Acknowledge Patient Name

Introduce Yourself

Duration: How long will interview last

Explanation: Purpose of Interaction

Thank you:

Bias

Failure to consider whole situation

Impatience

Lack of experience

Assessment

Nursing Diagnosis

Expected outcomes

Implementation

Evaluation

Safe

Effective

Patient centered

Timely

Efficient

Equitable

Establish a complete database concering all aspects of the patient's health.

Must be completed within a certain amount of time after admission

Pt's health status

Health problems

health risks

need for nursing care

Follows initial Assessment

Never touch a pt without permission

Inspection

Palpation

Percussion

Ausculatation

Be alert to signs of distress

-Be alert to anything out of the ordinary-rashes, consciousness

Can the pt self care

is the environment safe

pt- primary and best source

Family and significant others

Patient record

As soon as possible after obtaining data

Be specific not vague- don't use words like small and large

Subjective data should be in quote marks

Goal or end

Expected conclusion to a pt problem

Consider:

Pt's health state

expected length of stay

Growth and development stage

pt's values and culture

Planned therapies for pt.

Available resources

Risks, benefits, current scientific evidence

Cognitive

Psychomotor

Affective

Subject- pt/family/support person

Verb: action the pt will perform

Conditions: circumstances in outcome will be achieved

Performance criteria- observable and measurable

Target Time: when outcome is expected to be met

Independent actions- don't require physician order

Dependent actions- response to a doctor's orders

collaborative actions- treatments ordered by other health care providers

Assist the patient in achieving the identified goals for the health problem

Includes collecting data useful for modifying the plan of care

Provide pain control

diminish distractions

is it ok to perform interventions with visitors there

pt learning new skils- do it in private

Anticipate what you will need and take it to room

Don't OVERSTOCK

Respect pt's privacy needs

Determine if you can perform task alone or require assistance

Lack of family support

Lack of knowledge

Low value attached to outcomes

Adverse effects of treatment

Lack of money

limited access to treatment

To terminate plan of care if outcome was achieved

To modify plan if interventions have not been affective

Continue the plan if more time is needed

identifying expected patient outcomes

Collecting data to determine whether these are met

Interpreting and summarizing findings

Documenting your judgment

Terminating, modifying, or continuing the plan

Reevaluate each step of the NP to identify the cause of the plan not being effective

-Delete or modify the nursing diagnosis

-Clarify the expected outcome

-Change the nursing interventions

Written legal record of all pertinent interactions with pt/family

-compilation of a pt's information

Complete accurate concise and current facts- not our view

Reflects the nursing process

avoid words such as good and average and small

Avoid generalizations like appears to be sleeping and seems better

Date, time of contact

Purpose of the call

Physician response- no new orders

Notification of chain of command

Gives legal protection to those involved in care

Problem

Intervention

Evaluation

Data

Action

Response

Resident

Assessment

Instrument

One of the most important roles a nurse performs

The process of influencing a pt's behavior to break about changes in knowledge, attitude, and skills needed to improve or maintain health

Preparation for receiving care

Preparation for discharge

Documentation of pt. education and pt. response to education

Results from planned invasive procedure

Wound edges are clean bleeding controlled

Minimal risk for infection, short healing time

Contamination is likely

Wound edges are jagged, bleeding uncontrolled

High risk for infection and longer healing time

Intentional or accidental

Skin is open portal of entry for microorganisms leading to increased risk for infection and delaying healing

Due to blow, force, or strain

Skin is not broken

Internal hemorrhage may occur

Deep bruises

Heal within days/weeks

Edges are well approximated

Risk of infection low

Do not go through normal repair

Edges are not approximated

risk for infection high

delayed healing

Intentional

Unintentional

Closed

Open

Acute

Chronic

Primary intention healing- intentional closed wound

Secondary intention healing- Unintentional open wound

Tertiary- wounds are intentionally left open for days to allow infection to resolve

Immediately after injury

Short period of Vasoconstriction at site

Vasodilation at site- increased blood flow causes heat and redness

Last 4-6 days

Leukocytes and macrophages move to the site

low grade temp, increased white blood cell count, general feeling of just don't feel good

Lasts several weeks

Fibroblasts- new tissue is built to fill the wound

produces new growth factors to encourage new blood vessels to form in new tissue

Primary intention healing- 24-48 hours wound is sealed

Secondary intention healing- same process at slower rate

Begins 3 weeks after injury, continues for months/years

Deposited collagen tissue is remodeled to make wound stronger

Dead tissue appears as slough, moist, yellow stringy tissue

eschar is black dry leathery

Dead tissue and eschar must be removed

Pressure on blood supply to the wound tissue

Dehydrated tissue

Over hydration due to urinary and fecal incontenence

Edema slows blood supply to wound

infection

necrosis

Age

Circulation and oxygenation

Nutrition and Hydration

Wound condition

Medications

Health Status

Due to contamination with bacteria

Manifestations are seen in 2-7 days

surgical wound

Dislodged clot at site- ulcer

Infection or drain that erodes into a blood vessel

Internal bleeding

partial to total separation of wound layers

Due to excess pressure on unhealed wound

Obese

Malnourished

Smokers

Take anticoagulants

Infected wounds

excessive coughing, vomiting, straining at stool or with vomiting

Abnormal passage from an internal organ to the outside of the body or from one internal organ to another

due to infection that developed into an abscess