MODULE 1

●Nursing process are

Assessment-Subjective and objective data gathered
Dagnosis -Nursing focus and is based on real or potential health problems or human responses
Planning-Devising the best course of action to address the patients diagnosis
Implementation -Completed by the patient the family or the members of the healthcare team
Evaluation -Process to determine if the goals have been attained
●Type of health assessment
Comprehensive health assessment -Admission of a new patient to a clinic hospital long term care
facility
Focused or problem oriented assessment -Focuses on gathering information about the patients
problem
Focused assessment -Follow up history
Emergency histoy -Focus on the patients emergency problem
ABCs-Airway,breathing,and circulation
MODULE 2
●Phases of interview
Pre interview -Set the stage for a smooth interview
Introduction -Put the patient at ease and establish trust
Working -Obtain patient information
Termination -Summarize important points
●Key elements of the past history
-Allergies -Including specific reaction to each medication
-Medications -Including name dose/route and frequency of use
-Childhood illness -Such as measles,rubella,mumps
-Adult illness
*Medical -Disease
*Surgical-Operation
*Accidents-Accidents
*Psychiatric-Hopitalization
-Health maintenance
*Immunization -Inject
*Screening test -Tests
*Safety measure -Safety
MODULE 3
●Cardinal techniques of examination
*Inspection-Observation of the details
*Palpation-pressure of Finger or finger pads
*Percussion -Striking or plexorf finger
*Auscultation -Use diaphragm and belt stethoscope
MODULE 4
Vital signs
*Temperatures-36.5 to 37.5 degrees Celsius or 97.6 to 99.3 Fahrenheit
-ORAL
-RECTAL
-AXILLARY
-TYMPANIC
*Respiration -60-100
*Pulse-
*Blood pressure -120/80
MODULE 5
*Spiritual assessment
Spirituality -most human experiences seeks to transcend self find meaning purpose
through connection
Religion -system of beliefs or practice of worship
Spiritual distress -individual sense of purpose or meaning of life is threatened
Nursing presence -holistic and reciprocal exchange between nurse and patient
involves sharing a human experience listening attentiveness and intimacy
MODULE 6
*Mood-define a sustained emotion
*Thought content-to determine whether or not a patient is experiencing
hallucination
HALLUCINATION
*auditory (hearing things)
*visual (seeing things)
*gastatory (tasting things)
*tactile (feeling sensations)
*olfactory (smelling things)
DELUSION
*grandiose(grandeur)
*religous(special status with god)
*persecution(believe that someone wants to cause them harm)
*erotomanic(belief that someone famou is in love with them)
*jealousy(belief that everyone wants what they have)
*thought insertion(belief that someone putting ideas in their mind)
* ideas of reference(belief that relatively ordinary)
MODULE 7
The purpose of indigenous system
*diseases of the skin D
*systematic diseases that have skin manifestations S
*physical abuse P
*risk for pressure ulcer formation R
*risk for skin cancer R
*need for help promotion education regarding the skin N
Common or concerning symptoms
*rash
*non healing lesions
*moles
*lesions
*bruising(ecchymosis)
*hair loss
Physical examination of the skin
-skin color will vary according to genetic background and may have fair,olive,tan
brown,or golden hues
-inspecting the palms and souls may be useful in dark people
MODULE 8
Common are concerning symptoms of the head
*headache
*head injury
*head are neck surgery
* traumatic brain injury
Headache
-one of the most common symptoms in clinical practice 30%
Migrane Headaches
-by far the most frequent cause of headaches 80%
Traumatic brain injury (TBI)
-interfers with a function of the brain