Introduction to nursing Flashcards
Nursing process
Assessment: collecting/interpreting data
Problem: identifying actual & potential
Planning: prioritise, identify goals and timeframe
Implementation: delegation, document, report
Evaluation: goals, reassess, document, level of success
Subjective vs objective data
Subjective: patient’s perspective, symptoms, feelings, concerns
Objective: observable & measurable through physical exam, lab testings, observation
ISBAR
Intro: who you are, who patient is, identifiers
Situation: current status, any issues
Background: presenting complaint, history
Assessment: any physical exam, vital signs, lab tests
Recommendation: goals of care, tasks required
Rules of documentation
- Right chart
- Date, 2400 hour format
- Signature, printed name & designation
- Blue, black pen
- Write accurately & completely
- Single line through errors
- Write as close to event as possible
Components of a health history
- Demographic data
- Presenting problem
- History of presenting problem
- Past medical/surgical history
- Medications/allergies
- Family history
- Social history
Social history
- marital status
- employment
- drug/alcohol/tobacco use
- mood/stressors
- social supports
- living conditions
- hobbies/environments
- nutrition
- sleep
- ADLs
Pain assessment
Provocation: what makes it worse/better Quality/quantity: what does it feel like (sharp, ache, tight) Region: where, radiation? Severity: scale of 1-10 Timing: onset, frequency, duration
Physical exam techniques
Inspection Palpation Percussion Auscultation * GI = IAPP
Palpation
Fine discrimination/pulsations: fingertips
Vibrations: palmar/ulnar surface
Temperature: dorsal surface
Primary assessment
Danger Response - AVPU Send for help Airway Breathing Circulation Disability Exposure
5 moments for hand hygiene
- Before touching a patient
- After touching a patient
- Before a procedure
- After a procedure
- After touching patient surroundings
