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MS Assessment A - Templates
Templates
Course
Medical Surgical (NUR425)
418 Documents
Students shared 418 documents in this course
University
Arizona College of Nursing
Academic year: 2022/2023
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Nursing Skill
STUDENT NAME _____________________________________
SKILL NAME____________________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Description of Skill
Indications
Outcomes/Evaluation
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
Luanne Brocks
AirwayManagement/Oxygen Therepy
Airway management.
When the nurse maintains or assits withthe maintenance
of the clients airway, consisting
of the upper and lower respiratorysystem.
OxygenTherapy administrationofsupplementaloxygen via nasal camula or mask.
when theclient begins to show
signs
of hypoxia,
including respirations
Interventions will occur
when the
over 20 /min, and anxiety/restlessness,
clients O2 levels drop
below the
or when the clients 02 sats drop
desired range, or a patent
below 92% for those without
COPD, airway can no longer be maintained
and 85% for those with COPD.
through
less invasive metroals.
The desired outcome
world
be the returnof the client's
no open flames near your O2,
On Saturation
to return to the
including smoking.
Be sure to monitor
desiredrange,andforthem for skin breakdown on the tops of
to breathe as independantly as your ears,
on your cheeks, and in
Possible. your
nose. If you are on more than
4L/min, then
humidificationneeds
to be added. Do not use any
Petrolium based products nearyour
02.
Potentialcomplications can include interventions
would include lowering
oxygen toxicity,
skin breakdown, the flow rate on
the clients oxygen,
and in the worst case, the client using
alternative deliverymethods to
reduce skin break down, and working
becomes dependent on a machine to reduce or Preventthe clientfrom
to assist in respiration.
beaming vent
or bipup dependent.
Basic Concept
STUDENT NAME _____________________________________
CONCEPT ______________________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Related Content
(E., DELEGATION,
LEVELS OF PREVENTION,
ADVANCE DIRECTIVES)
Underlying Principles Nursing Interventions
WHO? WHEN? WHY? HOW?
Luanne Brooks
Safety/risk reduction.
I assessment
Safety isatthe
care of
thenursing Professionas a nurse will intervene
safetyis related to all
whole. We use it when any timethere is threat
aspects of the nursing Pricratizing
care byusing or risk to besafety of
the ABCs, in med pass with the clients or staff.
process example a the three checks, and in
registered nurse can only
many other aspects
of Nurses can
reduce risk in
delegante tasks that
it is
the field.
several ways, but one of
Safe for a UAP or LPN 40 the most important
and
Preform. There are also easiest is to slow down,
and
multiple checks in place Risk reductiongoes be thorough in everythingfrom
to ensure maximumsafety
hand in hand
with safety. our assessments, to meal pass,
when itcomes to medication Client interactions.
administraction. If there is no active
risk reduction,
then When
There are several assessing for
things
the environment is
not Safety, the nurse should
that can be clone to improve askthe client about their
risk reduction. These likely
to be very safe. current ideatim, as well
include groel Stuff:client as remove all potentially
warmfull objects fromthe
veutics, Propper meal checks, environment. Thesecam
andstaff training include sharp objects,
clienta family glass,
metal utensils, cards,
laces, or strings.
education
If client
has a
Seizurediscreter,
educate family an
how to ensure a
safe environment.
Nursing Skill
STUDENT NAME _____________________________________
SKILL NAME____________________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Description of Skill
Indications
Outcomes/Evaluation
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
Luanne Brooks
Airborne Precautions
Initiating airborne precautions
varies slightlybyfacility. Some require full hood
Positive pressure respirators,gown, and gloves. Others just require an N95 mask andgown.
one thingthat always happens, is that the clientis placed
in a negative air pressure room
to reduce the spread of the pathogen.
Airborne precautions are used when a client
has been diagnosed with, or is suspectedto
have contracted is, measles, chickenpox, The client will need to be in a
negative
or SARS. Pressure room, andwear a surgical mask
Whenever they leave the room. Visitors should
be restricted
Expectedoutcomes include no
spread of the disease up to
and the client will need to stay in
including
time of discharge their room as much as possible,
and if theydo need to leave their
room, they need to
wear a procedure
mask the whole time to reduce the
Spread of infection.
complicating can include spread monitor for disease progression,
ofthe infection, disease and spread, provide activities
complications,
andthe client feeling if desired to help reduce the
trappedin their
roun client'sfeelingsof isolation.
