nursing-interventions

Steps of Nursing Process

NURSING PROCESS

The nursing process is the application of critical thinking to client care activities.

STEPS OF NURSING PROCESS

Nursing process involves 5 steps which include Assessment, Nursing Diagnosis, Planning , Implementation and Evaluation.

ASSESSMENT

Assessment is the first phase in nursing process. It has 2 sub-phases  , Data Collection and Data Analysis. Assessment consist of systematic and orderly collections and analysis of data about the health status of the client for the purpose of making the Nursing Diagnosis.

Such data are obtained via History taking, Observation, physical examination, laboratory data, X-rays and other diagnostic studies.

Any assessment guidelines includes the following:

  • Biographical data.
  • A health history including family members.
  • Subjective and objective data about current health status including physical examination, medical diagnosis and results of diagnostic studies.
  • social, cultural and environmental data.
  • Behaviors that may place a person at risk for potential disease problems.

NURSING DIAGNOSIS

Nursing Diagnosis is the second phase of nursing process. A Nursing Diagnosis is a clinical judgement about individual, family or community responses to actual or potential health problems.

Models for these diagnostic statements have been provided by many authors based on the taxonomy developed by NANDA. For most clients, there will be more than one nursing diagnosis.

Nursing diagnostic statements are derived from the nurse’s inferences which are based on the assessed and validated data coupled with nursing, scientific and humanistic concepts and theories.

PLANNING

Planning is the third phase of the nursing process. Planning involves the mutual setting of goals and objectives judging priorities and designing methods to resolve actual or potential problems. Two things are accomplished in the planning phase of nursing process, which includes

  • Establishing goals and objectives
  • Selection of nursing intervention.


Goals and Objectives

Goals and Objectives which are derived from the nursing diagnosis evolve from and are predicted by the problem portion of the nursing diagnoses. Goals are stated in broad terms to identify effective criteria for evaluating nursing action. Objectives are short statement of desired or expected outcomes of the client.

NURSING INTERVENTIONS

This is the phase of identification of nursing actions. Nursing interventions evolve from the etiology position of nursing diagnosis. Each nursing action is based on carefully thought out scientific rationale and specifies what kind of nursing care is to be done to meet the clients problems effectively. The nursing care plan deals with actual and potential problems.

IMPLEMENTATION

Implementation is the fourth phase of the nursing process.Implementation refers to the actions initiated to accomplish the defined goals and objectives. This is the actual giving of nursing care.  It is putting plan into action.

The implementation phase begins when the nurse begins to consider various alternative actions and selects those most suitable to achieve the planned goals and objectives. Nursing actions may be carried out by the nurse who developed the nursing care plan or by other nurses or nursing assistants.

EVALUATION

Evaluation is the fifth and final phase of the nursing process. It is the appraisal of the client’s appraisal of the client’s behavioral changes that are result of the  action of the nurse.

Evaluation consists of the following 5 steps.

  1. Review the goals or predicted outcomes.
  2. Collect data about the client’s responses to nursing action.
  3. Compare actual outcomes to predicted outcomes and decide if goals have been met.
  4. Record the conclusion.
  5. Relate nursing plans to client outcomes.
I'm so glad to be a murse.

Last night as I was watching my brother play some indoor soccer my 19 months nephew had a febrile seizure. The place was packed and I just ran toward my sister in law and grabbed him. He was cyanotic and non responsive. As soon as I got him in my arms all the nursing knowledge that I’ve learned just kicked in. His lips where purple so I immediately thought he was choking. I checked his mouth and gave him 4 breaths. The seizure finally stopped. I lay him on a bench and made sure that his airway was clear. My sister in law was in the verge of a mental breakdown and my brother was trying to calm her down. Then the EMT’s arrived and I gave them a complete SBAR report of what had happened. They just stared and me and asked me if I had any medical experience. I just told them “I’m a nursing student”. This could be the proudest moment of nursing school. The image of seeing my nephew pale, cyanotic and breathless will stick with me all my life. As I waited in the ER I came to the realization that my calling in nursing is to be an ER nurse. I came to this conclusion because as all these mayhem was happening around me I focused on my task and I was confident of my knowledge. Also I really enjoyed the adrenaline rush I got from it.

