Facilitates individual care
• Defines the domain of nursing
the importance of nursing diagnoses.
• Improves communication within the profession
• Increases nursing autonomy and accountability
* Analyze the data
how to select nursing diagnoses • identify health problems, risks, and strengths
• formulate diagnostic statements
must equal desired client outcomes
characteristics of goals.
must be: realistic, measureable, and concise
are specific, measurable, observable, and realistic actions performed by the nurse
how to select nursing interventions
• Interventions should be related to the etiology statement
* Collect data from the client based on the criteria established as patient goals
evaluation of goal achievement • Determine which problems have been solved and which need to be reassessed
• Analyze effectiveness of nursing interventions
An approach to a comprehensive assessment. Uses a structured database format,
Functional Health Patterns
based upon an accepted theoretical framework or practice standard. (Gordon's 11)
* Health perception-health management
• Nutrition-metabolic
• Elimination
• Activity-exercise
• Sleep-rest
Gordon's 11 Functional Health Patterns • Cognitive-perceptual
• Self-perception-self-concept
• Role-relationship
• Sexual-reproduction
• Coping-stress
• Values-beliefs
verbal communication spoken, written, influenced by tone, volume, and pace
* Development
• gender
• values and perceptions
• personal space
factors that influence the communication • territoriality
process • roles and relationships
• environment
• congruence
• interpersonal attitudes
• boundaries
* assessing: uses verbal and nonverbal communication skills, uses active listening,
• diagnosing: helps identify nursing diagnosis' that are related to ineffective
communication, i.e., anxiety, social isolation, impaired verbal communication,
powerlessness, impaired social interaction
communication skills in each phase of the • planning: nurses and patients work together to determine appropriate
nursing process goals/outcomes
• Implementing: therapeutic communication is vital for successful implementation of the
care plan.
• Evaluating: analysis of client communication by active listening, and observing
nonverbal cues
- structured goals, 2-way communication, participation/leadership,
effective groups ability/information/power, shared decision-making, structured controversy, equal
conflict mgmt, cohesion, individuality endorsed.
, • Promotes client safety
• Minimizes miscommunication
assertive communication • Honest, direct, and appropriate
• Open to ideas
• Includes "I" statements, not "You"
communication techniques for infants Gentle soothing voice, since they respond to sensory stimuli
common interdisciplinary team members RN, LPN, Student RN, Physician, PT, OT, Chaplin, CNA, pharmacist, dietitian
nurse's role in working with interdisciplinary Nurses must work with ALL members of the interdisciplinary team in order to provide
team members optimal patient care.
Etiologic agent
Reservoir
Portals of exit
chain of infection
Modes of Transmission
Portals of entry
susceptible host
Dry Staphylococcus epidermidis
normal flora of the skin
Moist Staphylococcus aureus
* Number of microbes present
• Virulence of microbes
microbial characteristics which influence it
• Invasiveness of that microbe
ability to cause infection and disease
• Susceptibility of the host
• Compatibility
"Infections that occur as a result of delivery of healthcare services in a health care
heath care associated infection
facility"
• Portal of exit- standard precautions, proper wound care
• Transmission- Hand hygiene, Transmission based precautions (i.e. airborne
nursing measures that can break each link in
precautions)
the chain of infection
• Portal of entry-face masks, hand hygiene, standard precautions
• Susceptible host- transmission precautions to prevent infection to susceptible host.
* Extremes in age (i.e. very young and old)
• Immunosupressed
clients at risk for infections • People with impaired primary defenses (i.e. incisions, wounds)
• Malnourished
• Clients with impaired mobility
* Goal: to decrease transmission of pathogens
principles and procedure for hand hygiene Washing with soap and water 20 secs.
Decontaminating with alcohol based cleanser
1. They are self-regulating
2. They are compensatory
four main characteristics of homeostatic
3. They tend to be regulated by negative feedback systems
mechanisms
4. They may require several feedback mechanisms to correct only the one physiologic
imbalance
