Chapter 4 Fundamental Nursing Flashcards
Components of the
Nursing Process ***
⬤ Assessment- first step in nursing process***
⬤ Diagnosis (nursing diagnosis)
⬤ Planning
⬤ Implementation
⬤ Evaluation- last step of the nursing process
The nursing process.
Assess- LPN only collect data.
Diagnose- Identify problem through nursing diagnosis.
Plan- Set your goals to solve the problem.
Implement- Reach those goals through nursing action.
Evaluate- Determine outcome of goals and what if anything needs.
Assessment
⬤ Collection of data about the health status of the patient
⬤ Data- facts and statistics collected for reference or analysis
⬤ A registered nurse must perform the initial admission
assessment for each patient
⬤ The LVN/LPN collects data through surveillance and monitoring
and performs focused nursing assessments
⬤ A focused nursing assessment is defined as “an appraisal of the
patient’s status and situation at hand that contributes to ongoing
data collection.” ***
Subjective data ***
Information reported by patient and family in a
health history.
Usually documented in the patient’s own words
and include information such as previous
experiences and sensation or emotions that only
patient can describe.
Objective data-
can be seen or measured.
Information that nurse or another member of
health care team obtains through observation,
physical examination, or diagnostic testing.
Physical Examination
Inspection
Purposeful observation of the person as a whole
and then systematically from head to toe.
Observation and inspection is fundamental to physical
examination and begins at the first point of contact with
a patient***
Palpation
Uses touch to assess various parts of the body
and helps confirm findings that are noted on
inspection.
The hands, especially the fingertips, are used to
assess skin texture, moisture, and temperature or
the presence of swelling, lumps, masses,
tenderness, or pain.
When examining the abdomen, palpation should
be light at first for surface characteristics and then
deeper for abdominal contents.***
Physical Examination (cont.)= PERCUSSION
Tapping on the skin to assess the underlying
tissues.
⬤ Short, sharp strokes elicit sounds and subtle
vibrations that are characteristic of underlying
organs and certain conditions.
To percuss:
●Place one hand flat on the skin over the area to be
assessed.
● Use the tip of the middle finger of your other hand to
lightly tap the middle finger of the hand that rests on the
patient.
● Tap two times just behind the nail bed before moving to
the next area.
Copyright © 2016 by Saunders, an imprint
Auscultation
Listening to sounds produced by the body.
Auscultation is performed with a stethoscope.
What is the difference between the diaphragm
and the bell of a stethoscope?
The stethoscope diaphragm is useful for detecting high-pitched
sounds, while the bell is suitable for detecting low-frequency
sounds. The function of the diaphragm is to collect sound
waves through vibrations, while the function of the bell is to
collect sound waves through pressure changes.
Nursing Diagnosis
⬤ Derived from data gathered during the assessment
⬤ Nursing diagnosis is different from medical diagnosis.
⬤ Medical diagnosis- Process of determining which
disease or condition explains a person’s symptoms
and signs. It is most often referred to as diagnosis
with the medical context being implicit.
⬤ Focuses on the patient’s physical, psychological, and
social responses to a health problem or potential
health problem
The RN formulates nursing diagnoses; the LVN/LPN
is expected to assist with identifying patient needs
and implementing plan of care
North American Nursing Diagnosis
Association International (NANDA-I)
Develops and revises nursing diagnoses
⬤ Written in a PES format
P = problem
E = etiology or cause of the problem
S = signs and symptoms of the problem
Planning
Develop a nursing care plan for the patient
based on nursing diagnoses
⬤ Nursing care plans a form of communication
with other health care professionals which:
Improve continuity of care
Help prevent complications
Provide for health teaching
Eases the discharge planning process
⬤ Steps in planning nursing care
Determine priorities from the list of nursing
diagnoses
Set long-term and short-term goals to determine
outcomes of care
Develop objectives to reach the goals; stated in
terms of patient outcomes.
Write nursing orders to direct care to meet the goals
Priorities established according to the most
immediate needs of the patient