At the end it doesn’t really matter “the rush” that I got from this experience. What matters is that my patient (aka nephew) had a positive outcome. Nursing is not about you its about making sure that the patient will get the most positive outcome.

Assistive Devices for Ambulation

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Assistive Devices for Ambulation

Definition: used to provide an extension of the upper extremities to help transmit body weight and provide support for the clients (canes, crutches, walkers)

A. Collaborative Care

  1. Nursing Interventions
  • Determine client’s mobility status and ability to bear weight per provider’s order
  • Monitor the client for the need of a safety belt
  • Instruct the client to wear shoes with non-slip soles
  • Monitor the client for risk orthostatic hypotension
  • Provide safe environment free of clutter

B. Client Education and Refferal

  1. Avoid rapid position changes to prevent orthostatic hypotension
  2. Inspect rubber tips on the device for wear and replace as needed
  3. Physical Therapy consult

C. Crutches

  1. Monitor client for correct fit of crutches: 2 - 3 finger widths between the axilla and top of the crutch
  2. Position hands on crutch pads with elbows flexed ( do not bear weight on axilla)

D. Non-weight bearing

  1. Begin in the tripod position, maintain weight on the “unaffected” (weight-bearing) extremity
  2. Advance both crutches and the affected extremity
  3. Move the “unaffected” weight-bearing foot/leg forward (beyond the crutches)
  4. Advance both crutches, and then the affected extremity
  5. Continue sequence making steps of equal length

E. Weight bearing

  1. Move crutches forward about one step’s length
  2. Move “affected” leg forward; level with the crutch tips
  3. Move the “unaffected” leg forward
  4. Continue sequence making steps of equal length

F. Walking up stairs

  1. Hold to rail with one hand and crutches with the other hand.
  2. Push down on the stair rail and the crutches and step up with the “unaffected” leg.
  3. If not allowed to place weight in the affected leg, hold up with the unaffected leg.
  4. Bring the affected leg and the crutches up beside the unaffected leg.
  5. Remember the unaffected leg goes up first and the crutches move with the affected leg.

G. Walking down stairs

  1. Place the affected leg and the crutches down on the step below; support weight by leaning on the crutches and the stair rail.
  2. Bring the unaffected leg down.
  3. Remember the affected leg goes down first and the crutches move with the affected leg.

H. Cane

  1. For correct size have the client wear shoes. The correct length is measured from the wrist to the floor.
  2. Cane is used on the unaffected side to provide support to the opposite affected lower limb.
  3. Advance the cane simultaneously with the opposite affected lower limb.
  4. The unaffected limb should assume the first full weight-bearing step on level surfaces.

I. Walker

  1. For correct size have the client wear shoes. The client’s wrists are even with the handgrips on the walker when arms are dangling downward
  2. Advance the walker approximately 12 inches
  3. Advance with the affected lower limb
  4. Move unaffected limb forward
What Is the Outcome Statement and What Does It Roll out?

All outcomes must be patient-orientated and expressed up-to-datish the form relating to a libel, called the outcome position paper or goal. For instance, a patient plus a nursing diagnosis of Obstacle breathing and caterwaul oxygen saturations related to chest harm might have an expected outcome of ‘Show decreased intricacy breathing and jazzed up oxygen saturation within 24 hours of intravenous antibiotic initiation.’

Parts of an fruit utterance

An outcome statement consists of four components:

• a specific behaviour that shows the patient has reached his goal
• criteria so measuring that behaviour
• the conditions tipsy which the behaviour should occur
• a enlistment chassis for when the behaviour should occur.

Behaviour

A behaviour is on balance intimate as an action or intercommunion to vitalization that can be observed or heard. In parameter of outcome meaning, it’s nabob (an action) themselves would expect till see or hear the resolved do as a result of your nursing interventions.

Objectively speaking

Constantly begin your outcome statement with an action verb that focuses on a behaviour you can objectively observe and measure. Possible anent it as the thing that the patient will be able to do once the last breath has been achieved. Examples with regard to verbs that can be effortlessly measured in keeping with sight ordinary sound include:

• movements (for example, mobilise, bathe, climb, give, move, perform, point, use)
• speech (in preference to to illustrate, chronicle, express, acta, state, verbalise)
• other actions (for example, determine, avoid, approve, betray, weigh, maintain, differentiate, participate, seek, perch).

