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Describe briefly the history of
nursing and what led to its emergence as a profession.
- After the capture of Jerusalem 1099, crusaders noticed the excellent nursing care
- provided by the Hospital of St. John and decided to join the nursing group. The
- “Maltese Cross” became a symbol for those who cared for the sick including the
- US Cadet Nurse Corps. Florence Nightingale chose this as a symbol for the
- graduates of her first nursing school; her first school was at Bellevue
- Hospital—credited with developing the first school badge or pin presented to
- class of 1880.
- Isabel Hampton Robb: Helped establish American Nurses Association (ANA) and National League of Nursing
- (NLN) & Advocated rights of nursing students (learner vs. unpaid employee)
Describe the contributions of Dorothy Orem’s Theory
=>Self-Care Deficit Theory of Nursing, which is composed of three interrelated theories:
=>The Three Basic Nursing Systems:
Specifically defines when nursing is needed:
Nursing is needed when the individual cannot maintain continuously that amount and quality of self-care necessary to sustain life and health, recover from disease or injury, or cope with their effects.
- Orem developed the Self-Care Deficit Theory of Nursing, which is composed of three interrelated theories:
- 1. Theory of self-care: the performance or practice of activities that individuals initiate and perform on their own behalf to maintain life, health and well-being
- 2. Self-care deficit theory: delineates when nursing is needed. Nursing is required when an adult (or in the case of a dependent, the parent or guardian) is incapable of or limited in the provision of continuous effective self-care.
- 3. Theory of nursing systems. The product of a series of relations between the persons: legitimate nurse and legitimate client.
This system is activated when the client’s therapeutic self-care demand exceeds available self-care agency, leading to the need for nursing.
2. Partly compensatory
- The Three Basic Nursing Systems:1. Wholly compensatory nursing system is represented by a situation in which the individual is unable “to engage in those self-care actions requiring self-directed and controlled ambulation and manipulative movement or the medical prescription to refrain from such activity… Persons with these limitations are socially dependent on others for their continued existence and well-being.”
nursing system is represented by a situation in which “both nurse and perform care measures or other actions involving manipulative tasks or ambulation… [Either] the patient or the nurse may have the major role in the performance of care measures.”
- 3. Supportive-educative system also known as supportive-developmental system, the person “is able to perform or can and should learn to perform required measures of externally or internally oriented therapeutic self-care but cannot do so without assistance.”
Discuss the definition of nursing according to the American Nurses Association.
“Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
eflects nurses’ increasing role in promoting health and wellness and advocating for the recipients of care
The essential core of nursing practice is to deliver holistic, patient-centered care. It includes assessment and evaluation, administration of a variety of interventions, patient and family teaching, and being a member of the interdisciplinary.
Describe the techniques for assisting with Activities of Daily Living, maintaining comfort and safety
Aseptic or clean technique like you mentioned, fall safety, privacy and dignity, warmth, skin safety
Apply Erickson's developmental theories to varied client populations.
There are 8 stages of development:
1. Infancy (0-18 months): Trust vs. Mistrust (from caregivers to give care, affection). Feeding is important
2. Early childhood (2-3): Autonomy vs. Shame/Doubt (develop personal control over physical skills for independency). Toilet training is important.
3. Preschool (3-5): Initiative vs. Guilt (Begin asserting control over environment, but too much will result in guilt). Exploration is important.
4. School Age (6-11): Industry vs. Inferiority (need to cope w/ new social/academic demands to develop sense of competence) School is important.
5. Adolescence (12-18 yrs): Identity vs. Role confusion (develop a sense of self/personal identity and find true self or role confusion will give a weak sense of self.) Social Relationships are important.
6. Young adult (19-40): Intimacy vs. Isolation ( need to form intimate, loving relationships with other people or else loneliness and isolation). Relationships are important.
7. Middle Adulthood (40-65): Generativity vs. Stagnation (need to create/nurture things that will outlast them thru children or positive changes that benefit others for accomplishment or else shallow involvement in world). Work and Parenthood are Important.
8. Maturity (65-death): Ego Integrity vs Despair (looking back at life and feeling sense of fulfillment, leads to feelings of wisdom, or else results in regret, bitterness and despair)
Define the role of client advocate as it relates to nursing.
As a nurse you are in excellent position to be an advocate for equity for older women in the the health care system; mandated reporters; encourage older adults to be evaluated by their primary care provider and to use memory aids for age-associated memory impairment.
