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NU 116 ECC
Module I
| Question | Answer |
|---|---|
| Health Promotion | Is a way of thinking that centers around wholeness, wellness, and well being. |
| Health Protection | Aka Illness Prevention, is avoiding the developement of disease in the future, or limit the progression of disease |
| Primary Prevention | Used to decrease the risk or exposure of a person to disease. Ex. Accident & Poisoning prevention, immunizations. |
| Secondary Prevention | Early stage of disease and limit future disability. Ex Medical and dental checkups, self exams health screening |
| Tertiary Prevention | Return pt. to best level of function possible. Ex Teaching DM pt to id. & prevent complications |
| Nursing Process | A framework systematic, dinamic & cyclic approach used to identify, prevent & treat actual or potential health problems & promote wellness |
| Steps to the Nursing Process | 1.Assessment 2.Diagnosis (Problem Identification)3.Planning 4.Implementation 5.Evaluation |
| Assessment is: | The systematic gathering of relevant client info for use identifying health problems |
| Three Activities of Assessment: | 1.Systematic gathering, sorting & organizing data 2.Documenting data in a retrievable format 3.Data is must be validated & clustered to id. patterns of health |
| Types of Data: | *Subjective (symptoms that pt. reports)*Objective (signs that the nurse observes) |
| Sources of Data: | Primary: Pt. (if alert & oriented)Secondary: a)Significant others b)other health care providers c)pt's medical records d)Nursing literature |
| Methods of Data Collection: | 1)Interview 2)Nursing History 3)Physical Examination |
| 1) Guidelines for a Successful Intervie: | Preparation, Time, Understandable, Rapport, Listen, Organize & Document |
| 2) Nursing History | Biographical, Hx of Present Illness, Present Level of Function, Current Health Practices, Emotional & social status |
| 3) Physical Examination | Objective data to validate subjective one. Baseline. Asses all body parts & systems in systematic manner |
| Assessment Techniques | a) Inspectionb) Palpationc)Percussiond)Auscultation |
| Data Collection: (Printed Sources) | Medical Kardex, Medical Record, Medication Book & Treatment Book |
| Information on Kardex: | Name, age, sex, MD, allergies. primary c/o. MD diagnosis, reent surgeries. PMH & PSH. Diet and ability to feed self. activity level and ADL. Safety precautions, frequency o VS Treatments and Therapies. Code Status |
| Info on Medical Record: | MD Hx and Physical. Nurses Admission Sheet, Social Work Assessment, Lab Data, Progress Notes, Nutritional Assessment, Nurses Notes |
| 4 types of Nursing Diagnosis | Actual Nursing Diagnosis, Risk Diagnosis, Wellness Diagnosis & Collaborative Problems |
| Actual Nursing Diagnosis: | 3 part statement = Problem + r/t "related to" + etiology. ie. |
| Risk for Nursing Diagnosis | 2 part statement Risk for (problem) + r/t + etiology |
| Wellness Diagnosis | Diagnosis only. Readiness for Enhanced ... |
| Collaborative Problems | Potential Complication (PC): ex. PC Head Injury: Increased Intracranial Pressure |
| Homeostasis | Tendency of the body to maintain a state of balance or equilibrium while continually changing. |
| Closed System: | Doesn't exchange energy, matter, or information with its enviroment. Receives no output from enviroment. |
| Open System: | Energy, matter, and information move in and outof the system through the system boundary. All living systems are open system. |
| Maslow's hierarchy of needs | Physiologic, Safety/Security, Love & Belonging, Self-Steem, Self-actualization. |
Created by:
Formiga
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