1) Assesment

2) diagnosis

3) planning

4) implementation

5) evaluation

~ Based on the belief that a person has a natural drive toward optimal health

~ a relationship that benifits the clients health statis

~ RN goals focus on facilitating comfort by alleviating pain

.data collection

.weeding out

.validating data

.organizing data

~ The collection & analysis of data that is used in formulating a diagnosis, identifying outcomes, planning care, & developing nursing interventions.

what is the purpose of

ASSESMENT 1

~ to establish a data base concerning a clients physical, psychosocial, & emotional health

~Identify health promoting behaviors & potential health problems

~ determine clients functional abilities or dysfuctions

~allows RN to form a therapeutic relationship w/ client

1) Comprehensive

2) Focused

3) ongoing

~ performed upon admissions

~ includes health history

~ includes assesment of physical and psychosocial aspects

~ includes systematic monitoring & observation related to a specific problem

~ broadens clients data base

~ important when problem has been identified & plan of care has been implemented

~ determines clients response to RN interventions

S     state your name

W    wash hands

I      identify client

P     provide client privacy

E     educate client

S     safety

~ Integumentary                        ~ Abdomine

~ Head & neck                            ~ Musculoskeletal

~ Thorax & lungs                         ~ Neuro

~ Heart & vasc. system                ~ Reproductive

~ Breast                                      ~ Anus & rectum

1) Inspection

2) Palpation

3) Percussion

4) Ausculation

~ Careful observation using all 5 sences

~ Identify abnormalities

~ note the general appearence and mentality of client

~ the assesment technique that listens to the sounds within the body, lungs, heart, abdomine, and blood vessels

~ stethascope is usually used

General Survey

C R A P L E S

C  color ~note color and tone of skin

R  respiration ~asses respiration patterns, symmetry

A  activity ~note the activity of the client

P  position ~

L  (LOC) level of conciousness ~

E  expression ~objectice findings of clients mood

S  safety

VITAL SIGNS

~always know the clients baseline

Temp

pulse rate

respirations

blood pressure

sp o2

pain

vital signs

Pulse Rate

normal range 60-100 beats per minute

~ check radial pulse for 30 sec and multiply by 2

~ if radial pulse is irregular check apical for 1 minute

~ always report if bradycardia (>60) or tachycardia (<1000

vital signs

respiratory rate

normal rate 12-20 full breaths per minute

~ count breaths for 30 sec nd multiply by 2

~ note rate, depth, rythym & symmetry

~ Apnea is te absence or paused breathing

Vital signs

blood pressure

normal rate for adult 120/80

normal rate for infants 70/45

~ use brachial artery first

~ backup site is the popliteal artery

vital sign

pain

~ use scale from 1 to 10

~ pain is always subjective data

~ moniter pain levels after med administered

~ Color of skin                     ~ Turger

~ Moisture                           ~ Edema

~ Temperature                     ~ Lesions

~ Texture

~ Pitting edema V.S. non-pitting edema

~ Note where it starts and ends

~ check for symmetry

~ Size                                ~ color

~ Shape                             ~ Distribution

~ location                           ~ Texture

~ Flat/raised                       ~ Exudates

~ Head                     ~ Nose & Sinus

~ eyes                      ~ Mouth & Pharnyx

~ Ears                       ~ neck

~Therapeutic interaction that has a specific purpose

~ Data collection

~ Educating client

~ Exploring clients feelings or concerns

~ Support

~ Observation of non-verbal behaviors

Introduction

Working

Closure

~ Primary gosl is the collection of data

~ Educate the clients of the purpose & use of the data collected

~ Give client adequate time & privacy

~ Educate client of the confidentiality policy

~ Inform client of approximate duration of interview

~ Focuses on the details of the data collected

~ Where information is gathered

~ use open ended & close ended questions

~ summerize what was covered or accomplished

~ Request validation of perceptions from the client

~ Closure is established in the introduction

~ the process of recovery from illness, accident or disability

~ encompasses the physical, emotional, & spiritual domains of the individual

~ Being able & willing to help others

~ The fundamental value in nursing

~ ongoing in the nurse/client relationship

~ nurtures the individual even if the disease is incurable

~ use of touch

~ effective non-verbal method of communicating a sense of caring

~ Used to sooth, comfort, & establish rapport

~ the 1-to-1 interactive process between client & nurse that is directed at improving the clients health statis or assisting in problem solving.

~ focus is on meeting the clients needs

~ this interaction greatly influences the clients progress in healing

ORIENTATION

WORKING

TERMINATION

what are the goals of the ORIENTATION PHASE

of the NURSE-CLIENT-RELATIONSHIP?

~ RN and client become aquainted

~ establish trust

~ determine the expectations

~ RN gets to know client as an individual

~ problems are identified

~ golas are established

~ problem solving methods are selected (consider clients value system when determing these methods)

~ evaluation of goal acheivment

~ Discuss the effectivness of treatment

~ WARMTH                        ~ TRUST

~ HOPE                             ~ EMPATHY

~ RAPPORT                       ~ ACCEPTANCE

~ HUMOR                          ~ COMPASSION

~ SELF-AWARENESS          ~ FLEXIBILITY

~ RISK TAKING                  ~ ACTIVE LISTENING

~ NONJUDGMENTAL APPROACH

~ proposes that an individuals basic needs must be met before progressing to a higher level of need

~ consits of 5 stages

1) PHYSIOLOGIC NEEDS

2) SAFETY & SECURITY NEEDS

3) NEED FOR LOVE & BELONGING

4) SELF ESTEEM NEEDS

5) SELF ACTUALIZATION NEEDS

what is the PHYSIOLOGIC NEEDS

in Maslows Hierarchy of Needs?

~ the most basic needs

~ EX: food, water, oxygen

what are the SAFETY & SECURITY needs in

Maslows Heirarchy of Needs?

~ Both physiaclly & Psychological

~ EX: protection from bodily harm

~ EX: security & stability

what is the need for LOVE & BELONGING in

Maslows Heirarchy of Need?

what is the need of SELF ESTEEM in

Maslows Heirarchy of need?

what is the need of SELF ACTUALIZATION in

Maslows Hierarchy of Need?

~ Inspection, Palpation, Percussion, & Ausculation of the posterior, lateral & anterior thorax & lungs

~ Ausculation reveals the presence of normal &

abnormal breath sounds

1) BRONCHIAL SOUNDS

2) BRONCHOVESICULAR SOUNDS

3) VESICULAR SOUNDS

loacation & sound of BRONCHIAL SOUNDS

(normal breath sounds)

~ sound of air moving over the trachea

~ sounds are harsh, loud & clear

~ Ausculate on the upper chest, next to trachea

location & sound of BRONCHOVESICULAR breath

(normal breath sounds)

~ blowing continuous

~ heard between scapular & 1st & 2nd rib

location & sound of VESICULAR SOUNDS

(normal breath sounds)

~ soft & breezy

~ heard on the lung periphery

1) CRACKLES

2) RHONCHI

3) WHEEZES

4) PLEURAL RUB

5) STRIDER

location, cause & sound of CRACKLES

(abnormal breath sounds)

~ heard on insperation

~ sounds fine, high pithed OR

coarse, low pitched

~ Caused by air moving through fluid OR opening of airways

location, cause, & sound of RHONCHI

(abnormal breath sounds)

~ heard on experation over the trachea

~ may clear with a cough

~ caused by upper airway junk

~ ausculate on upper chest, next to trachea & sternum

location, sound, & cause of WHEZES

(abnormal breath sounds)

~ heard on experation, all over lungs

~ musical, hissing sound

~ caused by narrowing airways