Jane R Bordner, RN, BSN Nursing Instructor HACC N100 Spring 2014

Jane R Bordner, RN, BSN Nursing Instructor HACC N100 Spring 2014
Nursing Process Jane R Bordner, RN, BSN Nursing Instructor HACC N100 Spring 2014

Nursing If someone asked you what do nurses do? What would you say?
DISCUSS Your answers are based on the knowledge you have from personal experience or perhaps TV and movies. Has your idea changed since you started at HACC? In order to do our jobs, we nurses use a specific step by step process call the NURSING PROCESS.

The Changing Face of Nursing
Nursing is always growing and changing. When you are finished with this program, you are not finished learning. Must be a life-LONG learner as a nurse. Always new info and technology being developed everyday in the medicine. You as a nurse MUST keep up with new development in your practice. Just like a new mother, always developing, growing, changing with every new developmental stage Evidenced based..why we do what we do. Used to that on a reddened area of the skin we were encouraged to massage it to promote healing. Through research we mow know this practice should be avoided. Trends in nursing today: more men, more complicated and sicker patients, and more technology to learn.

What Do Nurses Do? Nursing process gives us a direct and precise way to answer Nursing process = a problem solving approach used to meet client needs The most accurate definition would be… NEXT SLIDE

Nursing Process Is an organized, systematic method of giving individualized nursing care that focuses on identifying and treating unique responses of individuals or groups to an actual or potential alteration in health. As nurses we learn to treat the patient’s responses to illness or potential threats to health, what does that mean? EXAMPLE: A Paralyzed PATIENT We cannot treat the medical cause of the paralysis. Cannot repair the spinal cord injury and make the patient walk again. As nurses we treat patient’s physical, emotional, psychosocial, and spiritual response to his/her paralysis. If unable to feed self – we provide nourishment If unable to bathe self – we bathe If unable to move bowels - we assist with evacuation May be depressed, cannot understand what has happened to them – we provide a listening ear, information, and support We evaluate learning needs of patient and the family If unable to move – we provided ROM, get them OOB, prevent skin breakdown WE must be organized, our role is very important WE need keen observation skills, decision making skills, and communication skills.

Nursing Process continued…
Based on the fundamental belief that every person is endowed with personal worth and dignity, and has a right to high quality care regardless of socioeconomic status, cultural background, or religious belief. We care for everyone!! Need to put the patient’s concerns first and foremost by asking the question Can you tell me today what matters most to you?” (Anne Boykin ) Viewing the patient’s health needs with the patient’s perspective and responding to their call is the goal of nursing. Why do we use the nursing process?

Purpose of Nursing Process
ID nursing-related client health care needs Establish a plan of care to meet needs Implement nursing interventions/actions Provide basis for ongoing evaluation Purpose is to provide for maintenance and restoration of health Provide structure to help nurses organize the intellectual and physical tasks involved with nursing practice. Assist nurse to evaluate own practice. The nursing process is a professional, systemic, step-by step approach to selecting, organizing, and delivering care to patients. The nursing process differentiates nursing practice from the practice of all other health care professional Evidenced Based: why we do what we do

Nursing Process and Critical Thinking
Critical thinking is very important in nursing decision making Critical thinking is necessary to make complex decisions involved in patient care Critical thinking answers the question: who benefits and whose outcomes are being met by my nursing actions? This is thinking that has a purpose and is goal directed. As nurses we need to look at alternatives and choose the best one to meet the needs of the client. We will discuss critical thinking in more detail in a few weeks, when we discuss Concept Mapping. Now lets look at the steps more closely.

Nursing Process and Critical Thinking
Critical thinking : analyze assumptions, challenge status quo, recognize limitations, and take actions to improve it.

Steps in the Nursing Process
Step 1 Assessment Step 2 Nursing Diagnosis Step 3 Planning Care Step 4 Implementation Step 5 Evaluation It is an ongoing process, each step is interrelated. Critical thinking is involved in each step.

Use of Nursing Process Family member illness Assessment Diagnosis
Planning Implementation Evaluation You already use this process, even if you do not realize it. Your child wakes you at 2:00 am. Saying “My throat and head hurt and I don’t feel good.” Assessment: You check temp. Ask about throat pain. Diagnosis: What is the problem? Child is in pain; may have fever; you and child are loosing sleep; must get child comfortable, so that you both can sleep Planning: What will you do to get child comfortable and back to sleep, so that you can sleep? You think of alternatives that may work for your child; Motrin and a cool drink Implementation: You give your child the Motrin and cool drink and tuck him/her back into their bed or your bed. Evaluation: Now you want to see if your actions work. Do you and your child get to go back to sleep?

We will discuss ASSESSMENT as part of this lecture in much greater detail. The information obtained will be used to formulate the nursing diagnosis. Data is grouped into data clusters, which we will talk about when we cover concept mapping. Critical thinking is used to decide what data you need to gather and how to group that data. DIAGNOSIS: The patient problem identified by the nurse for nursing intervention by analysis of assessment findings in comparison with what is considered to be normal. Critical thinking occurs as you determine which diagnosis is appropriate to your patient. We will cover this in much more detail in my next lecture. PLANNING: A conscious design of desired future states and of the goals, objectives and activities required. Nursing Care Plan = is documentation of plan of care. Use critical thinking about which plan will work best. May have 3 or 4 choices and you must decide which is best for your pt. IMPLEMENTATION: Interventions are initiated. They act as a road map; directs the nursing care of your patient. The more clearly they are written the easier it is to complete the journey and arrive at the destination (the goal). EVALUATION: An ongoing process, done continually. Client outcomes are evaluated to determine if goals were met. If not met, process starts all over again. Can go to any step in process from evaluation. Critical thinking is important in determining if the outcome was met, were the interventions effective, should the plan of care be changed and how.