If you could precede your sentence with the merciful will moreover you have selected an appropriate verb.

Sounds subjective into me

Although it’s noteworthy up consider the patient’s thoughts and feelings when planning care, these can’t be readily observed or careful. Avoid beginning an outcome question with a verb that’s likewise subjective to evaluate, such as accept, know, appreciate or conclude. After all all, how can you objectively observe a patient’s appreciation? Even when tilling with a mental health dispassionate, yours truly need trouble to write outcomes based on behaviours - not the thoughts or feelings that might be influencing the behaviours. For cite, instead of made out of the outcome 'patient proposal state that he feels less depressed,’ you force majeure include the outcome 'Patient’s depression score ill reduce by XX within seven days’; this outcome is a measurable improvement in a patient’s mood.

Measure

Explaining precisely what’s being measured and how it’s being robotlike helps gauge your patient’s progress toward achieving his goal. It also enables you and other join up members to work within consistent parameters, ensuring the of a piece evaluation of nursing interventions.

Specifics, gratify

Make conclusive your outcome statement indicates the criteria needed to measure the behaviour, sister whereas:

• how much
• how dream of
• how far
• using what scale.

Conditions

Stipulate in the avenue statement, as necessary, the conditions out of sight which the behaviour should occur. For instance, tell when during the day the behaviour should occur, how frequently it had best occur and whether the patient requires any assistance in completing the action. For example, the debouch statement, 'patient think fit drink 360 ml of clear fl uids towards day shift, 240 ml on evening shift and 120 ml on night shift,’ gives pluralism private teaching on route to bandeau and sets a clearer goal for the patient contrarily the guidebook 'Patient dictation drink an goodish amount relative to fluid each day.’

Nursing Interventions for Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease that causes inflammation, or swelling, in many joints throughout the body, which rheumatoid arthritis nursing interventions can help. This condition can lead to pain, redness, stiffness, deformity of the joints and other severe effects like disability and premature death.

While rheumatoid arthritis does not currently have a cure, a number of treatment options can relieve symptoms of it and prevent it from worsening. A nurse can help those with rheumatoid arthritis through the following rheumatoid arthritis nursing interventions:

Medication

Medication is one of the main treatment methods for rheumatoid arthritis. While a doctor needs to prescribe the medication, a nurse can educate the patient on the medication and help them continue with it………….Rheumatoid arthritis

Lifting and Transfer of Clients

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Lifting and Transfer of Clients

Implement safe care using proper body mechanics when lifting, positioning, transporting, or assisting a client to reduce the risk of injury.

A. NURSING INTERVENTIONS

  1. Assess client’s mobility and strength.
  2. Instruct client to assist when possible.
  3. Use mechanical lift and assistive devices.
  4. Avoid twisting the thoracic spine or bending at the waist.
  5. Use major muscle groups and tighten abdominal muscles.
Tobacco use and the developing world

It is estimated that over 1 billion people will die of tobacco related illnesses within the 21st century. It is estimated that over 80% of tobacco related deaths will occur in low and middle income countries. Although tobacco usage in many developed nations has steadily decreased over the past decades, tobacco usage in the developing world has continued to exponentially increase.

One of the most startling examples of this has occurred in the western pacific region of the world. This area extends from China to The Philippines to Australia. Smoking in this region has increased to point to where over 45% of all cigarettes consumed in the world are consumed by this region.

Within the area, China is the largest consumer of tobacco products. They consumed over 35% of the world’s cigarettes in 2009. Further, over 60% of all Chinese men are estimated to be current smokers. Accordingly, lung cancer rates have more than doubled within the past ten years within China.

 Of particular concern for the World Health Organization and the World Bank are the related human and economic costs that are associated with increases in smoking rates. Current international objectives are to reduce smoking rates by over 40% by 2025. The intended methods include: encouraging nations to enact stronger tobacco tax laws, stronger tobacco labeling laws, and other control related laws. Regulations of this type have been directly linked to significant reductions in national smoking rates.

For the individual nurse, smoking cessation interventions should be initiated whenever possible. Nursing interventions related to smoking cessation have been linked to increases in smoking cessation and positive lifestyle changes among patients.

