NUR 2115 Exam 2 Concept Guide
Focused Learning Concept Guide: Exam 2
• Pleural effusion: Fluid in the pleural space
Pleura: serious membrane lining of the lungs and thoracic cavity, allows for filling and
emptying of the lungs
• Asthma: a condition in which the airways narrow and swell
- an example of airway resistance related to a decrease in the size of air passages
• Pneumothorax: air in the pleural space
• What causes numbness and tingling in the LE:
• Assessment: the systematic and continuous collection, analysis, validation, and
communication of patient data.
- Preparing for data collection
- Collecting data
- Identifying cues and making inferences
- Clustering data
- Clustering related data and identifying patterns
- Reporting and recording data
Types of Nursing Assessments:
- Initial assessment: preformed shortly after admission with the purpose of establishing
a complete database for problem identification and care planning. It also provides a
baseline for future comparison
- Ongoing assessment: alerts the nurse to any changes in the patient’s health and illness
so that she may suggest necessary changes in the plan of nursing care
- Focused assessment: data about a specific problem that has already been identified. It
is usually apart of ongoing data collection. It also used to identify new or overlooked
problems.
- Emergency assessment: when a crisis occurs. Ex: chocking in a dining hall
- Time-lapsed assessment: is scheduled to compare a patient’s current status to the
baseline data obtained earlier
*Medical assessments target data pointing to pathologic conditions, whereas nursing
assessments focus on the patient’s responses to health problems
Methods of Data Collection:
- Observation: use of the 5 senses to collect data
- Nursing History:
o Profile (name, age, sex, race, marital status, religion, occupation, education)
o Reason for seeking care
o Usual health habits
o Cultural consideration
o Current state of health
o Medications
o Perception of health status
o Developmental history
, o Patients expectations of nursing
o Patients educational needs and abilities
o Whether an Advanced Directive exists
o Strengths and weaknesses
o Potential for injury
- Interview: planned communication
- Physical Assessment: examination of the patient for objective data that may better
define the patient’s condition
• Diagnoses: the nurse interprets and analyzes data gathered from the nursing assessment.
actual or potential health problems that can be prevented or resolved by independent
nursing intervention
Types of Nursing Diagnoses:
- Actual: problems that have been validated by the presence of major defining
characteristics
o Label, definition, defining characteristics, related factor
- Risk: judgements that a person, family, or group is more vulnerable to develop than
others
- Possible: statements describing a suspected problem for which additional data is
needed
- Wellness: about a patient in transition from a specific level of wellness to a higher
level of wellness
o Two cues MUST be present
1. A desire for a higher level of wellness
2. An effective present status or function
- Syndrome: comprise a cluster of actual or risk nursing diagnoses that are predicted to
be present because of a certain event or situation (ex; rape & PTSD)
Parts of nursing diagnosis Statements:
- Problem: describes the health state or health problem of the patient
- Etiology: identifies the physiologic, psychologic, sociologic, spiritual, and
environmental factors believed to be related to the problem as either a cause or a
contributing factor
- Defining characteristics: subjective and objective data that signals the existence of the
actual or possible health problem
• Outcome planning:
• Implementation:
• Evaluation:
• What is the purpose of a nursing diagnosis?
Purposes of diagnosing:
- clarify the exact nature of the problems and risks that must be addressed to achieve
the overall expected outcomes of care
- Identify how a person, group, or community responds to actual or potential health and
life processes
- Identify factors that contribute to or cause health problems
- Identify resources or strengths that the given person, group, or community can draw
on to prevent or resolve problems
Focused Learning Concept Guide: Exam 2
• Pleural effusion: Fluid in the pleural space
Pleura: serious membrane lining of the lungs and thoracic cavity, allows for filling and
emptying of the lungs
• Asthma: a condition in which the airways narrow and swell
- an example of airway resistance related to a decrease in the size of air passages
• Pneumothorax: air in the pleural space
• What causes numbness and tingling in the LE:
• Assessment: the systematic and continuous collection, analysis, validation, and
communication of patient data.
- Preparing for data collection
- Collecting data
- Identifying cues and making inferences
- Clustering data
- Clustering related data and identifying patterns
- Reporting and recording data
Types of Nursing Assessments:
- Initial assessment: preformed shortly after admission with the purpose of establishing
a complete database for problem identification and care planning. It also provides a
baseline for future comparison
- Ongoing assessment: alerts the nurse to any changes in the patient’s health and illness
so that she may suggest necessary changes in the plan of nursing care
- Focused assessment: data about a specific problem that has already been identified. It
is usually apart of ongoing data collection. It also used to identify new or overlooked
problems.
- Emergency assessment: when a crisis occurs. Ex: chocking in a dining hall
- Time-lapsed assessment: is scheduled to compare a patient’s current status to the
baseline data obtained earlier
*Medical assessments target data pointing to pathologic conditions, whereas nursing
assessments focus on the patient’s responses to health problems
Methods of Data Collection:
- Observation: use of the 5 senses to collect data
- Nursing History:
o Profile (name, age, sex, race, marital status, religion, occupation, education)
o Reason for seeking care
o Usual health habits
o Cultural consideration
o Current state of health
o Medications
o Perception of health status
o Developmental history
, o Patients expectations of nursing
o Patients educational needs and abilities
o Whether an Advanced Directive exists
o Strengths and weaknesses
o Potential for injury
- Interview: planned communication
- Physical Assessment: examination of the patient for objective data that may better
define the patient’s condition
• Diagnoses: the nurse interprets and analyzes data gathered from the nursing assessment.
actual or potential health problems that can be prevented or resolved by independent
nursing intervention
Types of Nursing Diagnoses:
- Actual: problems that have been validated by the presence of major defining
characteristics
o Label, definition, defining characteristics, related factor
- Risk: judgements that a person, family, or group is more vulnerable to develop than
others
- Possible: statements describing a suspected problem for which additional data is
needed
- Wellness: about a patient in transition from a specific level of wellness to a higher
level of wellness
o Two cues MUST be present
1. A desire for a higher level of wellness
2. An effective present status or function
- Syndrome: comprise a cluster of actual or risk nursing diagnoses that are predicted to
be present because of a certain event or situation (ex; rape & PTSD)
Parts of nursing diagnosis Statements:
- Problem: describes the health state or health problem of the patient
- Etiology: identifies the physiologic, psychologic, sociologic, spiritual, and
environmental factors believed to be related to the problem as either a cause or a
contributing factor
- Defining characteristics: subjective and objective data that signals the existence of the
actual or possible health problem
• Outcome planning:
• Implementation:
• Evaluation:
• What is the purpose of a nursing diagnosis?
Purposes of diagnosing:
- clarify the exact nature of the problems and risks that must be addressed to achieve
the overall expected outcomes of care
- Identify how a person, group, or community responds to actual or potential health and
life processes
- Identify factors that contribute to or cause health problems
- Identify resources or strengths that the given person, group, or community can draw
on to prevent or resolve problems