Basic Concept
STUDENT NAME _____________________________________
CONCEPT ______________________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Related Content
(E., DELEGATION,
LEVELS OF PREVENTION,
ADVANCE DIRECTIVES)
Underlying Principles Nursing Interventions
WHO? WHEN? WHY? HOW?
Luanne Brock
nursing
Process
The
nursing process
its self is one of
All
nursing intervention
Every aspectof the centralaspects
are part of the nursing
process. This can be
the nursing profession of the nursing anything from
providing
is related to the Profession. Nurses a drink of water, to passing
use it every day meds, to preformingroutine
nursing process, assessments,
and many stem
with every client, in
everyencounter.
directlyfrom it.
System Disorder
STUDENT NAME _____________________________________
DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
ASSESSMENT SAFETY
CONSIDERATIONS
PATIENT-CENTERED CARE
Alterations in
Health (Diagnosis)
Pathophysiology Related
to Client Problem
Health Promotion and
Disease Prevention
Risk Factors Expected Findings
Laboratory Tests Diagnostic Procedures
Complications
Therapeutic Procedures Interprofessional Care
Nursing Care Medications Client Education
Luanne Brooks
Heart Failure
Left,or right sided, or high failure to adequatelypump exercise, how sodium diet, fluial
output heart failure. blood d/Aabnormal cardiac restriction, he smoking, medication.
function.
monifer for All of meds,
follow died restrictions,
Age, family Ax, HTN, NY, Dysoner fatigue,
hypertrophy,sms, watch for Pulmonary
Nocturia, JV, ascites, dependentedema, complications.
COPD, anemiar nausea/ancrexia, weightgain,
Human B pepticles Hemodynamic monitoring, ultrasound,
(hB3NP) 14E, chest x-ray, ECC, ABCs, caralian
enzymes, electrolyte levels.
A/E, SIfrom meals, not
followingalietrestrictions,
monitor 10, assess for Diuretics Ta kemedications as directed, not taking meals as directed
####### S
So, give O2 as prescribed, * 2 inhibitors, followdietaryrestrictoins, decreased pulmonary
moniber rikels and diagnostic function.
results, encourage energy Intropicagents follow up
with care team as
conservation t bea restS maintain Beta blockers needed, moniter weight
dietary restrictiers,provide daily.
support. Vasodilaters
#2NV Channel blockers
Anticoagulants
ventricularassistdevice, Cardiology/ Pulmonology,
hearttransplant. Respiratory,cardial renal,
dietary.
Nursing Skill
STUDENT NAME _____________________________________
SKILL NAME____________________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Description of Skill
Indications
Outcomes/Evaluation
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
Luanne Brooks
Postmortem Care
The nurse prepares the body for viewing by family, andfollows state andfederal
laws in terms of organ/lissuedonation, permissionfor autopsy, and ensuring proper
documentationof the death.
PostmortemCare is clone whenever
a clientdies, unless otherwise requested
bythefamily/friends.
The nurse will clear the badly, and
remove any and all lines, unless the
bodyisgoing to the corroner for an
forensic investigation.
The client is made readyfortransport no client
educantrem, but the family
to a funeral home. mayask for an explanationof
what comes next,
mishandelingof the badly, wishes of The nurse shouldwork to rectify
any
clientsfamilynot followed. wrongdoingto the bestof their
cabilities.
Basic Concept
STUDENT NAME _____________________________________
CONCEPT ______________________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Related Content
(E., DELEGATION,
LEVELS OF PREVENTION,
ADVANCE DIRECTIVES)
Underlying Principles Nursing Interventions
WHO? WHEN? WHY? HOW?
Luanne Brooks
Client Education
Clienteducation is
Crucial to improving client The nurse will provide
prevention of relapse, outcomes. 18 no education education at the appropriate
future episoches, or reinfection. is provided client does not level for the clients
Research ontopic if understand,
or education is
education, as wellas
nurse is not well informed.
notsufficient,then the client in
a waythat accommodates
is much more likelyto have
Can notbe delegated to disense progression,hospital
forany sensory disfunctions
a UAP, but can be to another readmission within sockys the
client may have
RI. or recurrence of the infection.