Discuss the role that caring plays in building a nurse patient relationship.
Teaching roles, motherly,
Identify culturally sensitive nursing assessment and interventions
The first step in providing culturally competent care is for you to assess your own cultural background, values, and beliefs, especially those that are related to health and health care.
Recognition of own culture and cultural perceptions, beliefs, values, attitudes, and behaviors THEN Assessment of the patient’s culture.
“How to Develop Cultural Competence” (Table 2.4)
1. Cultural Awareness: Ability to understand patient’s unique cultural needs; examine your own background values and your own cultural biases towards people with different cultures from yours.
2. Cultural Knowledge: Process of learning key aspects of a group’s culture, especially as it relates to health and health care practices, patients are the best source of info about their culture. My role as nurse: Learn general info about predominant cult groups, don’t make assumptions due to varying acculturation degrees, view cultural documentaries.
3. Cultural Skill: Ability to collect relevant cultural data, performance of a cultural assessment. My role: be alert for unexpected responses related to cultural issues, become aware of cultural differences in predominant ethnic groups, develop assessment skills to do a competent cultural assessment for any patient, learn assessment skills for different cultural groups including cultural beliefs and practices.
4. Cultural Encounter: Direct cross-cultural interactions between people rom culturally diverse backgrounds, extended contract with a cultural group to enhance understanding of its values and beliefs. My role: create opportunities to interact with predominant cultural groups, attend cultural/religious ceremonies/life passage rituals, visit markets of ethnic neighborhoods, listen to different types of ethnic music and learn games, volunteer at health fairs in local or ethnic neighborhoods, and learn about prominent cultural beliefs/practices AND INCORPORATE THE KNOWLEDGE INTO PLANNING NURSING CARE!
Describe basic elements of therapeutic communication techniques
Elements: Purposeful & Goal-Directed, well-defined boundaries, Client-Focused, Non-Judgmental, active listening, Caring, Honest, Empathy, Encourage verbalization of feelings.
Effective communication is key in the interview process, creating a climate of trust and respect is critical to establishing a therapeutic relationship. Develop a personal style of relating to patients.
The Elements: Orientation, Working Phase,Termination
Guidelines for Effective communication: Introduce yourself by name and title, State your role in their care, Assure confidentiality and its parameters, Give reasons you must ask questions, Allow for privacy, Provide enough personal space, Be attentive to tone of voice, Be an observant active listener, Use silence
Avoid Barriers to Effective Communication: Giving advice, false reassurance, judgmental comments, “why?”, changing the subject, failure to clarify and obtain relevant data.
Key Aspects of Motivational Interviewing (using non-congrontational intperpersonal communication techniques to motivation patients to change behavior, uses intervention that enhances the patient’s motivation for change.
Describe teaching implications related to adult learning principles
- Adult Learner:
- -Immediate result, Desire practical use, meaningful to own life, Should be given responsibility for own learning, Prioritize when educating: What would my client need to know to prevent life threatening symptoms?
2. The learner’s readiness to learn:
- “Adult Learning Principles Applies to Patient and Caregiver Teaching”
- 1. The Learner’s need to know: patients need to know why they should learn something, what they need to learn and how it will benefit them
Readiness and motivation to learn are high when facing new tasks, health crises provide opportunities for patients to learn and change behavior, stress and anxiety may interfere with learning, thus requiring frequent reinformcement of content.
3. Prior experiences:
motivation increases when patients already know something about the subject from past experiences, identification of past knowledge and experiences can help find familiar ground to increase patient’s confidence.
4. Motivation to learn
: patient’s prefer to apply learning immediately, long term goals may have less appeal than short term goals, focus teaching on info that the the patient views as being needed right now.
5. Orientation to learning:
patients nseek out various resources for specific learning and prefer to have choice, relevancy of teaching is necessary so offer explanations of the value of learning
6. Learner’s self-concept:
patients need control and self direction (sense of autonomy) to maintain their sense of self-worth. Patients do not learn when they are treated like children and told what they must do.
Identify physical, psychological, and sociocultural characteristics that affect client care and teaching.
Patient teaching depends of effective communication b/w you and the patient/caregiver. No Medical Jargon, pay attention to non-verbal communication, uses active listening, Empathy.
Challenges to Teaching effectiveness: Lack of time, your own feelings/doubts as a teacher, nurse-patient differences in learning goals, and early discharge from health care system
- Caregiver support-they may need assistance to learn the physical and technical requirements of care, find resources for home care, locate equipment and supplies.
