The Confusion Assessment Method - ANS ✓Onset: Acute changes in mental
status. · Attention: Inattentive, stable, or fluctuating. · Thinking: Disorganized,
rambling, switching topics, illogical. ·
Level of consciousness: Altered (ranging from alert to coma). ·
Orientation: Time, place, person. ·
Memory: Impaired. ·
Perceptual disturbances: Hallucinations, illusions. Psychomotor abnormalities:
Agitations or retardation. ·
Sleep-wake cycle: Awake at night, sleepy in the daytime.
Nursing process - ANS ✓Assessment: Collecting data, history, and completing a
physical exam.
Med-surg. ANCC
, 2
Med
Diagnosis: Analyzing data, determining needs and problems, and applying a
nursing diagnosis.
Planning: Setting priorities, setting goals and expected outcomes, and planning
interventions and strategies of care.
Implementation: Applying interventions/treatments. Evaluation: Reassessing and
auditing.
Diabetes insipidus - ANS ✓Extreme thirst and urination cause by imbalance in
body fluid
CAGE - ANS ✓Alcoholism screening-
C -Cutting down: Do you think about trying to cut down on drinking?
A -Annoyed at criticism: Are people starting to criticize your drinking?
G -Guilty feeling: Do you feel guilty or try to hide your drinking?
E -Eye opener: do you increasingly need a drink earlier in the day?
Braden score - ANS ✓PU risk assessment
PUSH score - ANS ✓Pressure Ulcer Scale for Healing- measure over time to
indicate healing or deterioration
Five Stages of grief - ANS ✓1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
Bloom's Taxonomy(6 levels of learning) - ANS ✓Remember
Understand
Med-surg. ANCC
, 3
Med
Apply
Analyze
Evaluate
Create
Bloom's Taxonomy(3 types of learning) - ANS ✓1. Cognitive: Learning and
gaining intellectual skills and mastering categories of effective learning
(knowledge, comprehension, application, analysis, synthesis, and evaluation). ·
2. Affective: Recognizing categories of feelings and values from simple to complex
(receiving and responding to phenomena, valuing, organizing, and internalizing
values). ·
3. Psychomotor: Mastering motor skills necessary for independence, following a
progression from simple to complex (perception, set, guided response,
mechanism, complex overt response, adaptation, and origination).
Tertiary - ANS ✓Soften impact of longterm ,complex illness/injury
Secondary - ANS ✓Early detection and Treatment to halt or slow progress
Primary - ANS ✓Prevention
Orchiopexy - ANS ✓Sx to move undescended testicle or resolve testicular torsion
Orchiectomy - ANS ✓Removal of one or both testicules
Piaget's stages of
Cognitive Development - ANS ✓Sensorimotor (0 -2): Infants learn about cause
and
effect and the permanence of objects. · Preoperational (2 -7): Thinking is
concrete and tangible at the preconceptual stage, and later becomes intuitive.
Med-surg. ANCC
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