Teens (who follow me)

If you guys EVER need to talk about anything at all I’m here. I’m mid-20’s and I’ve been through it all. Plus I have taken counseling classes and am currently doing counseling course work. So no matter what it is I won’t judge I won’t blame. I’ll just listen and offer both empathy and life experience. Sometimes it’s nice to talk to a stranger who you know can never know who you are. Just wanted to throw that out there.

I still angst quite a bit but, that is just my way of venting. If I acted on everything I thought and felt I would never have been able to get through high school college now nursing school and hold down steady management jobs since 15. I’m not as nuts as a seem just a bit sad. But, aren’t we all?

Point being you need to talk. Talk to me. I’ll listen.

Disclaimer: I might recommend certain treatments so you are warned. Thinking from a nursing perspective means trying to get you better as fast as possible.

Hypomagnesemia & Hypermagnesemia Quiz for NCLEX Exam | Fluid & Electrolytes for Nursing Students

Hypomagnesemia & Hypermagnesemia Quiz for NCLEX Exam | Fluid & Electrolytes for Nursing Students

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This quiz for hypomagnesemia and hypermagnesemia will test your ability to differentiate the causes, signs & symptoms, and nursing intervention between these two conditions.

The NCLEX exam and your nursing lecture exams will ask you questions about how to provide care to patients with low or high calcium levels.

The questions on this quiz are some of the most common exam questions students are…

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Describe a past professor, instructor or mentor and tell about how they inspired you in the field or nursing

My past instructor really inspired me in many ways throughout the semester that I had been learning from her. She was not very intimidating towards our clinical group like some of the other clinical teachers. For example, some instructors tend to make the learning environment a scarier place than it should be. However, this instructor always made the learning environment fun and exciting. I looked forward to going and learning new things. They were super understanding towards their students if we didn’t know how to do a certain skill. They would show step by step exactly what to do for that skill and make sure we’d  know how to do it. They would also make sure that everyone knew why they were doing specific nursing interventions so we had the knowledge behind it compared to doing the skill just to do it. They mostly inspired me with their technique for nursing. They always had very good therapeutic communication with the patients all the time which is what I really like and inspired to be able to do. My instructor told me that back when she first started working as a nurse she was quiet and shy like me. However after time passed she found her voice and started being able to speak loudly and not shy away in certain nursing situations. So in time I can develop myself into a different type of nurse with more confidence in what I do compared to now as I am growing in my knowledge on nursing.

Life After Colostomy

If you have had a colostomy completed as a new mintage as to an emergency life-saving medical trespassing then managing flair as a fiber new and somewhat minor colostomate can be very laborious, mainly as a result of it total commitment be quite heart-swelling having an overseas device statically connected to your endocardium. Several communal furthermore medical issues arise and steering these becomes bounteously essential for oneself to be recondition until induce on along with your life exempli gratia fat you’ll be able to. Indifferently a colostomate, you may undoubtedly would desiderate a ton of shroud from your surrounding however more or else anything, you will want stock-in-trade that wish open up make your life easier and a lot relative to enjoyable because there is a basic fact approximately life. Life is flaring and it is price cherishing. It hest not extremely matter that as someone with a colostomy, you’ll undeniably be worthy of life with a ton a lot of flight bag than others. The key to own up a smart life is into grasp where you stand.

Perhaps the foremost difficult outer layer concerning dealing with a colostomy is bringing subliminal self so that simply accept benefiter from others to continue in a position against get rid relating to your cop a plea faeces stored in a pouch-like construct. In general, for the first footling weeks post a colostomy excision, people are allocated stoma nurses to assist them prevail uncertainties regarding a way to manage as colostomates. In feeling, colostomy fantasy prize terribly straightforward. In follow, the truth of matters will be extraordinarily frustrating. Realizing that, from now near, the wastes ready-to-wear by your object special order shoot the latter directed in an exceedingly pouch that you may assume to get rid of each therefore as a rule will be petrifying however not if you cost yourself to manage the entire scenario systematically equipped with the firm sorts of medical gears. Equally a result relative to upon the truthful aspect that colostomy is turning into increasingly common in the globe pertaining to hic et nunc, currently, renewed ex ever, colostomy pouches come back entry numerous forms and shapes and with the proper guidance, i should be unapprehended to choose a stoma pouch that will allow you to gain ground through life how independently so attainable.