- Sources of support: hospital to home transition-insurance compatinies, case managers at hospital, medicare/Medicaid offices.
Describe strategies that facilitate elderly adult's learning abilities
Nursing Management: You play a vital role in preventing downward trajectory of cascade disease patterns (falling>breakingHip>Pneumonia).
First attend to primary needs: Empty bladder first, Place all “assistive devices” (hearing aides, glasses) within reach, evaluate fatigue levels.
When setting goals with older adults, identifiy their strengths and weaknesses.
Learning Charcteristics by Generation: Elderly-printed materials
Describe the purpose of the National Patient Safety Goals, ACEN, BRN and Health Care Reform
Health Care Reform: Govt-Medicare, Medical vs Private: Independent providers and Pharmaceutical companies
NPSG that apply to hospitals: Identify patients correctly, Improve staff communication, Use meds safely, Use Alarms safely, Prevent infection, Identify patient safety risks.
NPSG: National Patient Safety Goals: promote specific improvements in patient safety, highlight problematic areas in health care and describe evidence and expert-based solutions to these problems
- NPSG’s: Improve accuracy of patient idefication, improve communication effectiveness b/w caregivers, improve the safety of using meds, reduce the risk of health care associated infections, accurately and completely reconcile medications across the continuum of care, reduce the risk of patient harm resulting from falls, prevent health care related pressure ulcer, identifies safety risk inherent in its patient population.
- Universal Protocol: Pre-procedure verification, mark procedure site, performance of time-out
Apply concepts of evidenced based practice to nursing.
-Steps of EBP: PICOT?
EBP is a problem solving approach to clinical decision making. Uses the best available evidence (research, professional organization standards) in combination with clinicial expertise and patient preferences and values to achieve desired patient outcomes. The most important reason to use EBP is the deliever of the highest quality of care for the best patient outcomes
TJC is a regulatory and accrediting agency that require documnentation of the effective use of evidence in clinical clare decisions.
- STEPS of EBP:
- 1. Create a spirit of Inquiry.
- 2. Ask a clinical question in PICOT format. P:Patients/population.
- I: Intervention.
- C: Comparison
- O: Outcome.
- T: Time Period.
- • Ex: In Cardiact patients, is morphine or fentalnyl more effective in reducing pain on the first postoperative day?
3. Thorough search for an collection of evidence based on the clinical question. Systematic reviews of “randomized controlled trials” are considered the strongest level of evidence to answer questions about interventions.
4. Critically appraising and synthesized evidence found in the search, determined the value of the research in actual practice
5. If evidence is found to be strong, then it can be implemented into practice interventions in combination with clinical expertise and patient preferences.
6. Evaluation of identified outcomes in the clinical setting, outcomes to be measured must match the clinical project objective implemented.
- 7. Lastly, share the outcomes so that patients can benefit from what you learned.
- I: Intervention.
- C: Comparison
- O: Outcome.
- T: Time Period.
• Ex: In Cardiact patients, is morphine or fentalnyl more effective in reducing pain on the first postoperative day?
Describe strategies for successfully communicating with a person who speaks a foreign language that the nurse does not understand.
Using a Medical Interpreter: use agency intepreter with health care background and knows patient rights and advice about the cultural relevance. Use a family member only if necessary, Be aware of limitations.
Working with an interpreter: speak slowly, maintain eye contact, one-two sentences, obtain feedback that patient understands, plan on taking twice as long for the interaction.
When no interpreter is available: pantomime, use simple words.
Identify physiologic aspect of culture and ethnicity that may affect a person's health
Time orientation, language/communication, economic factors, Health care systems (transportation,lack of knowledge in existing Health care Resources), Beliefs and practices, practices of religious groups.
Spirituality: a person’s efforts to find purpose and meaning in life. Vs. Religion: formal and organized system of beliefs including worship of God.
Describe how safety, quality, and evidence based practice can be improved using the Quality and Safety Education for Nurses (QSEN) competencies and The Joint Commission standards. (THE QSEN COMPTENCIES!)
QSEN: A project with six core competencies (QT-PIES)
1. Patient-Centered Care: the nursing process, standardized nursing terminologies, Nursing Care Plans
2. Informatics/Technology:Protected Health Info (PHI), Electronic Health records (EHR), Nursing informatics-build computer systems, Telehealth & videoconferencing.
