Page 1 Nursing Fundamental
1 kg 2.2 lbs
1 oz 30 mL
6 competencies of QSEN 1. Quality Improvement (QI)
2. Teamwork and Collaboration (TC)
3. Client-Centered Care (PCC)
4. Informatics (I)
5. Evidence-Based Practice (EBP)
6. Safety (S)
Abdominal Assessment 1. RUQ
2. LUQ
3. LLQ
4. RLQ
Inspect in a circular motion for correct fluid sounds.
Nursing Fundamental 1
,Page 2 Nursing Fundamental
Actual Diagnosis Client problem that is present at the time of the nursing assessment.
Ex. BP high due to anxiety.
Affects BP 1. Age
2. Exercise
3. Stress
4. Gender
5. Meds
6. Body Weight
7. Temp
8. Overall Health
Alopecia Hair loss.
Analyzing Data Steps 1. Compare data against standards (id significant cues).
2. Cluster cues; generate hypothesis.
3. Id. gaps & inconsistencies.
Apical Pulse Central pulse located at the apex of the heart.
Nursing Fundamental 2
,Page 3 Nursing Fundamental
Apical Pulse Locations 1. Second Intercostal Space
2. Third Intercostal Space
3. Fifth Intercostal Space, MCL/PMI
Arterial BP Measure of the pressure exerted by blood against the walls of the arterial
system.
Assessing: Data Collection 1. Build Rapport First.
2. Ask your questions.
3. Close the interview
4. Ask additional question during the physical assessment.
Assessing Sources of Data 1. Client-best source of data.
2. Support People (Emergency)
3. Client Records
4. Health Care Professionals
Nursing Fundamental 3
, Page 4 Nursing Fundamental
Assessing Steps 1. Initial Assessment (Admission assessment)
2. Problem-Focused Assessment (Pain)
3. Shift Assessment
4. Emergency Assessment (Shortness of Breath)
5. Time-Lapsed Reassessment (Home Health)
Assessment Est. a database about the client; includes health history, physical assessment,
& consultations with supports systems/health professionals.
Ex. physical, mental, spiritual, economic, & cultural status.
Ausculatation Process of listening for sounds within the body.
Auscultatory Gap Hypertensive clients; temporary disapperance of sounds normally heard
over the brachial artery when the cuff pressure is high followed by
reappearance of sounds @ a lower level.
Axillae Assessment 1. Hair dispersion
2. Odor
3. Enlarged lymph nodes.
Nursing Fundamental 4
1 kg 2.2 lbs
1 oz 30 mL
6 competencies of QSEN 1. Quality Improvement (QI)
2. Teamwork and Collaboration (TC)
3. Client-Centered Care (PCC)
4. Informatics (I)
5. Evidence-Based Practice (EBP)
6. Safety (S)
Abdominal Assessment 1. RUQ
2. LUQ
3. LLQ
4. RLQ
Inspect in a circular motion for correct fluid sounds.
Nursing Fundamental 1
,Page 2 Nursing Fundamental
Actual Diagnosis Client problem that is present at the time of the nursing assessment.
Ex. BP high due to anxiety.
Affects BP 1. Age
2. Exercise
3. Stress
4. Gender
5. Meds
6. Body Weight
7. Temp
8. Overall Health
Alopecia Hair loss.
Analyzing Data Steps 1. Compare data against standards (id significant cues).
2. Cluster cues; generate hypothesis.
3. Id. gaps & inconsistencies.
Apical Pulse Central pulse located at the apex of the heart.
Nursing Fundamental 2
,Page 3 Nursing Fundamental
Apical Pulse Locations 1. Second Intercostal Space
2. Third Intercostal Space
3. Fifth Intercostal Space, MCL/PMI
Arterial BP Measure of the pressure exerted by blood against the walls of the arterial
system.
Assessing: Data Collection 1. Build Rapport First.
2. Ask your questions.
3. Close the interview
4. Ask additional question during the physical assessment.
Assessing Sources of Data 1. Client-best source of data.
2. Support People (Emergency)
3. Client Records
4. Health Care Professionals
Nursing Fundamental 3
, Page 4 Nursing Fundamental
Assessing Steps 1. Initial Assessment (Admission assessment)
2. Problem-Focused Assessment (Pain)
3. Shift Assessment
4. Emergency Assessment (Shortness of Breath)
5. Time-Lapsed Reassessment (Home Health)
Assessment Est. a database about the client; includes health history, physical assessment,
& consultations with supports systems/health professionals.
Ex. physical, mental, spiritual, economic, & cultural status.
Ausculatation Process of listening for sounds within the body.
Auscultatory Gap Hypertensive clients; temporary disapperance of sounds normally heard
over the brachial artery when the cuff pressure is high followed by
reappearance of sounds @ a lower level.
Axillae Assessment 1. Hair dispersion
2. Odor
3. Enlarged lymph nodes.
Nursing Fundamental 4