Role of the LPN Assessment Nursing Diagnosis Planning Implementation
Evaluation Assist in data collection Assist in choosing ND Assist in formulating and choosing interventions Carry out plan within scope of practice Assist in evaluation and revision of plan of care What will your role be as an LPN? Development or formulation of a nursing diagnosis is the role of the registered nurse. LPN’s must have an understanding because your role is to assist with the process and to actually carry out the plan of action developed from the nursing diagnosis and problems identified. Data you gather is included in the RN’s decision making

Step 1: Assessment Thorough and holistic Based on: Requires:
clinical and laboratory data medical history patient’s account of symptoms. Requires: data collection data validation data sorting data documentation Always need to assess the situation before taking action Keep your mind open as you gather data. Don’t jump to conclusions. Must use critical thinking to distinguish between data that is relevant and irrelevant. Assessment = Evaluation of a client’s condition, based on: see slide Gather as much info as possible. You are developing a data base about this person. Data includes: level of wellness, health practices, past illnesses, and experiences, health goals of the individual. The assessment has 2 steps: 1. Collection and verification of data from multiple sources and 2. analysis of data Data can be subjective ( what the patient says) and objective (direct measurements and observations) Remember the purpose is to gather info in order to ID nursing problems.

Types of Data Subjective Data/Signs Objective Data/Symptoms
Client’s perceptions What the client tells you. Example: “I am in pain.” “I feel nauseous.” Objective Data/Symptoms Observations or measurements Things the nurse sees, hears, and feels. Example: Vital signs, bowel sounds, temperature of skin Subjective = symptoms expressed by the client (head ache, itching, pain) You can’t see, touch, or smell these things. Personal to the client and only the client can provide you the information. Where will most of this type of info come from? Interview. Objective = signs that are observable and measurable. Something you experience with your five senses. See, hear, smell, touch, (we usually don’t use taste very much) Where will most of this type of info come from? Physical assessment. Signs and Symptoms Signs = what you see = objective data Symptoms = what client feels/perceives = subjective data

Subjective vs. Objective Data
___ My leg pain is a throbbing pain ___ 2 seconds capillary refill ___ Lung sounds clear bilaterally ___ I have no allergies ___ I fell last night ___ Apical pulse 68 and regular ___ Patient moaning ___ Moderate yellow sputum ___ I am extremely tired ___ Skin warm and dry to touch Now let’s practice this Which is subjective or objective? Write S or O in blank. 1 = S 2 = O 3 = O 4 = S 5 = S 6 = O 7 = O 8 = O 9 = S 10 = O

Shift Assessment Organized Systematic Brief Accurate
Order depends upon presenting S&S Will become brief with practice min.

Types of Assessments Shift Assessment Focused Assessment
Comprehensive Health Assessment

Focused Assessment Detailed assessment of particular system
Brief (2 to 5 minutes) “Quick check” ID changes in areas most likely to change Based on problems ID’d in shift assessment or new problems that arise Find changes early and avoid complications More in-depth assessment of one or 2 systems that need more information Which system is based on client’s needs and/or problems

Example Patient admitted with pneumonia. Though the nurse asks questions and assesses all systems, he/she will focus much more attention on the respiratory system - listening to breath sounds, asking about shortness of air, cough, etc…

Example Next shift, same patient,
New nurse enters his room and he reports abdominal pain. The nurse will briefly assess all systems, but in addition to focusing on the respiratory system, he/she will also do a detailed assessment of the GI system. HOW DO YOU DO A FOCUSED ASSESSMENT? WHATSUP? IS A TOOL THAT YOU CAN USE TO HELP BOTH YOU AND YOUR CLIENT FOCUS ON ONE PARTICULAR AREA OF CONCERN Helps you ask enough questions to get all the info that you need to know. Common pitfall is to not ask enough questions or get enough detail.

WHATSUP guide to Symptom Assessment
W Where is it? H How does it feel? Describe it? A Aggravating and alleviating factors? T Timing: When did it start? How long does it last? S Severity on scale of 1 to 10 U Useful other data. Other symptoms? P Patient’s perception of problem At times your client may express specific symptoms or concerns. You will need to further assess these abnormal or unusual symptoms You will need a systematic way to do this Many MD and NP use this when getting information about a specific complaint or problem Use WHATSUP THIS HELPS YOU ASK ENOUGH QUESTIONS TO GET ALL THE INFO THAT YOU NEED COMMON PITFALL IS TO NOT ASK ENOUGH QUESTIONS AND MISS IMPORTANT DETAILS Let’s practice this.

Using WHATSUP Mrs. Cooper, age 47, had a hysterectomy 2 weeks ago. She is admitted with a right calf deep vein thrombosis that she thinks resulted from having surgery. She rated her pain, which began 2 days ago and is constant, at 8. She has increased calf tenderness with leg movement. Leg elevation and Tylenol #3 increases her comfort. Her calf is hot to touch and red. Her legs measure: R calf 9 inches; L calf 8 inches; R thigh 14 inches; L thigh 14 inches. WORKSHEET AT END OF LECTURE Use the Whatsup method to be sure you have obtained all the data that you need. Where is it? R calf How does it feel? Constant pain Aggravating & alleviating factors? More with movement; less with leg elevation and Tylenol #3 Timing days ago Severity on pain scale Useful other data hyster 2 wk ago; hot and red; leg measurements Pt perception thinks resulted from surgery

Comprehensive Health Assessment
Assessment of all body systems and detailed health history Provides baseline of client’s health status and functional abilities at that time Helps nurse determine plan of action to address client’s nursing needs Abnormal assessment findings signal nurse to gather additional data in that area We have talked about the first 2 types of assessment, Now let’s talk about a Comprehensive Health Assessment Nursing assessment done upon admission to medical facility (hospital, rehab center, clinic, long-term care). Purpose: record present and past medical history ID actual health problems and risk factors ID client’s strengths and support ID teaching needs ID discharge and referral needs Baseline = ? Client’s state of health upon admission. All other assessments are compared to this to gauge the progress or lack of during care MAY TAKE A DIFFERENT FORM AT EACH HEALTH CARE INSTITUTION ADM/DC MODULE WILL TALK ABOUT THIS MORE USING JEWISH HOME FORM

Parts of Comprehensive Health Assessment
Interview Physical Exam Complete shift assessment Auxiliary Data Purpose of interview Obtain health Hx and health risks/needs Ask about signs and symptoms Obtain info regarding physiological and emotional changes Provide time to observe client and gather objective data Excellent time to establish therapeutic relationship NURSE IN USUALLY FIRST CONTACT; FIRST IMPRESSION IS IMPORTANT; SETS TONE FOR ENTIRE HEALTH-CARE EXPERIENCE NEED TO CREATE TRUST AND DEVELOP RAPPORT Cues you in to which part may need more thorough investigation

Components of Nursing Interview
Biographical Data Chief Complaint History of Present Illness Past Medical History Environmental History Psychosocial and Cultural History Review of Systems (ROS) Health Hx usually informal Reasons for seeking health care: goals of care, expectations Present illness or health concern: onset, symptoms, nature of symptoms, precipitating factors, relief measures Chief Complaint = why did they seek care at this time; in their own words; use WHATSUP which we will discus next Past Hx = their hx of illness and health problems, surgeries, immunizations, family hx of disease Environmental = job habits, smoking, ETOH use, travel, pets Psychosocial /cultural= religion, education, marital status and support system, primary language, developmental stage Discuss Jehovah Witness, Catholic, Jewish Education Master’s vs. not finished high school Review of Systems = head to toe; ask questions about each system (Neuro, Circulatory, etc.) Do they have symptoms on each of these areas? Not routinely done by LPN or RN, but MD and Advanced Practice Nurse will use all the time in a Comprehensive Assessment. This is a good way to get info in systems that you are uncomfortable asking about. (GU, sexuality). Start with general questions and then get more specific if needed.

