PA Nursing

• Subjective data


  The patient's own perceptions and recollections about health, illness, values, beliefs, and practices
• Objective data


  Measurable and observable behaviors
• Health assessment


  The systematic and ongoing process of collecting, verifying, and communicating data about a patient's health status
• Nursing process


  A systematic, problem-solving method used to identify, prevent, and treat actual or potential health problems and promote wellness
• Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity
• The nursing process includes assessment, nursing diagnosis, planning, implementation, and evaluation
• Health assessment


  A systematic method of collecting data about a patient for the purpose of determining the patient's current and ongoing health status, predicting risks to health, and identifying health-promoting activities
• Health history


  Obtains information about the patient's health in his or her own words and based on the patient's own perceptions
• Focused interview


  Enables the nurse to clarify points, to obtain missing information, and to follow up on verbal and nonverbal cues identified in the health history
• Anatomic planes


  • Frontal plane
  • Median plane
  • Horizontal plane
  • Sagittal plane
• Terminology in relation to anatomic planes

  • Anterior (ventral)
  • Cephalad
  • Distal
  • Deep
  • External
  • Medial
  • Superior
  • Supine
  • Posterior (dorsal)
  • Caudad
  • Proximal
  • Superficial
  • Internal
  • Lateral
  • Inferior
  • Prone
• Interpretation of findings


  Making determinations about all of the data collected in the health assessment process
• Psychologic and emotional factors

  • Impact physiologic health and must be considered as predisposing or contributing factors when interpreting health assessment findings
  • Physical problems can impact emotional health
• Family factors


  • A family history of illness or health problems must be considered in the health assessment and interpretation of findings
  • Family dynamics may influence one's approach to health care
• Cultural factors


  • Culture impacts language, expression, emotional and physical well-being, and health practices
  • Findings regarding physical and emotional health must be interpreted in relation to the cultural norms for the patient
• Environmental factors


  • Internal and external environmental factors impact the health assessment and interpretation of findings
  • Data must be considered in relation to norms and expectations for age, race, and gender and in relation to factors impacting the individual patient
• Nursing process


  A systematic approach to nursing practice that includes assessment, diagnosis, planning, implementation, and evaluation
• Assessment includes the interview, physical assessment, documentation, and interpretation of findings
• Nursing practice is concerned with health promotion, wellness, illness prevention, health restoration, and care for the dying
• Nursing process


  A systematic, rational, dynamic, and cyclic process used by the nurse for assessing, planning, and implementing care for the patient
• Steps of the nursing process

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
• Assessment


  The collection, organization, and validation of subjective and objective data
• The database from the assessment will describe the physical, emotional, and spiritual health status of the patient
• Assessment begins when the nurse meets the patient and starts to gather information
• Each piece of information collected about a patient is a cue, because it hints at the total health status of the patient
• The baseline data act as a marker during future assessments
• Subjective data


  Information that the patient experiences and reports to the nurse
• Objective data


  Data observed or measured by the nurse
• Nursing diagnosis uses critical thinking and applies knowledge from the sciences and other disciplines to analyze and synthesize the data
• Data are compared to normative values and standards
• Similar data are clustered or grouped together
• Nursing diagnosis


  The basis for planning and implementing nursing care
• NANDA-I diagnoses that represent actual problems are formulated using a three-part PES statement
• Nursing diagnoses that represent potential problems—or risks—are written as two-part statements
• Wellness-related nursing diagnoses are written as one-part statements
• Planning involves setting priorities, identifying measurable patient goals or outcomes, and selecting evidence-based nursing interventions that promote achievement of the measurable patient goals or outcomes
• Implementation is the step where the nurse carries out the nursing interventions
• Implementation of evidence-based nursing interventions promotes the patient's achievement of the goals or outcomes
• There are reports of taking ibuprofen without food. This nursing diagnosis will generate the following measurable patient goal: The patient will correctly explain the risks associated with taking NSAIDs on an empty stomach prior to discharge from the physician's office.
• Nursing interventions


  Focused on achievement of the patient goal