The nursing process Final Foundations Review Latest 2020/2021

The nursing process: Assessment Diagnosis Planning (Patient will…)(SMART) Implementation (Nurse will..) Evaluation subjective and objective data Subjective: What the patient says, feels, experiences Objective: Measurable data (Vital signs, Diagnostics, Pain) What to document when giving medication 1. Right patient 2. Right medication 3. Right Dose 4. Right Route 5. Right Time 6. Right Documentation Three checks: 1.MAR 2. Band 3. Verbal Confirmation (DOB, F/L NAME) Routes: 1.IV 2. Subq (45-90 degree angle) 3. Oral (PO) 4. IM (AVOID THE DORSOGLUTEAL!!)(Z track method) 5. Intradermal (Think of your PPD test!!) Vital signs (normal values) PULSE: 1. Sites a. Radial, temporal, dorsal pedialis, posterior tibial, femoral, etc. b. Bradycardia <60BPM c. Tachycardia >100BPM 2. 0 (Absent), +1 (Diminished), +2(Brisk, normal), +3(Bounding) RESPIRATIONS: 1. 12-20 RR 2. O2 SAT 95-100%( <70 LIFE THREATENING) 3. Eupena (Normal), Tachypnea (too fast), Bradypnea(Too slow), Orthopnea (Upright Position), Apnea (Stop breathing), Dyspnea (labored breathing) TEMPERATURE: 1. Sites and methods of assessing temperature: -Oral (sublingual) = 36.5-37.5 (C) and 97.7-99.5 (F) -Tympanic -Temporal artery -Rectal = BEST ROUTE/HIGHEST/BASAL TEMP/BABIES -Axillary 2. Afebrile (w/o fever): 35.9C (96.4) – 38 C(99.6) 3. Febril (PYREXIA): 100.3 4. Hypothermia DEATH HAPPENS @ 35C (95F) BLOOD PRESSURE 1.Blo dpresureranges: -Normal:<120(systolic)and<80(diastolic) -Elevated:120-129(systolic)and<80(diastolic) -HypertensionStage1:130-139(systolic)and80-89(diastolic) -HypertensionStage2:>orequalto140(systolic)and>orequal to90(diastolic) -HypertensionStage3:>180(systolic)and>120(diastolic) OrthostaticHypotensionDecreasedinSystolic>20,Diastolic>10 2.Sites:Brachial,Radial,Popiteal Pain (OPQRST)(5th Vital Sign) 1. Onset 2. Provocation 3. Quality 4. Radiate 5. Severity 6. Time 2. The 4PS: PAIN, PEROSNAL, POSITIONING, FALL PREVENTION 3. Sources of pain a. Nociceptive (Bothersome) b. Cutaneous (Skin) c. Somatic (joints and bone) d. Visceral (Organ) e. Neuropathic (Nerves) 4. Pain scales a. Numeric (0-10) b. Flacc (Behavioral) c. Won baker (Faces) Infection control 1. handwashing a. Proximal  Distal PPE(ON) 1. Gown first 2. Mask 3. Googles/wear (if needed) 4. GLOVES PPE(OFF) 1. Gloves off 2. Gown 3. Eye wear 4. Mask