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:
ï‚§ Person (patient)
ï‚§ Environment
ï‚§ Health
ï‚§ Nursing
- Dorothea Orem:
o Selfcare is a human need, selfcare deficit requires nursing actions
ï‚§ Based on the ability of a person to meet their selfcare needs
ï‚§ An individual who is unable to meet selfcare needs has a selfcare deficit
ï‚· Organization of an assessment by Orem:
o Hazards:
ï‚§ Infection, inflammation, temperature
 Lymph nodes, skin, IV’s, drains, lab data
ï‚§ Medication
ï‚§ Wounds
ï‚§ Environmental safety
ï‚§ Allergies
ï‚§ Code Status
ï‚§
o Air:
ï‚§ Heart:
ï‚· Vital signs, heart sounds, rhythm, skin color,
mucosa, conjunctiva, nails, edema, JVD
ï‚· Pulses, capillary refill, skin color & condition of
extremities, pulse ox
ï‚§ Lungs:
ï‚· lung sounds, patency, general appearance, use
of accessory muscles, symmetry, cyanosis,
clubbing, smoke?
o Normalcy:
ï‚§ Ability to care for self
ï‚§ General appearance
ï‚§ Cognition, hygiene, grooming, self-concept, body image,
attitude, mood.
ï‚§ Speech, posture, movements
ï‚§ Signs of distress
ï‚§ Age, height, weight, gender, race,
ï‚§ Safety concerns, habits
o Solitude/ social interaction:
ï‚§ Level of consciousness, orientation, mental status,
communication
ï‚§ EENT (eyes, ears, nose and throat)
ï‚§ Sexuality, reproductive factors
ï‚§ Religious preference
o Food and water:
ï‚§ General appearance (Ht & Wt) / wt loss/gain
ï‚§ Skin (and turgor) hair, nails
ï‚§ Mouth (edentulous)/dentures
ï‚§ Appetite preferences
ï‚§ Intake & output
ï‚§ Fluid volume IV solutions etc.
ï‚§ Blood sugar
o Elimination:
ï‚§ Abdominal assessment + BS
ï‚§ Last bowel movement
ï‚· Color, consistency, frequency, mucous, blood
ï‚§ Condition of anus
ï‚§ Tenderness/pain
ï‚§ Bladder& urine assessment
ï‚· Continence
ï‚· Frequency, output, pain, retention, distention,
catheters, characteristics of urine, condition of
genitalia
o Activity/ rest:
ï‚§ Activity:
ï‚· posture /alignment
ï‚· Muscle tone & strength
ï‚· Numbness/tingling
ï‚· Reflexes
ï‚· Coordination
ï‚· ROM
ï‚· Mobility
ï‚· Activity tolerance
ï‚§ Rest:
ï‚· Sleep patterns
ï‚· Problems with sleep
ï‚§ Comfort level:
ï‚· Pain level
ï‚· Types of pain & where originated
ï‚· Pain as the 5th vital sign