3. Evidence Based Practice
5. Quality Improvement: A culture of safety to minimize risk to patient, identify issues associated with poor quality and unsafe care. NSPG’s.
6. Teamwork & collaboration: Situation-Background-Assessment-Recommendation/Request (SBAR)
The Nursing Process and Care Plans
a problem solving approach to the identification and treatment of patient problems that is the foundation of nursing practice; a framework for the delivery of nursing care for the best patient outcomes. (ADPIE)
1. Assessment: collection of subjective and objective patient info.
2. Diagnosis: analyzing the assement data and making a judgement about the nature of the data.
3. Planning: the nursing diagnosis directs the development of patient outcomes or goals
4. Implementation: activation of the plan with use of nursing interventions
5. Evaluation:a continual activity; determines whether the patient outcomes have been met, if not-review the steps and revise
Nursing Care Plans: documentation of the Nursing Process, can use flow/concept maps
Apply professional standards to nursing students.
Veracity, Liability, Mandated Reporters, Advocates (pg. 300)
Discuss RN nursing licensure process in California and reasons for license revocation.
Two procedures: licensure by Exam or Endorsement (getting in another state)
Revocation is a disciplinary action; reasons include: Drug abuse, violating a board order, documentation errors,Failure to comply with requirements, Medication Errors and Felonies
Identify nursing student liability and ethical responsibilities inside and outside the clinical setting.
Liability: an obligation or debt that can be enforced by law, a person found guilty of any tort. You are always liable for your actions as an educated professional
Your duty: to report or seek medical care for a patient, “failure to rescue”, identify deterioration and intervening to assure care, advocate-ensure patient gets proper physician attention. Identify obvious discrepancies or problems in medical orders, nurse should have physican verify an over-the-phone order, maintain HIPAA privacy, avoid Defamation of Character. Receive informed consent
Define veracity, autonomy, fidelity, justice, beneficence, and nonmaleficence.
Autonomy: involved the right to self-determination or choice, independence, freedom. Closely tied to Informed concent because it requires patient to have enough information to make good decisions for themselved.
Beneficience: doing or producing good, especially performing acts of kindness and charity.
Nonmaleficience: the prevention of intentional harm
Justice: aka fairness, distributive justice criteria of limited resources
Fidelity: refers to the obligation to be faithful to the agreements, commitments and responsibilities that one has made to oneself and to employers, government
Veracity: Refers to telling the truth or not intentionally deceiving or misleading patients.
Define negligence, malpractice, informed consent, and confidentiality.
Malpractice: a term used to identify professional negligence—liability from improper practice based on standards of care required by the profession for which the person has been educated.
Negligence: “Conduct Lacking in due care”, there are four main characteristcs. (1) Harm (2) Duty (3) Breach of duty-person failed to fulfill her responsibility and (4) causation: Harm should have been caused from the breach of Duty.
Informed Consent: No coercion exists and person clearly understand the choices being offered and takes risks and benefits into consideration and assessment of patient’s understanding
Nurse Practice Acts of 1974:
-Help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment requires scientific knowledge or technical skill, including:
(1) Services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures.
(2) Admin of medications, implement a treatment, disease prevention, or rehabilitative regimen ordered by a physician, dentist, podiatrist, or clinical psychologist.
(3) Skin tests, immunization, and withdrawal of human blood.
- (4) Observation
- (B) Implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen
- (c) "Standardized procedures/care": NPSG's
Cite the nurse’s role and responsibilities in the signing of informed consents and advanced directives.
The nurse should NOT participate in assisted suicide; violation of the Code for Nurses instead we should focus on reversing pain and providing end-of-life compassionate care.
Define ethical conduct for nurses as defined by the American Nurses Association.
ANA’s code for nurses: practice with compassion, respect for dignity, primary commitment to the patient, improves health care conditions, contribution to advancement of profession through educaton and knowledge development, collaboration with other
health care professionals to promote community efforts to meet health needs, shaping social policy.
Explain the purpose, components, and techniques related to a patient history and physical examination.
Purpose: patient history: subjective data, first and best chance a person has to tell you what he or she perceives his or her health state to be.
Components of patient history: biographical data, source of history, reason for seeking care, history of present illness, past health, accidents or injuries, hospitalizations/operations, Family history, Review of symptoms, Functional assessment of ADL’s and Perception of Health
Assessment Techniques: Inspection, Auscultation, Palpation Percussion
Describe the key parts of a Nursing Diagnosis using NANDA’s (North American Nursing Diagnoses Association) approved format and lists.
