What you observe by inspecting, percussing,
palpating, and auscultating during physical
Objective data
examination
Basing practice on the best available research
evidence.
Evidence-based practice
Emergent, life threatening, and immediate (ex.
supporting breathing)
ABS plus V or CPR (If.needed)
First-level priority problem A-Airway problems
B-Breathing problems
C-Cardiac/circulation problems
V-Vital signs concerns (high fever)
Next in urgency, requiring attention so as to avoid further deterioration (ex.acute pain,
Second-level priority problem
mental status change, risks of infections)
Important to patient's health but can be addressed after more urgent problems are
Third-level priority
addressed (ex. family problems, lack of knowledge, rest, family coping, activity)
Assessment, Diagnosis, Planning, Implementation,
Evaluation
A= assessment data
ADPIE D= nursing diagnosis
P= plan
I= implementation of care
E= evaluation of care
An object worn, especially around the neck, as a
charm against evil or injury. "evil eye" or "evil spirit
The glass blue eye hung in the home (Turkey)
A seed with a red string placed on the crib
Amulets
(Mexican)
Bangles may be worn for protection (Caribbean)
Small packet placed on a crib or room of a baby
(Japanese)
remedies from the natural environment (ex. herbs,
plants, minerals, and animal substances) to treat
Natural folk medicine
illnesses.
occurs when an individual identifies equally with two
or more cultures
Biculturalism
, Process by which people of one culture merge into
and become part of another culture
Assimilation
to examine a patient and provide appropriate care
based around their cultural beliefs
Cultural nursing assessment
concepts about health individuals belief are true.
Influenced by culture
Health beliefs
Pain that is caused by tissue injury
nociceptive
Pathologic pain
neuropathic
nociceptive vs neuropathic
Visceral pain (organ pain)
Deep somatic pain (blood vessels, bone, tendons,
joints)
Sources of pain
Cutaneous pain (skin or subcutaneous tissue)
Referred pain (away from origin)
A pain that comes on quickly, can be severe and
lasts for a short time.
acute vs chronic pain
pain lasting longer than 6 months; it is constant or
occurs off and on
assessing chest pain P=palliative Q=quality
R=radiates S=severity T=Timing
PQRST
a mnemonic to quickly evaluate chest pain
initial pain assessment
asks the patient to rate his/her pain within 24 hours
from a scale of 0-10
brief pain inventory
used for cancer pain, also valid for chronic
nonmalignant pain, multidimensional pain
assessment
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