Summary NR 304 Final Exam Concepts.pdf

Chapter i1: • Identify isteps iof iNursing iProcess: iEvaluation o Reassessment iof ipatient o Have igoals ibeen imet? • Identify itasks iin iNursing iProcess: iDiagnosis o Compiling idata ito idetermine iNANDA idiagnosis ifor ipatient o Cluster idata, idiscard iirrelevant iinformation • Types iof iDatabases: iProblem iCentered o Limited ior ishort-term iproblem o Concerns ione iproblem, icomplex, ior ibody isystem o Used iin iall isettings Chapter i9: • Identify iComponents iof ithe iGeneral iSurvey o Study iof ithe iwhole iperson o Begins iupon ientry ito ithe iroom o Physical iappearance ▪ Age: iperson iappears itheir istated iage ▪ Sex: idevelopment iis iappropriate ifor isex iand iage; iif itransgender inote istage i of itransformation ▪ Level iof iconsciousness: ialert iand ioriented ito iperson, iplace, itime, iand i situation ▪ Skin icolor: icolor itone ieven, ipigmentation ivaries, iskin iintact, inote itattoos i and ipiercings ▪ Facial ifeatures: inote isymmetry ▪ Overall iappearance: iacute idistress? o Body istructure ▪ Stature: iheight iin inormal irange ifor iage/genetics? ▪ Nutrition: iweight iwithin inormal irange ifor iheight/build? ▪ Symmetry: ibody iparts iequal ibilaterally? ▪ Posture: istand ierect icomfortably? i “plumb iline” ithrough ianterior iear, i shoulder, ihip, ipatella, iankle • Exceptions iare itoddler ilordosis iand iaging iperson iwith ikyphosis ▪ Position: isits icomfortably iwith iarms irelaxed iat isides iand ihead itowards i examiner ▪ Body ibuild, icontour: • Arm ispan i= iheight • Crown ito ipubis i≈ ipubis ito isole ▪ Obvious iphysical ideformities? o Mobility