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.
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
I PASSED THE NCLEX-RN

In 78 questions. Which was really nice of the computer, imho. Thanks for that.

I went in there expecting six hours of bitter battle against a Computer Assisted Testing algorithm. I brought the caloric equivalent of an eight-hour shift and a liter of water. I made sure my bowels and bladder were empty. The number of drug side effects, diseases and nursing interventions I can list off the top of my head right now is staggering.

And then, after four years in nursing school, after 600 hours of clinical, after two years of reslife and three of transition, I walked into a testing center and took a 78 question test. Boom. Done.

A tad anticlimactic, not that I’m complaining.

You may now refer to me as: MedicBaymax, RN-BSN.

Patients who touch the soul

My patient today had a HR of 42, asymptomatic. The first thing he said when I triaged him, “you’re not going to make me go to the hospital, are you? They treat me like I don’t exist. I’d rather go back to the streets.” He looked so fearful, and for a few moments I was lost for words. He’s a veteran, which is not unusual in this unit. He spoke about the terrifying events he witnessed in Afghanistan, lives of his fellow soldiers sacrificed, large healed scars running up his right arm as a brutal reminder of the catastrophic attacks he survived - and now he was both homeless and frightened of our hospital system. I said simply, “You are safe here. We will care for you.”

He spoke about the sons and daughters he couldn’t face, the birthdays and Christmases he would never see, and the survivor’s guilt he felt today, on Memorial Day, surviving while so many others in Afghanistan lost their lives. As I listened, for a brief moment in time I was transported into his world of grief. His was a perspective I hadn’t considered. Somewhere in the back of my mind, I vaguely wondered why people say “happy Memorial Day.” I honestly do not understand much of war, but this statement confounds me a bit, and I wonder what Veterans think when they hear it. This unit specializes in crisis intervention, and we receive a great deal of people from all walks of life, devastated by loss of home, or any basic human rights. I’m relieved there are medical/nursing nonprofit organizations like this who see the human beyond the exterior, and won’t turn their backs on them.

He may not remember my name, or those of any of his caregivers, and that’s ok; I hope he remembers simply that we respected him. I will remember him, far beyond today. Some patients just have that impact. Today is the first day in a long time I am struck by the beauty of simplicity in nursing, and why I choose it over and over again.

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.

arowlsilvers  asked:

Are there any nursing journals you read/suscribe to/would recommend?

My favorite (that I’ve found so far) is Critical Care Nurse: http://ccn.aacnjournals.org

The last edition had articles on Acute Coronary Syndrome treatments, Alcohol withdrawal, and Palliative Care in critical access hospitals. All stuff we do.

I also get Nursing 2016, but I haven’t found that one to be as interesting or useful. A lot of filler and nursing interventions we already know.

Anyone else have a suggestion?