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• Fundamentals of nursing


  Essential skills, knowledge, and attitudes required to provide high-quality care to patients
• Head-to-Toe Assessment


  1. Introduction

  2. Orientation

  3. Normal Vital Signs

  4. Head and Face
• Introduction


  1. Knock

  2. Introduce yourself

  3. Wash your hands

  4. Provide privacy

  5. Verify patient's ID using 2 patient identifiers (name and date of birth)

  6. Explain what you are doing (using non-medical language)
• Orientation


  • What is your name?
  • Do you know where you are?
  • Do you know what month is?
  • Do you know what brought you here?
  • A&O x4 = oriented to person, place, time and orientation
• Normal Vital Signs


  • Heart Rate: 60 - 100 bpm
  • Blood Pressure: 120/80 mmHg
  • Oxygen Saturation: 95 to 100%
  • Temperature: 97.8 degrees F to 99 degrees F (36.5 degrees C to 37.2 degrees C)
  • Respiratory Rate: 12 - 20 breaths/min
• Head and Face


  1. Head

  2. Eyes

  3. Face

  4. Ears

  5. Nose

  6. Mouth
• Head


  • Inspect head/scalp/hair
  • Palpate head/scalp/hair
• Eyes


  • Inspect external eye structures
  • Inspect the color of the conjunctiva and sclera and PERRLA (Pupils Equal Round Reactive to Light and Accomodation)
• Face


  • Inspect
  • Check for assymetry
  • To assess for CRANIAL NERVE II check (raise eyebrows, smile, frown, show teeth, puff out cheeks, tightly close the eyes)
• Ears


  • Symmetry, drainage/discharge, pain, hearing, deficits
• Nose


  • Symmetry, patency, drainage/discharge, presence of deviated septum
• Mouth


  • Color of the mucous membranes, moist/dry, lesions, abnormal dental findings, abnormal breath odors
• Nursing Process


  A systematic approach to nursing care that involves Assessment, Diagnosis, Planning, Intervention, and Evaluation
• Maslow's Hierarchy of Needs


  A theory proposing human needs are hierarchical, prioritizing: Physiological, Safety, Love and Belonging, Esteem, and Self-Actualization needs
• Nursing Theories


  A set of concepts describing, predicting, and explaining nursing phenomena, such as Self-Care Deficit and Health Belief theories
• Theory of Nursing


  A framework combining nursing concepts and psychological theories to explain, predict, and influence nursing practice
• Nurse-Patient Relationship


  The dynamic interaction between a healthcare provider and patient, prioritizing trust, communication, and empathy
• Nurse-Patient Relationship


  The dynamic interaction between a healthcare provider and patient, prioritizing empathy, communication, trust, and boundary setting
• King's Theory of Goal Attainment

  Focusing on the nurse-patient interaction and the nurse's role in helping patients achieve their goals
• Rogers' Theory of Unitary Human Beings


  Emphasizes interconnectedness and holistic care in nursing practice
• Ethics in Nursing


  Principles of Autonomy, Beneficence, Non-maleficence, and Justice guiding ethical decision-making in nursing practice
• ABG


  Arterial Blood Gas
• ACLV


  Adrenal Crisis Life-sustaining Values
• ALS


  Advanced Life Support
• BPOC


  Basic Pain Outcome Criteria
• CABG


  Coronary Artery Bypass Graft
• CPAP


  Continuous Positive Airway Pressure
• BP


  Blood Pressure
• PULSE


  Pulse Rate
• Temp


  Temperature
• IV


  Intravenous
• TSO


  Topical Systemic Ophthalmic
• PO


  Oral
• ESR


  Erythrocyte Sedimentation Rate
• LDH


  Lactate Dehydrogenase