=>Code of Ethics-
Ethical principles that are accepted by all members of a profession;Ethics is the study of good conduct, character, and motive, guiding principles.
-The Nursing Code of Ethics sets forth ideals of conduct-website http://nursingworld.org/ethics/chcode.htm
=> Universal Moral Principles
- Beneficence- doing good.
- Nonmaleficence-not doing harm
- -Integrity, “I’ll be back in half hr.”Justice
=>Ensuring Public Safety
- Laws, Policy & Procedure'
- Licensing: Medicare, State Public Health agency, State Board of Nursing
Accreditation: NLN, The Joint Commissionwww.jointcommission.org
=>Common Law Legal Actions
-Criminal:Theft, Drug violations,Murder, dependent abuse
- -->Civil torts (unintentional)
- -Negligence: duty, injury, fault. (35 min)
- -Malpractice: fail to meet prof. standard
- -Issues of informed consent
--> Intentional Torts: - Assault - Defamation of character- Battery - Fraud- Invasion of privacy - False imprisonment
=>What Nurses Can Do to Protect Themselves Legally
- Competent practice through continuing education
- Client education
- therapeutic relationship
- When executing physician orders, clarify, BE ASSERTIVE
- Clear, concise, correct documentation
- Risk Management Programs
- Incident or Unusual Occurrence formsHave Liability Insurance
=> Informed Consent
a person’s agreement to allow something to happen, such as surgery, based on a full disclosure of risks, benefits, alternatives. Right to refuse anytime.Obtaining informed consent does not fall within the nursing duty. The nurse is witnessing that signature is voluntary, pt. seems competent to give consent.
=>Right to refuse treatment
- Mentally competent adult
- fully informed about condition and consequences of refusal
- Some refuse because of religious reason
State or hospital: court order can compel parents to get treatment for children.
=>Life Sustaining Procedures
Defined by California Health & Safety Code:“Any medical procedure or intervention which utilizes artificial means to sustain, restore or supplant a vital function which when applied to a qualified patient would only serve to artificially prolong the moment of death.”
=>California Natural Death Act – Living Will (1976)
A competent adult can direct physician in writing to withhold or withdraw life sustaining procedures if no recovery expected.
Living will (Advance Directive) must be signed by the adult and 2 witnesses, and be notarized.
Protects hospital, physician from lawsuit
-POLST (vs. DNR's?)
Living will: Advance care document that specify wishes about medical care if unable to communicate.
Durable Power of Attorney for Health care: Appoint another person to make decision regarding your health care in case you are incompetent.DNR or Allow Natural Death
- =>Do Not Resuscitate Orders
- Most institutions have a policy that resuscitative measures will be initiated unless there is a written DNR order
- DNR orders must be renewed per protocol (usually every 7 days)
- Order must be written in chart and signed by MD.
- =>POLST: “Physician Orders for Life-Sustaining Treatment”
Physician initiates discussion with patient or patient’s surrogate about treatment options.Incorporates preferences for end-of-life treatments into medical orders.
- Is in addition to advanced directives.
- -->Difference from an advanced directive:
- -Involves medical orders, not just documentation of the patient’s wishes.
- -Meant to be portable, and go with the patient from one setting to another.
- Date/time of the assessment, intervention, or evaluationUse military time Follow policy regarding frequency of charting; adjust according to client’s conditionDocument ASAP after an assessment or interventionDocument events in the order in which they occurredDo not document PRIOR TO an assessment or intervention (2:45 min)
- Black ink and LegibleSignatures should include the name and title Example: Irene Smart, MCSNMCSN= Moorpark College Student NurseComputer Documentation: Safeguard user ID & password. Log off when leaving the computer.
- => Accuracy
- Chart facts and observations, rather than opinions or interpretations of an observationAvoid general words, such as large, good, or normal Spell correctly Appropriateness Only information that pertains to the client’s health problems and care should be recorded
=>Completeness Be complete, concise, meaningfulAvoid opinion, cliché, bias, “seems” Use quotes, any instructions, interventions given, client’s response. If it isn’t documented, it didn’t happen.
- =>Confidentiality: HIPAA
- Access to medical record is restricted
- Available to health care professionals providing client care, and for the purposes of education and researchClient gives written permission to share record only with those that need to use it.