Improves client outcomes
Nursing Skill
STUDENT NAME _____________________________________
SKILL NAME____________________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Description of Skill
Indications
Outcomes/Evaluation
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
Luanne Brooks
Insertion of XV catheter
The nurse will locate anappropriatesite, clean the skin, apply a tourniquet,and
them using a needle, insert the cutmeter into time selectedvein.
Inclizations
include dehydration,
medication welministration,
and
blued transfusion.
CleanSite befor insertion, monitor
for infiltration,inflamation, or infection,
inspect cathete to ensure it is
intact upon remover.
no eclema, inflamation, or infection
atsite. If formal, ceV, and
more carefullyto reduce risk
insert a new one.
of
snaging tubing, or dislodging
in catheter.
Infiltrationor extrevisationel/tfluiel Remove/if infiltration
or extravisation
or meds leaking outof the vein. Infection, occur, andtreatanyinfectionsor reaction.
or allergicreactionto materialsin dressing
or catheter.
System Disorder
STUDENT NAME _____________________________________
DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
ASSESSMENT SAFETY
CONSIDERATIONS
PATIENT-CENTERED CARE
Alterations in
Health (Diagnosis)
Pathophysiology Related
to Client Problem
Health Promotion and
Disease Prevention
Risk Factors Expected Findings
Laboratory Tests Diagnostic Procedures
Complications
Therapeutic Procedures Interprofessional Care
Nursing Care Medications Client Education
Luanne Brooks
Dehydration
Insuficientfluialdi Totalbody fluialdeficit. Adequate fluidintake
excessive loss or insufficient especiallywhen exercising
inteke
Fall risk c/A
Excessive N/V/D, alteredintake, Gly-Thirst, NIV, anorexia, acube weight clizzyness,
burns, excessive sodium intake, loss. weakness,
DKA, Prolongedfever. Neurolmus
- Syncope,confusion, weakness, orthostatic
Renal-Oliquria hypotensi
Act, BUN, urine specificgravity, Assess skin turgor, mucous
blood Sodium, bloodosmolality. membranes.
Injuries from falls,
PO/Therapy, 10, fluiel Increase intake
Confusion,organ
monitor vitals, Loc,
weight, replacement causes
of dehydration failureinextreme
Cases.
can include N/V/D, large
drainingwounds,excessive
ostomylosses,
Encourage
increased Collaborationas
fluiel intake. needed.
Was this document helpful?
MS Assessment A - Templates
Course: Medical Surgical (NUR425)
418 Documents
Students shared 418 documents in this course
University: Arizona College of Nursing
Was this document helpful?
ACTIVE LEARNING TEMPLATES
Nursing Skill
STUDENT NAME _____________________________________
SKILL NAME ____________________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Description of Skill
Indications
Outcomes/Evaluation
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
Luanne
Brocks
Airway
Management/Oxygen
There
py
Airway
management.
When
the
nurse
maintains
or
assits
with
the
maintenance
of
the
clients
airway,
consisting
of
the
upper
and
lower
respiratory
system.
Oxygen
Therapy.
The
administration
of
supplemental
oxygen
via
nasal
camula
or
mask.
when
the
client
begins
to
show
signs
of
hypoxia,
including
respirations
Interventions
will
occur
when
the
over
20
/min,
and
anxiety/restlessness,
clients
O2
levels
drop
below
the
or
when
the
clients
02
sats
drop
desired
range,
or
a
patent
below
92%
for
those
without
COPD,
airway
can
no
longer
be
maintained
and
85%
for
those
with
COPD.
through
less
invasive
metroals.
The
desired
outcome
world
be
the
return
of
the
client's
no
open
flames
near
your
O2,
On
Saturation
to
return
to
the
including
smoking.
Be
sure
to
monitor
desired
range,
and
for
them
for
skin
breakdown
on
the
tops
of
to
breathe
as
independantly
as
your
ears,
on
your
cheeks,
and
in
Possible.
your
nose.
If
you
are
on
more
than
4L/min,
then
humidification
needs
to
be
added.
Do
not
use
any
Petrolium
based
products
near
your
02.
Potential
complications
can
include
interventions
would
include
lowering
oxygen
toxicity,
skin
breakdown,
the
flow
rate
on
the
clients
oxygen,
and
in
the
worst
case,
the
client
using
alternative
delivery
methods
to
reduce
skin
break
down,
and
working
becomes
dependent
on
a
machine
to
reduce
or
Prevent
the
client
from
to
assist
in
respiration.
beaming
vent
or
bipup
dependent.
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