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Lesson 150 min read
Fundamentals of Nursing
Nursing Process, Vital Signs, Levels of Prevention & Core Concepts
In This Lesson
Nursing Process (ADPIE)
The nursing process is a systematic, patient-centered approach to care. It provides a framework for thinking critically and planning effective nursing interventions.
A - Assessment
Systematic collection of subjective and objective data about the patient.
- Subjective data: What the patient tells you (symptoms, feelings)
- Objective data: What you can observe/measure (vital signs, lab results)
- Includes health history, physical examination, and review of records
D - Diagnosis
Analysis of data to identify patient problems using NANDA nursing diagnoses.
- PES Format: Problem + Etiology + Signs/Symptoms
- Example: "Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by dyspnea and abnormal ABG"
P - Planning
Setting goals and determining nursing interventions.
- SMART Goals: Specific, Measurable, Achievable, Realistic, Time-bound
- Prioritize using Maslow's hierarchy or ABCs (Airway, Breathing, Circulation)
I - Implementation
Carrying out the nursing interventions.
- Document all actions taken and patient responses
- Types: Independent, dependent, and collaborative interventions
E - Evaluation
Determining if goals were met.
- Compare patient outcomes with expected goals
- Reassess and modify plan as needed
Vital Signs - Normal Values
| Age Group | Heart Rate (bpm) | Respiratory Rate | Blood Pressure | Temperature |
|---|---|---|---|---|
| Newborn | 120-160 | 30-60 | 70/50 | 36.5-37.5°C |
| Infant (1-12 mo) | 100-150 | 25-40 | 90/60 | 36.5-37.5°C |
| Toddler (1-3 yrs) | 90-140 | 20-30 | 95/65 | 36.5-37.5°C |
| School Age (6-12) | 70-110 | 18-25 | 100/65 | 36.5-37.5°C |
| Adult | 60-100 | 12-20 | 120/80 | 36.5-37.5°C |
Fever Classifications
- Low-grade: 37.5-38.0°C
- Moderate: 38.1-39.0°C
- High-grade: 39.1-40.0°C
- Hyperpyrexia: >40.0°C
Blood Pressure Terms
- Hypotension: <90/60 mmHg
- Normal: 120/80 mmHg
- Prehypertension: 120-139/80-89
- Hypertension: ≥140/90 mmHg
Levels of Prevention
Primary Prevention
Prevent disease before it occurs
- Health education
- Immunizations
- Nutrition counseling
- Environmental sanitation
- Use of seat belts
Secondary Prevention
Early detection and treatment
- Screening programs
- Case finding
- Early treatment
- Preventing complications
- BP monitoring
Tertiary Prevention
Rehabilitation and restoration
- Rehabilitation
- Disability limitation
- Preventing recurrence
- Support groups
- Physical therapy
Infection Control
Chain of Infection
Infectious Agent→Reservoir→Portal of Exit→Mode of Transmission→Portal of Entry→Susceptible Host
Standard Precautions
- Hand hygiene
- Use of PPE (gloves, gown, mask)
- Safe injection practices
- Respiratory hygiene/cough etiquette
- Safe handling of contaminated equipment
Transmission-Based Precautions
- Contact: MRSA, C. diff, scabies
- Droplet: Influenza, pertussis
- Airborne: TB, measles, varicella
WHO Hand Hygiene Moments
- Before touching a patient
- Before clean/aseptic procedure
- After body fluid exposure risk
- After touching a patient
- After touching patient surroundings
Documentation
SBAR Communication
- S - Situation: What's happening?
- B - Background: Context/history
- A - Assessment: What you think
- R - Recommendation: What you need
Documentation Principles
- Be accurate, objective, complete
- Document immediately after care
- Never erase or use whiteout
- Sign with name and credentials
Patient Safety
RACE - Fire Safety
- R - Rescue patients in immediate danger
- A - Alarm: Pull the fire alarm
- C - Confine/Contain the fire
- E - Extinguish/Evacuate
PASS - Fire Extinguisher
- P - Pull the pin
- A - Aim at base of fire
- S - Squeeze the handle
- S - Sweep side to side
Fall Prevention
- Use bed rails appropriately
- Keep call light within reach
- Ensure adequate lighting
- Non-skid footwear
- Clear pathways of obstacles
- Assist with ambulation as needed