Important Interview Techniques
Introduce yourself Unhurried manner Good eye contact (if culturally appropriate) Silence/Listening skills/Clarifying Observation skills (Get objective data during interview) Age and developmental considerations Continually work on developing therapeutic relationship Keep it informal, as you spend time with client you will develop relationship and rapport LPN is in position to be at the bedside collecting data Give them time to think about and answer questions Assessment is ongoing and continuous throughout their stay During interview, assess and observe physical condition; Are they SOA? What is their skin color? How is their memory? General appearance? Interview process has 3 phases = orientation; working; termination Therapeutic relationship is extremely important and involves demonstrating caring and developing trust

What is Caring? Responding Sensing emotions Acceptance
Making a connection “Caring for the Whole Person” When assessing the client especially the psychosocial aspects we must remember that caring should accompany assessment. We are gathering the data in order to care for the patient. Responding to others as unique individuals. Sensing their emotions Accepting them where they are, unconditionally Making a connection with another human being and breaking down the alienation that not caring creates. Mind, body, and spirit. Whole person and all ramifications for that person. A person, family or community calls for help regarding a health issue. The nurse hears the call and responds using her own personal gestalt. The act of being heard is the humanizing experience. The nurse incorporates all that she is; her knowledge, relationships, past experiences, religion and culture to assist the patient, through a nurturing response to reach his full potential. Nursing theories incorporate the holistic and caring aspect of our discipline; the essence of nursing. Patients and families do not write thank you letters to the nurse that maintained their blood pressure within the doctor’s stated limits. They write thank you letters to the nurse who sat with them during times of stress or sadness. They thank the nurse who took the extra time to make their mother comfortable and maintain dignity during her last week with her family. They remember the nurse who took the time to care and made them feel like a valued person.

Critical Thinking: Data Collection
Your neighbor, Mr. Lewis, age 76, knocks on your door. He says “Look at my left foot. It is very swollen. I wore new shoes yesterday that felt tight. Now I can hardly get any shoes on this foot. There is a tender area on the top of my foot. I think something is wrong. Can you help me?” What would you do? invite him in and have him sit down 2. What kind of data do you have, so far? SUBJECITVE 3. What action should you take next? (Remember steps of nursing process. What is the 1st step?) Focused assessment on Musculoskeletal system and Circulatory system gait; ROM pedal pulse and capillary refill; assess skin (redness, swelling, broken skin, temp of foot) 4. What kind of data is this? OBJECTIVE 5. What actions would you recommend for Mr. Lewis? see his MD Never diagnose as nurse 6. What can you do to show caring? Listen to him Empathize (I can see that you are worried about this, let’s take a look and make a plan.) Do not belittle him for wearing shoes that may be too small (How many of us have worn shoes that hurt our feet, but we wore them anyway because they looked good or we just spent money on them or what ever?) Get involved (help him make the appointment, ensure transportation)

Sources of Data Client Family members or significant others
Other members of health care team Current and previous hospital records Diagnostic studies/Laboratory reports Where do nurses get the data/information that they will need to plan and implement individualized and effective care? Primary source is client; most of the time, this is best source Can get both objective and subjective from client Talking to them, asking questions, observing their behavior All else is secondary source of data Family info may be biased and/or incomplete Physician and nursing notes are also a source of data Chart from previous admission Records from other facility Physician’s H&P and progress notes Lab reports X-ray reports and other diagnostic tests Nurse’s notes Info from family members Info from Kardex

Documentation of Data ALL objective and subjective data must be documented Only what was observed by or stated to you Subjective data using direct quotes NOT DOCUMENTED, NOT DONE This is the 6th right of nursing. Proper documentation is extremely important. See Common Abbreviations When do you document the info from your assessment? As soon as possible DO NOT try to remember; may be easy to remember when you have 1 or 2 clients; What about when you have 5, 10 , 15 clients that you are responsible for? How would you remember then? Get into the practice of writing it down ASAP!! How do you do this in the clinical setting? write notes to yourself on the CLIENT INFORMATION SHEET, then organize them and write it onto the first page of your worksheet: see example in PP after this lecture We will spend a great deal of time teaching you to document properly.

Common Diagnostic Tests
Blood CBC Electrolytes ABG’s Blood Glucose Urine Urinalysis (UA) Urine Culture and sensitivity The last part of the Comprehensive Health Assessment and an important part of your Worksheet is diagnostic tests INTRODUCE LAB BOOK Discuss how to use it. These are examples of some basic and frequently used diagnostic tests Discuss diagnostic test page of green sheet

Radiological Chest X-ray Exams Upper GI Lower GI CT & MRI scans Stool Ova and Parasites Clostridium difficile (C. diff) Occult blood

Sputum Culture and Sensitivity Acid Fast Bacilli Cytology Other EKG or ECG Stress Test TB Test

Medications Patient History Laboratory Studies Assessment Data
All these pieces of data that you collect are important parts of a large puzzle. All the pieces must come together for you to see the big picture of what is actually happening with the patient. Medical Hx is your diagnosis cards that you will make for your patient. We will work on putting the pieces together with the Concept Map. END OF DAY ONE? BRING NURSING DIAGNOSIS HANDBOOK, NURSING PROCESS WORKSHEET, AND NURSING DIAGNOSIS WORKSHEET to next class

Step 2: Nursing Diagnosis
Standardized label that identifies client’s problem Makes it understandable to all nurses Language of nurses Address actual or potential health problems START OF DAY 2 It is distinctive to nursing. Nursing diagnosis guide the selection of interventions that will help achieve a desired outcome. It is a means of communication with each other. The language used is very specialized and they are written in a specific format. Address actual or potential health problems that nurses can treat by initiating nursing interventions that prevent, resolve, or reduce problem Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. A medical diagnosis is the identification of a disease or condition. The nursing diagnosis is the formulation of a disease or condition It is client centered and patient involvement is necessary. Nurse and client may have different priorities. Nurses are constantly asked to make decisions based on their clinical experience and nursing judgment using critical thinking skills. Critical thinking: How does this data fit together? What is the problem exactly and what nursing diagnosis would work? Which diagnosis is appropriate for your client at this time?