- ->Log out of computer charting when doneDo not use names, initials onlyDo not discuss case in public or social media!S.N. MAY NOT PRINT OR PHOTOCOPY RECORDS
The Nursing Process:
THE NURSING PROCESS: Assessment
- => Assessment
- Types of data: Objective = signs (overt data). Use you senses. & Subjective = symptoms. What client SAYS “ “
- => Sources of Data
- ClientFamily and significant others
- Health care team members
- Medical records
- Other records (employment, military, etc.)
- Literature review
- Nurse’s experience
=> These Are Not Nursing Diagnoses
- Medical diagnosis
- Medical pathology
- Diagnostic test
- Therapeutic client need
- Therapeutic nursing goal
- Single sign or symptom
=> Types of Nursing Diagnoses: l
Physical, Psychosocial, Educationa
=> Writing a Nursing Diagnosis: *imp*
PROBLEM related to ETIOLOGY (related factors) manifested by DATA (defining characteristics)
=> Examples of Nursing Diagnoses
-Fluid volume deficit related to decreased fluid intake as evidenced by dry mucous membranes, poor turgor, tachycardia, increased HCT and BUN, no oral fluid intake.
-Activity intolerance r/t insufficient oxygen transport secondary to anemia AEB SOB with transfer from bed to chair, client states “I can’t breathe when I move around” SpO2 92%
-Social isolation R/T contact isolation aeb by client withdrawn, tearful at times, states “I feel all alone”, no visitors, and staff enter room for procedures only
-Knowledge Deficit re: antiembolism measures r/t lack of exposure AEB wearing only one compression hose and asking “what are these for, anyway?”
=>“Risk for” diagnoses
- -Use when the problem has not actually
- happened yet but is of high priority to prevent.
- -Since it has not happened yet, there should not be any defining characteristics.
-Ex: “Risk for impaired tissue integrity related to decreased mobility and thin frame.”
=> Writing Goals/Expected Outcomes
- -Clearly relate to the nsg diagnosis.
- -Involve client and family in making goals
- -Realistic-Goals should indicate time frame for when it’s to be achieved
- -Goals are what the client should accomplish not what the nurse should do
**WHO should do WHAT by WHEN.
"_______ will _____________ by _________."
- =>Examples of Goals/Expected Outcomes
- Goal has a subject, verb, and criteria. MEASURABLE!
ex 1: Pt. will ambulate 100ft with a walker and stand-by assistance by day 3 post-op
ex 2:Mrs. C’s 8 hr fluid intake will total at least 500 ml by 1400.
- ex 3:Mr. D will demonstrate proper incision care by end of shift.
- Types of Nursing Interventions:
- Independent - activities the nurse orders and carries out
- Dependent - activities that require physician orders
- Interdependent - activities carried out in collaboration with other healthcare professionals
- =>Guidelines for Nursing Interventions
- Who, when, how often. Why?
- Make sure they directly relate to the goal that was formulated.
- Involve the client and the family.
- Use hospital protocol.
- Individualize for your patient. Some creativity ok.
- Use action verbs. Assess, ambulate, encourage, refer, etc.
- Write as if making directions for someone else to follow.
- Include when, or time interval for them.
- -ex: “ASSESS LUNG SOUNDS Q 4HR , VS Q SHIFT, TURN Q 2HR, DRESSING Q AM, etc….
- => Examples of Interventions
- Goal: Pt. will have no pressure ulcers during this admission.
- -Keep skin clean and dry throughout shift.
- -Turn patient off of boney prominences q2h.
- -Encourage intake of at least 240 ml of fluids in between meals, and 240 ml of fluids with meals.
- -Ambulate patient three times a day.
=>THE NURSING PROCESS: Evaluation
:Look back at Goal: Was it met or not met?The nurse and client together measure how well the client has achieved the goals
If goal met, celebrate! If the client fails to meet the goals, revise.Decision is made to terminate, continue, or modify the plan
- => Evaluation – what to write
- State if goal was met or not.Make brief statement about what signs or symptoms led you to determine if the goal was met or not.
- -->Do not just put “Goal Met” or “Goal not met.” BUT...“Goal met, patient had no areas of redness or skin breakdown upon discharge.”
- -“Goal in progress, patient had no areas of redness or skin breakdown on 4th day of admission.”
- -“Goal not met, patient with 2cm area of redness on right heel. Float heels off of bed using pillows, and re-evaluate tomorrow.”