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- Collect Data
- Organize Data
- Validate Data
- Document Data
- Purpose: To establish a database about the clients response to health concerns or illness and the ability to manage health care needs.
- Analyze data
- Identify health problems, risk & strengths
- Formulate diagnostic statements
- Purpose: To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions. To develop a list of nursing and collaborate problems.
- Prioritize problems/diagnoses
- Formulate goals/desired outcomes
- Select nursing interventions
- Write nursing interventions
- Purpose: To develop an individualized care plan that specifies client goals/desired outcomes, and related nursing interventions.
- Reassess the client
- Determine the nurses need for assistance
- Implement the nursing interventions
- Supervise delegated care
- Document nursing activities
- Purpose: To assist the client to meet desired goals/outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning.
- Collect data related to outcomes
- Compare data with outcomes
- Relate nursing actions to clients goals/outcomes
- Draw conclusions about problem status
- Continue, modify, or terminate the clients care plan
- Purpose: To determine whether to continue, modify or terminate the plan of care.
systematic, rational method of planning and providing individualized nursing care.
performed within specified time after admission
ongoing process integrated with nursing care
during any physiological or psychological crisis
time lapses reassessment
several months after initial assessment
- AKA symptoms, verified only by the person affected
- "i feel weak all over"
- "i feel sick to my stomach"
- AKA signs can be seen
- BP 90/50
- Resp. 20
- Abdomen distended
rapid involuntary rhythmic eye movement
instrument for examining the interior of the ear
Low set ears are associated with:
Straighten ear canal of an adult by pulling the pinna:
up and back
adventitious breath sounds
occur when air passes through narrowed airways or airways filled with fluid or when pleural linings are inflamed.
soft-intensity, low pitched "gentle sighing sound created by air moving through smaller airways
moderate intensity and moderate pitched blowing sounds created by air moving through larger airway
high pitched, loud, harsh sounds created by air moving through the trachea
fine, short, interrupted crackling sounds
continuous, low pitched, coarse, gurgling, harsh, louder sounds
superficial grating or creaking sounds heard during inspiration and expiration.
continuous, high pitched, squeaky musical sounds.
S1 occurs when:
"lub" AV vales close
S2 Occurs when:
"dub"semilunar valves close
What is bruit?
A blowing or swishing sound, suggest's occlusive artery disease.
What is bradycardia?
HR under 60 bpm.
What is tachycardia?
HR over 100 bpm.
Organs in RUQ
- Hepatic flexure of colon
Organs in LUQ
- left adrenal gland
- splenic flexure of colon
Organs in LLQ
active bowel sounds occur:
about every 5 to 20 seconds
a decrease in size
an increase in size