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NURS 6011 - Exam 2 Study Guide.
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NURS 6011 Study Guide Exam 2 Steps in Nursing Process (again)
o Is a systematic problem-solving approach to identifying and treating
human responses to actual or potential health difficulties. It serves as a
framework for providing individualized care not only to individuals but also
to families and communities. It is patient centered and focuses on solving
problems and enhancing strengths. It is applicable to patients in all stages
of the life span and in all settings
Assessing: begins with a complete and accurate health assessment
to promote health at its highest level. You set outcomes
collaboratively with patients.
Diagnose: provide a specific language and way of thinking. You use
diagnostic reasoning and critical thinking to formulate diagnostic
statements. Diagnoses may identify actual problems, risk for
developing problems and possible difficulties.
Planning: activities include determining resources, targeting nursing
interventions, and writing a care plan. The nursing plan requires
that you analyze the individual patient and his or her needs to
provide individualized and holistic care. You communicate the plan
verbally and write it in the patient’s chart.
Implementation: types include assessment, education, supervision,
coordination, referral, support, therapeutic communication, and
technical skills.
Evaluation: Is the judgment of the effectiveness of nursing care in
meeting the goals and outcomes. It is based on the patient’s
responses to the interventions. To make judgments about the
progress of the patient, analyze the effectiveness of nursing care,
review potential areas for collaboration with and referral to other
health care professionals and monitor the quality of nursing care
and its effect on the patient.
You will use subjective data collection for interviewing skills
and physical assessment for objective data.
What are normal Vital Signs (again)?
o Temperature
Axillary, rectal, temporal, tympanic, oral
Normal oral temperature is 97.7 to 98.6 degrees
o Pulse
Radial, brachial, femoral, dorsalis pedis, tibial, temporal, carotid
60-100 bpm
o Respirations
Tachypnea, hyperventilating, hypoventilation
Normal: 12-20 breaths
, o BP
Most common is brachial artery BP
Normal 120/80
What is the point of nursing diagnoses?
o The clustering of data to make a judgment or statement about the patient’s
difficulty or condition
o The clinical judgment about an individual, their family or community
responses to actual or potential health difficulties/life processes. A nursing
diagnosis provides the basis for selection of nursing interventions to
achieve outcomes for which the nurse is accountable
Measuring Intake and Outputs
o Measuring how much a person drinks or how much fluid they are given is
measuring intakes
Fluid intake and loss in adults ranges from 1,500 to 3,500 mL each
24 hours.
Urine is about 1,500 mL/24 or about 40-80mL on average
o Outputs is measuring the amount of urine excreted from the body
o Anything that is liquid record as input
o Urine, diarrhea, NG tube and that is all output
What is the difference between interstitial fluid, intracellular fluid,
extracellular fluid, intravascular fluid?
o Intracellular: is fluid inside of a cell
Makes up about 70% of total body water and 40% of the body’s
weight
o Extracellular: is all the fluid outside of the cell
Makes up about 30% of total body water
ECF includes intravascular and interstitial fluids
o Intravascular fluid is the plasma, the liquid
component of blood
o Interstitial is the fluid that surrounds the cell
How do you measure acid-base balance?
o Body fluids must maintain an acid-base balance to sustain health and
homeostasis
o It is determined by the concentration of H+ ions.
o A strong acid dissociates (separates) completely in solution and releases
all of its H+ ions a strong base will accept these H+ ions
o As the H+ ions increase in a solution it will become more acidic. When H+
ions are reduced in a solution or accepted by another substance the
solution will contain more base
3 mechanisms:
Chemical blood buffer system, respiratory system and renal
system
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