Step 2: Nursing Diagnosis
ID’d by nurse after analyzing assessment data and comparing it with what is considered to be normal Abnormal findings are organized into data clusters Nursing diagnoses are developed from data cluster Critical thinking: What is abnormal/normal? What is important for this client? What abnormal findings go into which clusters? What nursing diagnosis is relevant to this data cluster?

Nursing, Medical, Collaborative Diagnoses
Nursing diagnoses: problems which can be treated independently by nurses Medical diagnoses: those that require care that only a physician or nurse practitioner can render Collaborative diagnoses: problems that can be helped by both medical and nursing interventions Not dependent on physician’s orders That is why there is a very specific APPROVED list of Nursing diagnoses Look at back cover of your Nursing Diagnosis Handbook. These are the only nursing diagnoses available. Nursing: Altered nutrition, excess or deficient fluid volume, ineffective coping, risk for impaired skin integrity Medical: Hypertension, heart failure, diabetes, appendicitis, asthma We cannot treat these without MD or nurse practitioners orders, but we can treat the clients response to these problems/diseases Most problems are collaborative in nature. PAIN for example Nurses cannot order Morphine, but we can reposition, rub back, offer mouth care, provide a quiet environment to promote comfort and administer pain med as ordered.

Medical VS. Nursing Diagnoses
ID’s pathological basis for illness Focuses on physical condition only Addresses actual problems Nursing ID’s response to illness Focuses on physical, psychosocial, and spiritual needs Addresses actual and potential problems Defines the client’s needs. Need is something wanted or desired. Physical Needs: activity, elimination, circulation, hydration, nutrition, oxygenation, protection from infection Psychosocial Needs: development, mental health, self-esteem, love, belonging, sexuality, social, cultural, ethnic, ID Spiritual Needs: values, beliefs A diagnosis is considered a “ medical” when th physican directs most of the care A diagnosis is considered “nursing” if the interventions needed to treat the problem are mainly independent nursing functions. A well written nursing diagnosis helps guide development of the plan of care.

Medical VS. Nursing Diagnoses
Not validated with client Uses standardized treatments and goals May not be resolvable Nursing Validated with client Uses individualized goals and interventions Usually resolvable Nursing diagnosis is client focused; validated and individualized for specific client You can have 2 clients with the same nursing diagnosis that have different goals and interventions. HTN is treatable by MD, but not resolvable. But a clients lack of knowledge about the disease and the treatment plan is resolvable through a nurse educating them about the treatment plan and disease pathology; this would be resolved when client understands management of his/her disease.

Medical VS. Nursing Diagnosis
Client admitted with medical diagnosis of congestive heart failure (CHF) Look up medical diagnosis in front of your Nursing Diagnosis Handbook. Many potential nursing diagnosis based on one medical problem Assessment data will reveal which may best FIT YOUR client Use book in two ways First example - using medical diagnosis CHF on page 33

Writing Nursing Diagnoses
Part 1 Nursing Diagnosis Label related to (R/T) Part 2 Etiology (cause) as evidenced by (AEB) Part 3 Signs and Symptoms We have talked about the specialized language and APPROVED diagnoses Now let’s turn to the defined format that is used to write them Writing a ND is a 3 part statement One sentence with 3 distinct parts This is the specific format as to how the sentence must be structured Problem is a difficulty that arises when a client’s needs are not met. Let’s look at an example, then we will break in down into each specific piece.

Example Client has abdominal surgery this am. Assessment data reveals that the client is experiencing pain. It is rated by the patient as 4 on a scale of 0 to 5. The patient is also exhibiting facial grimacing and is moaning. The nursing diagnosis related to this assessment data is ACUTE PAIN. This is the assessment data that you collected. What is the problem? What is the nursing diagnosis? Second click How would we write this nursing diagnosis in the proper format?

Writing Nursing Diagnosis
Part 1 Acute pain related to… Part 2 actual tissue damage from abdominal surgery as evidences by… Part 3 Patient stating “My pain is 4 of 5.” Moaning/ facial grimacing This is an example of how a nursing diagnosis would be written What else could we use for Part 3? Facial grimacing and moaning So, where do you get these parts? Three parts: Problem: approved nursing diagnosis Etiology the cause or factor ( usually proceeded by the words “related to” Signs and symptoms; subjective or objective data that provides evidence this is a valid diagnosis for this patient‘ as Evidenced by ‘ An out come is a statement that describes the patient ‘s desired goal for the problem area. It MUST BE MEASURABLE , realistic for that patient and have an appropriate time frame for reaching the outcome goal. Make a list of diagnosis to prioritize Interventions are the actions you as a nurse take to assit the patient in reaching the desired outcomes Evaluation continually re-evaluates, reassess and documents outcomes

Part 1 of Statement NANDA list of approved nursing diagnosis labels
Problems that nurses routinely address in practice List in back of your Nursing Diagnosis Handbook “I am so nauseated from my chemo treatments that I cannot eat anything.” Only diagnosis labels from NANDA (North American Nursing Diagnosis Association) list are acceptable First part MUST BE WRITTEN IN THESE EXACT WORDS This is that specific language that I talked about before. Read some examples from list. Must be familiar with this list This is where you state your client's problem in nursing language. Problem = your patient has cancer tells you, “I am so nauseated from my chemo treatment that I cannot eat anything”. Let’s look in the back of your book. Which of the APPROVED ND’s could you use? Nausea pg 561

Part 2 of Statement Etiology or cause
Statement follows nursing problem and words “related to” = R/T Comes from your nursing knowledge and assessment data Etiology is individualized for each client NO MEDICAL DIAGNOSIS “I am so nauseated from my chemo treatments that I cannot eat anything.” Contributing factors; What is causing problem? In the beginning you will need to use your book for this part, because you probably don’t have the nursing knowledge that you need By fall we will expect you to do this part without the book. Lets look up nausea on page 561 and read R/T factors What could work for this person? You CANNOT use medical diagnosis (cancer). What words in the book describe the problem? Pharmaceuticals/treatment meds

Part 3 of Statement Defining characteristics
Follows words “as evidenced by” = AEB List signs and symptoms obtained from assessment S&S that supports your statement Use all relevant information Objective Subjective “I am so nauseated from my chemo treatments that I cannot eat anything.” This piece comes directly from your assessment data In our example, what would you use here? Pt’s statement “I am so nauseated from my chemo that I cannot eat anything.” Final complete statement would be:

Nursing Diagnosis Nausea R/T treatment/medications AEB
pt stating “I am so nauseated from my chemo treatment that I cannot eat anything”. See the 3 parts and how they fit together? Normally written as a sentence, but I am separating the pieces to show them more explicitly.

