Chapter 1 - Nursing Process: o Assess: the situation (gather data) o Diagnose: (identify): identify the problem o Plan: identify options o Implement: your decision/ interventions o Evaluate: your decision/ intervention  The nursing process is used to meet your patient’s health care needs - Florence Nightingale: o Founder of professional nursing o Challenged prejudices against women and elevated the status of all nurses o Established the first training school for nurses, and wrote books about health care and nursing education - Promoting Health o Health is individually defined by each person o Health is a state of optimal functioning or well being o Health is a subjective state: if a person is diagnosed with a specific illness they may still consider themselves healthy o Nurses promote health by identifying, analyzing, and maximizing each patient’s individual strengths Chapter 2 - Nursing Theories: o Definitions and the relations between them may differ from one theory to another o Four common concepts in nursing theories:  Person (patient)  Environment  Health  Nursing - Dorothea Orem: o Selfcare is a human need, selfcare deficit requires nursing actions  Based on the ability of a person to meet their selfcare needs  An individual who is unable to meet selfcare needs has a selfcare deficit  Organization of an assessment by Orem: o Hazards:  Infection, inflammation, temperature  Lymph nodes, skin, IV’s, drains, lab data  Medication  Wounds  Environmental safety  Allergies  Code Status  o Air:  Heart:  Vital signs, heart sounds, rhythm, skin color, mucosa, conjunctiva, nails, edema, JVD  Pulses, capillary refill, skin color & condition of extremities, pulse ox  Lungs:  lung sounds, patency, general appearance, use of accessory muscles, symmetry, cyanosis, clubbing, smoke? o Normalcy:  Ability to care for self  General appearance  Cognition, hygiene, grooming, self-concept, body image, attitude, mood.  Speech, posture, movements  Signs of distress  Age, height, weight, gender, race,  Safety concerns, habits o Solitude/ social interaction:  Level of consciousness, orientation, mental status, communication  EENT (eyes, ears, nose and throat)  Sexuality, reproductive factors  Religious preference o Food and water:  General appearance (Ht & Wt) / wt loss/gain  Skin (and turgor) hair, nails  Mouth (edentulous)/dentures  Appetite preferences  Intake & output  Fluid volume IV solutions etc.  Blood sugar o Elimination:  Abdominal assessment + BS  Last bowel movement  Color, consistency, frequency, mucous, blood  Condition of anus  Tenderness/pain  Bladder& urine assessment  Continence  Frequency, output, pain, retention, distention, catheters, characteristics of urine, condition of genitalia o Activity/ rest:  Activity:  posture /alignment  Muscle tone & strength  Numbness/tingling  Reflexes  Coordination  ROM  Mobility  Activity tolerance  Rest:  Sleep patterns  Problems with sleep  Comfort level:  Pain level  Types of pain & where originated  Pain as the 5th vital sign