Interv final

Nursing dx: based on pt's response to treatment of problem or disease. Focuses on pt

Medical dx: describes a disease, illness. Purpose is to ID pathology so appr med tx can be given.  More focused then nurse dx

• assessment
• nursing dx
• planning 
•   --planning outcomes
•   --planning interventions
• implementation
• evaluation

comprised of 5 communication qualities

• Empathy
• Respect
• Genuineness
• Concreteness
• Confrontation

*Every Respectful Guy Carries Condoms

• Primary : nonspecific. intact skin, GI tract, mouth etc.  
• Secondary: non-specific.  Phagocytosis, inflammation, fever
• Tertiary: specific immunity. body creates antibodies against specific pathogens

• A. local vs systemic
• B. Primary/secondary
• C. Exogenous/endogenous (Exo is acquired from healthcare envir, endo arises from pt normal flora issues)
• D. Acute/ChronicLatent

• Considered first tier of protection, applies to all pts
• Includes hand hygiene; use of gloves, gown, mask, eye protection or face shield (depending on expected exposure) and safe injection practices
• Practice respiratory hygiene and cough etequette

• Is a tier 2 protection:
• wear non sterile gloves
• wear clean gown
• remove PPE and observe hand hygiene before leaving room
• use disposable equipment
• Ex: MRSA, scabies, shingles, diarrhea

• is a tier 2 protection: keep droplet precautions outside pt room
• wear mask, donning on entry
• change PPE and perform hand hygiene btwn pts
• Ex: flu, RSV, Pneumonia, pertussis, strep

• is a tier 2 protection: keep airborne supplies outside pt room
• Don mask on entry, wear special fitting N-95 respirator if pt has TB or smalpox
• remove respirator/mask outside room after closing door
• EX: TB, measles

• is a tier 3 protection: for pts with suppressed immune systems
• Pt in private room
• restricted visitors
• wear mask, gown and gloves

• serves three purposes: health, social interaction, and pleasure or relaxation
• Bathing removes perspiration and bacteria from skin surface, helping to prevent body odor
• Warmth from water dilate blood vessels near surface of skin, increasing circulation
• Stimulates depth of respirations and improves sensory input

mentor: offers broad teaching, helps with career development. 

Preceptor:  someone who has more experience who provides practical teaching and guidance.  More focused

• Autonomy
• Nonmaleficence
• Beneficence
• Fidelity
• Veracity
• Justice

• a two-fold duty to do no harm and to prevent harm
• refers to both actual harm and risk of harm, as well as intentional and unintentional

Ex: Nightingale Pledge of nurses state that care providers have a duty to cause no harm

• refers to a person's right to choose and ability to act on that choice
• based on respect for human dignity
• freedom of choice

treating others like children

• the duty to do or promote good
• can be thought of as a continuum with nonmaleficence

faithfulness, is the duty to keep promises

duty to tell the truth

obligation to be fair

• Be aware
• assume responsibility
• function as team member
• Support pt and family
• support pt who are not allowed to decide
• Participate in ethics committees
• advocate for your pt

• violates a person's right to be left alone
• pt has right to:
• have private info protected
• Not be falsely portrayed or intentionally misrepresented in character
• Be free from unwanted intrusion (spying, eavesdropping)

Malpractice involves a professional person who has failed to act in a reasonable and prudent (careful) manner

Negligence is the failure to use ordinary or reasonable care of the failure to act in a reasonable and prudent manner

the permission for any and all types of care given by the pt with full knowledge of the risks, benefits, costs, and alternatives

you must report it

• 1. MVA
• 2. Poisoning
• 3. Falls
• 4. Drowning/submersion
• 5. Smoke/fire/flames

• can be physical or chemical
• Avoid when possible
• Doc specifically and in detail
• Maintain 1-on-1 view of pt
• know guidelines
• do not depend on side rails
• use bed alarms or other devices before resorting to restraints

• fall risk assessment (Morse fall scale)
• call light in reach
• frequent reorientation
• room by nurses station
• bed in lowest position
• keep water, urinal, bedpan w/in easy reach
• adequate lighting
• night light
• keep floors dry, clutter free
• etc

• Provide health teaching that addresses topics like healthy lifestyles, risk-reducing behaviors, developmental needs, ADL's, preventive self-care
• Use methods appropriate to situation and pt values, beliefs, health pratices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, socioeconomic status
• Seek opportunities for feedback and evaluation of effectiveness of strategies used

• important to record responses of pt and family to teaching interventions
• write objective statements about what was taught, client skills and behaviors that demonstrate learning