Unit one

• Nursing process was first introduced in 1958 and has been integrated with the nursing care plan since the early 1960s
• Health is a quality of life involving social, emotional, mental, spiritual, and biological fitness on the part of the individual, resulting from adaptations to the environment
• Wellness refers to the achievement of the highest level of health in several key dimensions
• Nursing assessment involves deliberate and systematic collection of data to determine the client's current/past health status and coping patterns
• Establish a database for the client's normal abilities, risk factors, and any alterations
• Plan strategies to encourage continuation of healthy patterns, prevent potential health problems, and alleviate or manage existing health problems
• Provide a holistic view of the client
• Provide an essential foundation for the care of the client
• Regardless of the patient's age, nurses must respond to their needs for safety, privacy, confidentiality, comfort, pain management, choices and control, and involvement of family and/or significant other
• Cuddling facilitates the development of trust and bonding with parents, especially the mother
• Protect neonates from stressors such as lights and excessive handling
• Recognize that the neonate's behavior is largely reflex in nature
• Minimize stressors for neonates: strangers, loud noises, bright lights, and sudden environmental changes
• Expect exaggerated responses to pain, frustration, and changes in the environment from neonates
• Toddlers are ritualistic and impulsive, with quickly changing moods
• Parents and nurses should use a firm, direct approach with toddlers
• Preschoolers engage in magical thinking and may become fearful based on imagined threats
• Support preschoolers when fearful and allow them to participate in their care
• Encourage peer visitation for adolescents
• Provide support and information related to threats to body image
• Assess physical and cognitive ability to work and communicate with co-workers, family, and friends
• Assess the impact of hospitalization on family, work, and body image
• Initial nursing assessment is performed within a specified time after admission to a healthcare agency
• Focus or ongoing assessment is an ongoing process integrated with nursing care
• Emergency assessment and time-lapsed assessment are also types of assessments
• Approaches in assessment include cognitive skills, problem-solving skills, psychomotor skills, affective and interpersonal skills, and ethical skills
• Primary and secondary sources are used for gathering data
• Methods of data collection include observation and interview
• Therapeutic communication techniques include facilitating interventions, reinforcement, reflection, summarizing, accepting, giving recognition, reassurance, offering self, giving broad opening, making observations, focusing, active listening, seeking clarification, and associations
• Examination involves four primary techniques used in physical assessment: inspection, palpation, percussion, and auscultation
• Guidelines in doing inspection include comparing each area with the opposite side of the body, inspecting before touching, and exposing the area being examined
• Guidelines in doing palpation include handwashing, explaining the procedure, and stopping if pain is severe
• Percussion techniques involve tapping fingers quickly and sharply against body surfaces to produce sounds
• Auscultation is the process of listening to sounds produced within the body using a stethoscope
• Types of auscultation include direct or immediate auscultation and mediate/indirect auscultation
• Documentation, different client positions, and the nursing process involve functional assessment, descriptive assessment, and indirect assessment
• Types of clients to be assessed include silent clients, overly talkative clients, anxious frightened patients, angry clients, intoxicated clients, and depressed clients