Nursing Diagnosis: Actual vs. High Risk Problems
High probability of occurring in future There are no S&S Requires 2 part nursing diagnosis statement Actual Existing problem Client has S&S of problem Requires 3 part nursing diagnosis statement Remember nurses can deal with actual or potential (risk) problems Risk problems are written a little bit differently You see risk factors that lead you to believe that this problem may occur; your plan would be to prevent it. Because this problem does not exist yet there are no S&S, just indications that it could happen. Was our nausea an actual or high risk problem? Actual!! Had all 3 parts to statement. Lets do a High Risk Problem. In a nursing care plan the most urgent problems are listed first. You and your patient decide together what problems take priority. Show maslow’s heiarchy of need

High Risk Diagnosis Assessment Data
Patient has been on bedrest for 1 week Patient is incontinent of urine Patient unable to move or turn self in bed Skin is clean and intact Look at list in back of your book. Now this client has several actual diagnoses; Impaired bed mobility, Urinary incontinence But what is this pt at risk for? What can you use for this patient? Risk for impaired skin integrity These are all factors that put this client at increased risk for skin breakdown, but no skin breakdown YET.

High Risk Diagnosis Risk of impaired skin integrity: Risk factors: incontinence and physical immobility. *Note: This is a risk problem because no skin breakdown has occurred yet. You are going to use your nursing skill to prevent skin breakdown. Your nursing care will be centered around preventing skin breakdown

Nursing Diagnosis Prioritize: One need to address immediate, basic needs prior to more elaborate ones concerns If one has a patient that has new onset diabetes, is homeless, and has no insurance, your first diagnosis is going to be……(basic survival needs: home, shelter, food and warmth).

Nursing Diagnosis Practice
Assessment Data Patient states she is feeling “nervous and anxious”. Her hand are shaking. Staff observes her crying. Progress notes state that her physician told her earlier that her lung biopsy was positive for cancer. What is the problem? Is it an actual or risk problem? How would you write it?

Nursing Diagnosis Anxiety R/T change in health status AEB pt stating that she feels “anxious and fearful” and episodes of crying and shakiness.

Assessment Data 92 year old female. Patient has weakness in all extremities. Fatigues rapidly with activity. Unable to perform ADL’s without becoming fatigued. Frequently makes statements such as “I feel so tired and weak”. What is the problem? Is it an actual or risk problem? How would you write it?

Nursing Diagnosis Activity intolerance R/T generalized weakness AEB
inability to perform ADL’s without fatigue and stating “I feel so tired and weak”.

Assessment Data 82 year old male Past medical history of a stroke with left-sided weakness and bilateral cataracts Walks with a walker Shuffling gait Problem? Actual or Risk?

Nursing Diagnosis Risk for falls R/T impaired vision/impaired mobility Impaired physical mobility R/T neuromuscular impairment AEB left-sided weakness and using walker to ambulate Where is AEB? Not actual problem (YET), so no need for AEB Anything else that you see for this client?

Nursing Process Worksheet
READ and HIGHLITE abnormal data IDENTIFY objective vs. subjective data What does abnormal data tell us? What are some nursing diagnoses? Let’s practice a little now. Look at your nursing process worksheet and read and ID all objective and subjective data This is step one in the nursing process.

Nursing Diagnoses What problems do you see here?
Are they actual problems or high risk problems? How would you write them? Look at NANDA list. What works for this patient? NOW PULL OUT YOUR NURSING DIAGNOSIS WORKSHEET WE HAVE ALREADY STARTED SOME FOR YOU LET’S PRACTICE WRITING THESE

Nursing Diagnosis Worksheet
ACTIVITY PROBLEMS Activity intolerance related to ____________ AEB ______________________________. Sleep deprivation related to ____________ AEB ______________________________.

3. Fatigue related to ____________________ AEB ______________________________.

PAIN Chronic pain related to _________________ AEB ______________________________. NUTRITION Imbalanced nutrition: less than body requirements related to ________________ AEB _______________________________.

SAFETY Impaired skin integrity related to _________________ ABE ___________________________________. RISK PROBLEMS Risk for injury related to ______________________________.

OTHERS? Impaired physical mobility related to _________________________ AEB ______________________________. Next week Mrs. Leib will continue the Nursing Process with you. She will review how to prioritize your diagnoses, write goals, develop nursing actions/interventions, and how to evaluate nursing care. BE SURE TO BRING THESE TWO SHEETS WITH YOU NEXT WEEK FOR HER LECTURE!!!!!

Nursing Process Summary
The nursing process is a problem solving approach. Experienced nurses engage in this type of thinking as a matter of routine. You need to learn how to think this way in order to be a successful nurse. Most experienced nurse do this without thinking through each step.

Nursing Process Summary
A CONTINUING PROCESS

Types of Assessments Shift Assessment Focused Assessment
Comprehensive Health Assessment

Shift Assessment Involves a brief systemic review of client’s condition at beginning of a shift Nurse compares assessment findings with those from previous shift Takes 10 to 15 minutes Typically takes 10 – 15 min. with practice. Always assess each client initially for BASELINE The patient’s condition and response affect the extent of your examination. The accuracy of your assessment will influence the therapies a patient receives and the evaluation of the response to those therapies

Preparation ID client Privacy Keep client comfortable Body mechanics
Lighting Quiet Equipment Room and hand temp Need to help client relax

Shift Assessment Equipment Needed Stethoscope BP cuff Thermometer
Watch with a second hand Pen light Measuring Tape (maybe) You must have this equipment and come prepared. Need your own stethoscope, watch, and pen light. You will need these to assess. The other stuff will be available at the clinical site. LOOK AT HACC NURSING 100 NURSING WORKSHEET (#3), YOU WILL DO THIS IN LAB. You will assess a classmate and write everything down on the front of the paper. Mrs. Leib will cover charting and you will use this info write a narrative note of your assessment. You will need to hand this in to your clinical instructor later.