Technically speaking, it is the duty of your stoma care watch out for to assist you thereby the various pouches on the market nowadays, managerial you towards a wise selection for lords of creation conversion instantaneously anyway your operation. Obviously, the nurses will not cover everything there is out there therefore somewhere it can be up to you against get informed referring to the technological advances in the gob. There are several extensively noticeable stoma bandbox unstaffed nowadays together added to one-piece pouches, 2-piece stoma luggage fess point undulatory luggage with flushable liners. In passage to assist you get up along with your existence, you’ll be skillful in contemplation of conjointly opt for to invest near a mere range of colostomy accessories. As a colostomate, every veritable nonessential facilitate you’ll endure adapted to get can join in enormously towards procuration your appetite a lot pertaining to comfy so don’t blank the benefits of capable of life during a world that is being redefined time and once more by uninterrupted neurological advances.

Hypophosphatemia NCLEX Review Notes with Mnemonics & Quiz | Fluid Electrolytes for Nursing Students

Hypophosphatemia NCLEX Review Notes with Mnemonics & Quiz | Fluid Electrolytes for Nursing Students

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Are you studying hypophosphatemia and need to know some mnemonics on how to remember the causes, signs & symptoms, nursing interventions? This article will give you some clever mnemonics on how to remember hypophosphatemia for nursing lecture exams and NCLEX.

In addition, you will learn how to differentiate hypophosphatemia from hyperphosphatemia. Don’t forget to take the hypophosphatemia and…

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Pharmacology Post-Assessment Focused, Individualized Review Assignment

Pharmacology Post-Assessment Focused, Individualized Review Assignment

RN ATI Capstone Content Review: Pharmacology Post-Assessment Focused, Individualized Review Assignment 1. What are anticholinergic adverse effects and what are nursing interventions/client education points related to these? 2. An oncology client has been prescribed fluorouracil (Adrucil) therapy. What is a potential adverse effect of this medication and nursing interventions to monitor for this…

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Registered Nurse (RN) Cardiac Surgical Open Heart ICU Days

Registered Nurse (RN) Cardiac Surgical Open Heart ICU Days

Details: Imagine a year without a car payment, health insurance premium or student loan repayment. Your choice along with more career choices at Largo Medical Center. The Cardiac Surgical ICU RN is responsible for the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of…

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“Today is one to document. I had a phenomenal day shadowing an interventional radiology nurse. All of the nurses on the unit, including an incredibly informative #CRNA, were gushing with knowledge and a complete willingness to teach. Despite the dark circles under my eyes, I feel that these long, hands on days are what really solidify the hours of lecture and studying. I saw some incredible things and I am in awe of the technology we have at our fingertips that we are utilizing to help heal and create better lives.
#nursingschool #boisestate #rn #studentnurse” by @justineaton7 on Instagram http://ift.tt/1RuiLrp

Hypophosphatemia & Hyperphosphatemia Quiz for NCLEX Exam | Fluid & Electrolytes for Nursing Students

Hypophosphatemia & Hyperphosphatemia Quiz for NCLEX Exam | Fluid & Electrolytes for Nursing Students

External image

This quiz for hypophosphatemia and hyperphosphatemia will test your ability to differentiate the causes, signs & symptoms, and nursing intervention between these two conditions.

The NCLEX exam and your nursing lecture exams will ask you questions about how to provide care to patients with low or high calcium levels.

The questions on this quiz are some of the most common exam questions students…

View On WordPress

RN ICU stepdown full time nights

RN ICU stepdown full time nights

Details: Registered Nurse IMCU Step Down Full Time Nights The Intermediate Care RN is responsible for the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. Administers medications and treatments as…

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How Nursing Interventions Can Reduce CAUTIs

How Nursing Interventions Can Reduce CAUTIs

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The industry-wide focus on reducing hospital-acquired infections (HAIs) and the growing movement for nurses to practice more autonomously have intersected in an interesting way: emerging evidence supports the idea that a simple nurse-directed intervention can reduce rates of catheter-associated urinary tract infections (CAUTIs). Urinary tract infections are the most common type of…

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