outer wall Abduction: moving from the midline of your body Adduction: moving toward the midline of your body Pronation: upward rotation **General survey** -- used to asses general appearance & behaviour of patient \- includes: \- body guilt, skin & tone, hygiene & grooming, body odor, signs of distress, affect, speech, though process, leve of consciousness (consciousness, unconsciousness, lethargic) **Vital Signs** Types of body temperature: \- surface: subcutaneous \- core: deep tissue temp (36.7-37.0) thermoregulation center of the body/hypothalamus **Pulse rate** \- regulated by: ANS \- 60 to 100 bpm \- pulse deficit: difference between apica pulse & radical pulse \- children: apical pulse (don't take if child is crying) \- do not use thumb \- sites: \- temporal popliteal \- parotid \- brachial \- caroted **Respiration** \- types of breathing: \- thoracic \- diaphragmatic \- primary respiratory center (medulla oblongata \- 3 process: ventilation, diffusion, perfusion \- movement of gas in & out of lungs \- exchange of gases from greater pressure to lower transport movement of gasses \- normal respiration (adult): 16 to 20 bpm **Blood pressure** \- 120/80 mmhg (normal) \- 130/90: boarderline \- systolic: contraction of ventricles \- diastolic: when ventricles are at rest \- men have usually higher blood pressure