Cultural Sensitivity Cultural differences influence a patient’s behavior Recognition of cultural diversity helps to respect the patient Consider a patient’s Health beliefs Use of alternative therapies Nutritional habits Family relationships Use of personal space In Chapter 19 we will further discuss cultural diversity. To be culturally aware nurses need to avoid stereotyping on the basis of gender, race, culture, and physical appearance.

Physical Assessment Includes
Inspection Palpation Percussion Auscultation

Inspection The use of vision and hearing to distinguish normal from abnormal findings Use adequate lighting Position and expose body parts Inspect for size, shape, color, symmetry, position, and abnormalities Side to side comparison Pay attention to detail Inspection is the first step and the easiest of all assessments. You will use communication skills, as discussed in Chapter 10, while performing inspection. Make sure to talk to the patient and inform them of what you are doing.

Palpation Involves using the hands Examine accessible body parts
Palpate skin Temperature, moisture, texture, turgor, tenderness, and thickness Palpate abdomen Tenderness, distention, or masses Assist the patient with proper positioning. Use relaxation techniques to calm the patient. Use good communication skills. You will use different parts of your hands to detect texture (palmar surfaces of fingers and finger pads), temperature (dorsal surface or back of hand), and perception of movements (palm of hand). You will want to warm your hands, keep fingernails short, and use a gentle approach.

Percussion Tapping the body with fingertips to produce a vibration
Character of sound Determines location, size, and density of structures Depends on the density of tissues Abnormal sounds can be mass, air, or fluid This skill takes practice. This skills takes dexterity.

Auscultation Listening to sounds produced by the body
Assess sounds heard in the heart, lungs, and gastrointestinal systems Requires the use of a stethoscope Characteristics include Frequency Loudness Quality Duration You will learn to identify normal sounds by auscultating a manikin or fellow student. Requires concentration and practice. The bell of the stethoscope picks up low pitched sounds, such as cardiac. The diaphragm picks up high pitched sounds, such as lung and bowel.

General Survey Begins when you first meet a patient
Begins with review of primary health pattern The survey provides information regarding Characteristic of illness Hygiene Skin condition Body image Emotional state Developmental status You can determine a lot about patients by looking at them while talking to them before even touching them.

General Appearance and Behavior
Gender and Race Age Signs of Distress Body Type Posture Gait Body Movements Hygiene and Grooming Dress Body Odor Affect and Mood Speech Patient Abuse Subculture Abuse This review of general appearance and behavior will give you clue to a patient’s illness and perhaps how culture, ethnicity, and age influence health, wellness, illness, and recovery. Don’t forget that part of the general survey includes vital signs (Chapter 14) and measurement of the patient’s height and weight. This is important information for many reasons. Drug dosages may be based on body surface area and weight.

Shift Assessment Includes
Vital signs Integumentary Neurological Musculoskeletal Circulatory Respiratory Gastrointestinal Genitourinary Psychosocial THIS IS WHAT YOU WILL BE DOING WITH YOUR ASSIGNED PATIENT(S) EACH CLINICAL DAY!! Review entire assessment worksheet. GIVE DETAILS. Get out Nursing Worksheet: Assessment Criteria laminated card. Let’s go over this in detail. Do not write within normal limits! What is normal? A setting on a washing machine!

Skin Assessment Nursing history Color Moisture Temperature Texture
Turgor Vascularity Edema Lesions The skin assessment will reveal changes in oxygenation, circulation, nutrition, local tissue damage, and hydration. You will ask the patient if they have any skin changes. You will note if patients report any abnormalities. Always remember to consider changes related to developmental stages, age, and ethnicity.

Nails Inspection and palpation Condition of nails reflects
General health Nutritional status Occupations Level of self-care Assess for artificial nails. Assess for presence of fungal infection. Determine if there are any risk factors that might affect nails, such as diabetes mellitus, peripheral vascular disease, or older age.

Hair and Scalp Use inspection Assess Distribution Thickness Texture
Lubrication You will want to note ethnic variations and normal age variations across the life span.

Neurological Mental Status Orientation Speech
More neuro assess in March

Neurological System Conduct a nursing history Assess Language
Intellectual function Cranial nerve function Sensory nerve function Motor function You can assess the neurological function while performing other parts of the physical examination because it is time consuming. You need to assemble various pieces of equipment, listed on page 369. The Glasgow Coma Scale (GCS), Table on page 365, indicates the patient’s level of consciousness from various levels. Table on page 367 presents the 12 cranial nerves. You may want to review your anatomy and physiology book to refresh your memory about this information.

Head and Neck Inspection and palpation Assess
Headache, dizziness, seizures, poor vision, loss of consciousness Head size, shape contour of head and skull Facial symmetry During the nursing history, you screen for previous or present head injuries. Take the opportunity to reinforce the use of helmets during contact and noncontact activities (biking, roller skating, ice skating, skateboarding, football, ice hockey, lacrosse).

Nose and Sinuses Inspection and palpation Assess for exposure to Dust
Pollutants Allergies Nasal obstruction Trauma Discharge, postnasal drip Headaches You will also ask if the patient uses nasal sprays, illicit drugs, and about frequency/duration of any nasal bleeding.

Mouth and Pharynx Assesses overall health Determine oral hygiene needs
Develop therapies for dehydration Assess oral trauma Assess for airway trauma Look for condition of teeth, use of partial tooth implants or dentures. The condition of the teeth and mouth can present an overall health status of the patient.

Oral Cavity Mucus membranes Chewing and swallowing Dentures Teeth
Oral hygeine

Neck Neck muscles Lymph nodes Carotid arteries Jugular veins
Thyroid gland Trachea Ask if the patient has had a recent cold or infection if the lymph nodes are enlarged. The trachea should be midline. The assessment of carotid artery and jugular veins will be included in the vascular system assessment.

