NUR 155 Theory and Lab(fully solved)2023 update

Critical Thinking Involves the application of knowledge and experience. Clinical Reasoning The ability to focus and filter critical data to recognize what is most and least important. Steps of the Nursing Process ADPIE 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation Assessment Collect data -subjective(health hx, symptoms) -objective(measurable, signs, labs, exams) Recognize cues Three ways -observation -interview (primary: patient- secondary: family, spouse) -exam Nursing Diagnosis NANDA -Analyze data/cues Supporting data -etiology -signs -symptoms Planning MASLOW -Prioritize ABC's then safety Set goals "patient will" Develop nursing interventions. Implementation DOCUMENT Put plan into action DELEGATION Evaluation -met -partially met reassess -not met reassess CANNOT DELEGATE T.A.P.E. Teaching Assessment Planning Evaluation Palpation Touch to assess body organs, skin texture temperature, moisture, turgor, tenderness, and thickness. Percussion Involves tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin. Auscultation Listening with the assistance of a stethoscope. Subjective Data spoken information; symptoms. Objective Data signs; can be measured or observed Etiology the underlying cause of disease Temperature (range) 97.6-99.5 F = normal range Factors affecting temperature Age, exercise, hormone levels, circadian rhythm, stress, environment, smoking....... Febrile patient with a fever Afebrile a patient without a fever Hypo- low, less than normal Hyper- high, excessive a- without Pulse (range) 60-100 bpm (beats per minute) factors affecting pulse Age Gender Fever Medications Hypovolemia Hypoxia Hypoxemia Stress Electrolyte Imbalance Pathology PULSE SITES (HIGHLY EMPHASIZED) Temporal- forehead (temporal lobe) Carotid- neck APICAL- 5th intercostal space, midclavicular line Brachial- inner arm Radial- wrist, thumb side Femoral-inguinal regional Popliteal- back of knee Posterior tibial- ankle Pedal- top of foot Pulse Intensity 0: absent 1: diminished/weak 2: normal 3: bounding Hypothermia low body temperature Hyperthermia high body temperature Hypotension low blood pressure Hypertension high blood pressure Fever Pyrexia Tachy- fast, rapid Brady- slow Tachycardia 100 bpm Bradycardia 60 bpm dysrhythmia/arrhythmia irregular rhythm due to early, late or missed heartbeat Blood Pressure (range) less than 120/80 normal range Factors affecting blood pressure Age Gender Race Circadian rhythm Food intake Exercise Weight Emotional state Pain Drugs/medications Head injury Hypoxemia low oxygen levels in the blood Hypercapnia high levels of carbon dioxide oxygen saturation (SpO2) amount of oxygen in arterial blood Eupnea normal respiration with a normal rate and depth for the patient's age Tachypnea increased respiratory rate bradypnea decreased respiratory rate hypoventilation shallow respirations Hyperventilation deep, rapid respirations Apnea absence of breathing Dyspnea shortness of breath, difficult or labored breathing orthopnea difficult breathing relieved by sitting or standing. Cyanosis blue discoloration of the skin caused by a lack of adequate oxygen in the blood systolic pressure PEAK of the pressure wave (top number) diastolic pressure lowest pressure; when the heart rests (bottom number) orthostatic hypotension Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions Eu- normal, good, well, healthy O2 saturation (SpO2) (range) 95%: normal range SpO2 affected by Hemoglobin Circulation Activity Carbon Monoxide Acrylic nails/polish Poor perfusion Dark skin tones Cold extremities Pain (scale) ranges from 0-10 0 being no pain 10 being the worst pain ever document as fraction.