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Nursing Fundamentals Basics Study Guide

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THE NURSING PROCESS: The nursing process is a step-by-step system for what you will do as a nurse, broken down into the mnemonic AD(O)PIE: ● Assessment ● Diagnosis ● (Outcome Identification ... ) ● Planning ● Implementation ● Evaluation Assessment Assessment is the number one most important thing you will ever do as a nurse. You are going to be asking your patient questions, doing your head to toe assessment, and using your critical thinking skills to get an idea of what might actually be going on with them, what you need to assess for further, and how you can plan their care better. The nursing assessment really has 2 main components: ● Collecting data ○ Take vital signs ○ Head to toe assessment ○ Focused assessment ○ Patient history ○ Activities of daily living (ADLs) ○ Psychosocial assessment ○ Spirituality ○ Life stressors ● Critical thinking: constantly thinking about what could be going on with the patient, what the underlying problems are, and what you need to assess for further, noticing slight changes in the patient, how they respond to questions, and being aware of if something just feels off EXAMPLE: You're taking care of a cardiac patient and you notice on their heart monitor that their heart rhythm is going all crazy. So you run into their room. But when you get there, they're talking to you and moving around. Are you going to shock them right away to get their heart back into a normal rhythm? No! You're going to ask them to sit down for a moment so you can see what their heart is really doing. [Show More]

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