Eyes This assessment detects visual alterations. It will give you an indication if patient needs help with ambulation or performing self-care. You will practice assessing the eyes for PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation). REMOVE GLASSES BEFORE ASSESSING EYES Look at sclera: clear, redness, drainage, swelling Look at pupils: size and PERRLA Demo use of pen light Vision

Discuss accommodation
Accommodation is how the pupil changes shape so that we can see objects that are close or far away. You can see the size of the pupil change when your client focuses on something far away and then something close. Look at pupils when you instruct them to look over your shoulder at a point on the wall then, watch pupils as you have person look at you finger/pen/penlight that is about 10 cm/4 in from their face. What happens? Pupils should constrict as their focus moves from far to near. ABNORMALS Ptosis- drooping of the eyelid Cateract Edema Double vision Halos Any drainage or redness

Ears Hearing Drainage, wax build-up Assess hearing ABNORMALS
Symmetry- low set ears Cerumen Lesions Redness Pain Nodules Mastoid process behind each auricle Hearing

Circulatory Core Body Temperature Skin Color Temperature
Skin color and temperature Pulse = apical and radial Apical 5th intercostal space or just medial to the left midclavicular line Rate and Rhythm BP Also look at peripheral pulses!! Carotid, , temporal,brachial, radial, femoral, Popliteal , dorsal predis, posterior tibial

Turgor Capillary Refill Skin turgor
Where to assess? Back of hand and over sternum. Color of nailbeds? Capillary refill < 3 sec? Capillary Refill

Edema Here edema is related circulation problems Pitting/non-pitting
Pitting :pressure forces fluid under tissue and causes an indentation that slowly fills; +1, +2, + 3 cm NON pitting: leaves an indentation because the fluid has coagulated in the tissue and the tissue feels tight and firm

Skin Integrity/Alterations
Moist membranes, skin temperature, pale? Hair dry and brittle Is the skin intact? Are there alterations of the skin? Discolorations, ecchymosis, wounds, abrasions Describe location, size, and appearance of any changes in skin color or integrity Use Body Planes/Anatomical Directions sheet from packet to describe location

BP Point of Maximal Impulse 5th intercostal space at midclavicural line Breasts What to do with them? RATE and RHYTHM APICAL PULSE

Peripheral Pulses Radial Pulses 80A/80R
Apical always, but especially if radial is irregular and/or weak Check both radial pulses for rate, rhythm, and quality. Are both sides the same? Equal/unequal? Sign of heart block if uneaqual Check most distal pulses on all for extremities (Dorsalis pedis (pedal)) for quality and rhythm, but not rate on both sides and compare. If weak or absent move proximal and assess quality and rhythm (post-tibial, popliteal, and femoral pulses or ulnar and brachial). All pulses on both sides and compare (equal or strong on L vs. R) Rate only for apical and radial.

Homan’s sign This is listed in your book and you may see nurses doing this, but we will not require this on your assessment This is done to assess for thrombophlebitis (blood clot and inflammation of a vein) in the calf. Research has shown that this is not very accurate and if there is a clot it can be dangerous. May cause clot to break off and travel in blood stream to heart, lungs, or brain, causing major problems (MI, CVA, PE) Why we will not have you do this.

IV’s Peripheral

PICC Peripherally inserted central catheter

Jugular and subclavian
Why called central lines? Seen mostly in ICU settings Used for weeks only High risk of infection (sepsis) unless meticulous aseptsis

Mediport Implanted under skin in chest
Tubing (catheter tunneled under skin into superior vena cava Accessed thru skin with specialized needle/tubing system (Huber needle) Central or peripheral line? Long-term IV access: months to years; blood draws; chemo; friend: in 4 years now; 2 years of weekly chemo for ovarian ca

Breasts Examine both female and male breasts Take a health history
Use inspection and palpation Men can develop breast cancer, especially if their mothers had breast cancer. Breast size and shape may vary across the life span. Take the opportunity to discuss the importance of breast self examination.

Respiratory Respirations Cough Rate, rhythm, depth
Look at chest expansion; is it even? Symmetrical? Use of accessory muscles to breath? ( trapezius, sternocleudomastoid) Any dyspnea Any change in respiration with activity Do they have a cough? How often are they coughing? (frequently, occasionally) Is cough productive or non-productive? You may use terms like dry, tight, hacking to describe non-productive coughing If productive, look at sputum. Color, character (consistency), amount, odor. 1. General apperanace 2.Inspect: symmetry, masses, scars, rate, rhythm 3. Palpation: tenderness, alignment, bulging, crepitis 4. percussion: dullness 5. Auscultation wheezes, rales rhonchi, decreased Retractions: suprasternal intercostal substernal subcostal

O2 nasal cannula face mask PULSE OX
O2 how many liters, by nasl cannula , mask??? face mask

Lung Sounds RUL LUL RML LLL RLL 5 lung lobes- 2 on left and 3 right
See pg. 556 in Williams and Hopper for systematic approach to auscultation of lungs or Elkin, Perry, and Potter pg. 276. Have client relax and take slow deep breaths with mouth slightly open If sounds are faint ask client to breath deeper Listen on front, back, and both sides (especially R) to get all 5 lobes Side to side; top to bottom On back follow scapulas down and around (no lung sound through bone) Compare one side to the other. Note location and quality of sounds you hear. Document by location and lobe Right or left first than upper, lower, or middle next then L for lobe Use diaphragm of stethoscope Be sure stethoscope is directly on skin; clothing can interfere with sound (muffled or add sounds that are not really there) ABNORMALS Funnel chest, barrel chest tachypnea, kussmaul’s Chenyne stokes

LUNG SOUNDS Fine crackles- intermittent, nonmusical, soft, high pitches popping sounds inspiration Coarse- intermittent, louder, low pitched, early inspiration and during expiration Rhonchi – musical, low pitched, snoring inspiration more thatn expiration Wheezes- musical, high pitched, expiration predominately but sometimes on inspiration

Gastrointestinal Nutrition Diet % eaten N&V Ht. & Wt.
Appetite; diet; way they eat; What are they eating? How are they eating? How much are they eating? Height and weight? BMI

Abdomen LOOK, LISTEN, & FEEL
Should have empty bladder and lie on back (supine) before assessment (as flat as client can tolerate). LOOK, LISTEN, FEEL Listen in each quadrant with diaphragm of stethoscope. Place stethoscope lightly and directly on skin (no clothing between stethoscope and skin). Normal BS heard Q 5 to 15 sec. about 5-30/min., Hypo BS < 5/min., Hyper BS > 30/min., Absent = no sounds after listening or 2 to 5 min in each quadrant. ID bowel sound in each quad. Remember right or left is first then upper or lower in next then quad. RUQ Use abbreviations as seen here (side, upper or lower, then quadrant) Symmetry, scars, massess, tenderness

