Nursing: a QuickStudy Laminated Reference Guide
By Julie Henry and Henry
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About this ebook
6 page laminated guide includes:
- Components of the Nursing Process
- Basic Head-to-Toe Assessment
- Assessing Lung Sounds (with diagram)
- Adventitious Lung Sounds & Potential Causes
- Assessment Techniques
- Percussion Sounds & Potential Causes
- System Assessment
- Glasgow Coma Scale
- Heart
- Normal Electrocardiogram (EKG) Pattern
- Grading of Heart Murmurs
- Edema Rating Scale
- Pulses
- Skin & Muscles
- Quick Guide to Skin Assessment
- Muscle Strength
- Decubitus Ulcer Staging
- Medication Administration
- Medication Dosage Calculation
- Injection Sites (with images)
- Insulin Types & Action Times
- IV Solutions & Calculations
- Laboratory Values
- Comprehensive Metabolic Panel
- Coagulation Studies
- Complete Blood Count (CBC) & Differential
- Common Abbreviations
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Nursing - Julie Henry
Table of Contents
Components Of The Nursing Process
Basic Head-To-Toe Assessment
Assessing Lung Sounds
Assessment Techniques
System Assessment
Glasgow Coma Scale
Heart
Skin & Muscles
Medication Administartion
Insulin Types & Action Times
Iv Solutions & Calculations
Laboratory Values
Abbreviations
NursingCOMPONENTS OF THE NURSING PROCESS
Assessment: The process by which a nurse investigates the physical, psychosocial, and spiritual needs of a patient through the collection of subjective and objective data.
Analysis (a.k.a. diagnosis): The data collected during the assessment phase is evaluated to determine a plan of care.
Planning: The data from the assessment and analysis phases is used to develop measurable goals and outcomes (i.e., nursing interventions).
Implementation: The nursing interventions are put into practice.
Evaluation: The outcomes of the nursing interventions are assessed.
NursingBASIC HEAD-TO-TOE ASSESSMENT
General: Assess general appearance and behavior, posture, gait, hygiene, speech, mental status, height and weight, hearing and visual acuity, vital signs, and nutrition.
Head and neck: Assess skull size, shape, and symmetry, as well as hair and scalp. Palpate for masses on scalp, ears, face, throat, and neck. Palpate sinuses for tenderness and masses. Inspect sclera and conjunctiva. Assess pupil response by using PERRLA (pupils equal, round, reactive to light and accommodation). Test convergence (as eyes shift from a far object to a near object, pupils constrict), confrontation (the extent of the peripheral field), and corneal light reflex. Inspect and palpate teeth and gums. Test rise of uvula and gag reflex. Assess sense of smell and taste.