RUQ LUQ RLQ LLQ Right Upper Quadrant Left Upper Quadrant
Feel = palpation. Where organs are located in abd. by quadrant. Watch patient’s face during exam to assess for discomfort. Save tender areas for last. We are expecting only light palpation for your assessments Do not percuss a patient with abdominal aneurysm or a transplanted abdominal organ------rupture RLQ LLQ Right Lower Quadrant Left Lower Quadrant

Bowels What is “normal”? Ask about Frequency Color Consistency Amount
Abnormals Jaundice Bloody stools Constipation Diarrhea Dysphagia Nausea and vomiting Hepatomegaly splenomegaly

Genitourinary Urine Intake and Output Perineal Area Intake in ml’s
Output in ml’s

Foley Catheter Draining urine People void urine Foleys drain urine
If they have a foley, they are NOT VOIDING

Know your landmarks—just because there is a hole, does not mean that’s the one that produces urine
Note: inspection of skin. Frequency of urine, burning, hesitation, pressure, pain, color, smell hx of uti or kidney infections

Female Genitalia Examination of the genitalia includes external and internal sex organs Must provide privacy Need to understand cultural sensitivity Conduct a nursing history Use inspection and palpation This assessment can be embarrassing to both patient and health care provider. You will want to use good communication techniques (Chapter 10). You will also need to be culturally sensitive to the patient’s practices (Chapter 19). During the nursing history you will ask about onset of menarche, history of problems with monthly periods, any problems with sexually transmitted infections. This also may be an opportunity to discuss birth control and use of male/female condoms.

Male Genitalia Assess the integrity of external genitalia, inguinal ring, and canal Conduct a nursing history Use inspection and palpation Patients may be embarrassed. You will need to use good communication skills learned in Chapter 10. You will also need to incorporate cultural sensitivities learned in Chapter 19. The opportunity may exist to discuss sexually transmitted infections, use of condoms, and past sexual history. Male genitalia may vary across the life span.

Musculoskeletal Gait Posture Extremities Contractures/Amputations
Enlargement Alignment/Symmetry Heat, tenderness, edema Contractures/Amputations Enlargements Alignment/Symmetry Heat, tenderness, edema of any joint (s) Discuss difference between joint edema and other edema Joint edema goes here!!! Synovial- move freely bones are separated from each other and met in a cavity filled with synovial fluid or lubricant Non synovial bones connect with fibrous tissue or cartilage. Bone may immobile or slightly movable- skull or vertebrae

ROM Active vs. passive Steve (SKELELTON) here has passive ROM; demonstrate on skeleton DOES HE HAVE MUSCLE STRENGTH? NO!! ROM is described by what the client can and cannot do or by the degree to which a joint can be moved.

Muscle Strength Bring skeleton. Skeleton has ROM, but no muscle strength. Ability to resist gravity only or gravity and force that you apply. Demonstrate resisting gravity on student; both upper and lower; right and left have student lift arms, then lift legs Demonstrate resisting force on student; both upper and lower; right and left have student push against your hands with their hands have student push against your hands with their feet ABNORMALS p’s pain, pallor, paresthesia, paralysis, pulse Crepitus Spasms Atrophy weakness 5/5 normal- patient moves joint through full ROM and against gravity with full resistance 4/5 good- as above but with moderate resistance 3/5- fair- no resistance against gravity 2/5 poor- nothing by self- only passive ROM 1/5 trace- muscle contraction but no joint movement

Abnormal Sensations

Musculoskeletal BUE RUE LUE BLE LLE RLE Abbreviations for extremities
What do they mean? Use ONLY these!!!! Always list both, left, or right first Then upper or lower Then E for extremity

Psychosocial Emotional Support System Cultural Spiritual/Religion
Social Interaction Need to assess these areas well. In long term care look to see if resident attends any activities or if they sit alone in their room all the time Visitors? Ho In what ways can your belief system efffect your health practices? does their religion affect their physical health – Jehovah's witness and no blood products.

Additional Data Pain Self-care Deficits
Remember to place information in the system in which it pertains. Pain scale 0 to 10 or 0 to 5 depending on institution. Different places use different scales, know the scale where you are charting. Self-care deficit may be included with Musculoskeletal, Circulatory (Skin), or Psychosocial If they have a difficulty with performing ADL’s, remember to include this info

Wounds/Incisions Kocher/Subcostal Midline McBurney Battle Lanz
Paramedian Transverse Rutherford Morrison Pfannenstiel YOU DO NOT NEED TO KNOW THESE Different incisions used for different procedures. You may see these terms in a pt chart (OR report). Incision is charted in system that applies. Chart in system that was operated on. (Appy would go with GI, C/S would go with GU, skin graft for burn would go in Circulatory with skin). Wounds would be under skin in circulatory ONLY NEED TO DOCUMENT IN ONE PLACE. DO NOT NEED TO REPEAT INFO Be sure to include location using Body Planes/Anatomical Directions sheet from packet Always measure and document size in cm CARRY SOMETHING TO MEAURE WITH ESPECIALLY IF YOU KNOW CLIENT HAS A WOUND/INCISION Estimating can lead to problems I think 2 cm by 3 cm wound. What is 2 or 3 cm’s? Do we all have the same idea? Next nurse actually measures and wound is 3 X 4 cm. Has it gotten bigger? We don’t know for sure. No payment by Medicare if worsening not improving, but maybe it has actually gotten smaller (imporvement)

Tubes/Drains Drains from surgery is charted in area of surgery (Abd. Drain in GI, hemovac from TKR would go in Musculoskeletal) Stoma are usually in GI area, but maybe in GU if it is urostomy. Document type of drain, location, and color, amount in ml’s, and consistency of output coming from drain JP in bottom left (JP in RLQ of abd. intact draining x ml’s of sang. fluid Stoma in pink and healing bottom right (stoma beefy red draining x ml’s of brownish-green liquid stool)

Jane R Bordner, RN, BSN Nursing Instructor HACC N100 Spring 2014

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Jane R Bordner, RN, BSN Nursing Instructor HACC N100 Spring 2014

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