nursing process Flashcards
Nursing Process: Assessment
- Self-Care Ability.
- Skin.
- Feet and Nails.
- Oral cavity.
- Hair and hair care.
- Eyes, ears, and nose.
- Use of sensory aids.
- Hygiene care practices.
- Cultural influences.
Nursing Process: Diagnosis
- Activity intolerance.
- Bathing self-care deficit.
- Dressing self-care deficit.
- Impaired physical mobility.
- Impaired oral mucous membrane.
- Ineffective health maintenance.
- Risk for infection.
- Use the patients’ actual alteration or the alteration for which they are at risk.
Nursing Process: Planning
- Goals and outcomes
- Partner with the patient and family.
- Measurable, achievable, individualized.
Set priorities based on assistance required, extent of problems, nature of diagnoses.
- Teamwork and collaboration
- Health care team members.
- Family.
- Community agencies.
Implementation
- Use caring to reduce anxiety, promote comfort.
- Administer meds for symptoms before hygiene.
- Be alert for patient’s anxiety or fear.
- Assist and prepare patients to perform hygiene as independently as possible.
- Teach techniques and signs of problems.
- Inform patients about community resources.
Health Promotion
- Make instructions relevant.
- Adapt instruction to patient’s facilities and resources.
- Teach the patient ways to avoid injury.
- Reinforce infection control practices.
Acute, Restorative, and Continuing Care
- Hygiene measures vary by patient needs and health care setting.
- Consider normal grooming routines, and individualize care.
Bathing and Skin Care
- Therapeutic: sitz, medicated.
- Complete bed bath.
- Self-help bath.
- Partial bed bath.
- Back rub.
- Foot and nail care.
what are the 5 guidelines?
- Provide privacy.
- Maintain safety.
- Maintain warmth.
- Promote independence.
- Anticipate needs.
Brushing removes particles, plaque, and bacteria; massages the gums; and relieves unpleasant odors and tastes.
- Flossing removes tartar at the gum line.
- Rinsing removes particles and excess toothpaste.
- Patients with special needs: diabetes, artificial airways, unconscious, chemotherapy.
oral hygiene
Care of Dentures
- Oral hygiene – Unconscious Patient:
- Turn patient’s head towards you.
- Place patient in semi-Fowler’s.
- Oral airway can be used to hold mouth open.
- Use a small brush or swab to clean the mucous membranes and teeth.
- Use suctions to remove secretions and fluid.
- Use chap stick or lip moisturizer.
- Prevent: Aspiration.
Hair and Scalp Care
- Brushing and combing:
- Distributes oil.
- Prevents tangling, as does braiding.
- Obtain permission before braiding or cutting.
- Procedures for head lice:
- Shampooing.
- Shaving.
- Mustache and beard care.
Care of the Eyes, Ears, and Nose
- Basic eye care.
- Eyeglasses.
- Contact lenses.
- Artificial eyes.
- Ear care.
- Hearing aid care.
- Nasal care.
Shaving
- Care of the genitalia:
- Can be embarrassing for the nurse and the patient.
- Should not be overlooked because of embarrassment.
- If the patient can do it themselves—let them.
- Hand them the washcloth and ask if they would like to “finish their bath.”
Peri-care: Female
- Wipe labia majora (outer) from front to back in downward motion using clean surface of wash cloth for each swipe.
- Wipe labia minora (inner) from front to back in downward motion using clean surface of wash cloth for each swipe.
- Wipe down the center of the meatus from front to back. If catheter in place, clean around catheter in circular fashion, using clean surface of wash cloth for each swipe.
- Wash inner thighs from proximal to distal.
- Rinse with warm to tepid water using pour from peri-bottle if available.
- Pat dry using clean towel in the same order as wash.
- Remove bedpan if one is used.
- Verbalize turning patient on side to wash anal area from front to back and dry.
Peri-care: Male
- Retract foreskin of penis if uncircumcised.
- Wash around the urinary meatus in a circular motion, using clean surface of washcloth for each stroke and around the head of penis in circular motion.
- Wash down shaft of penis toward the thighs, changing washcloth position with each stroke.
- Wash scrotum – front to back.
- Wash inner thighs.
- Rinse with clean wash cloth or peri-bottle using warm water in the same sequence as the wash.
- Dry with clean towel in the same sequence.
- Replace foreskin, as appropriate.
- Turn patient on side to wash anus from front to back and dry.
Perineal Care with Catheter
- Start at the urethra opening and clean outward.
Foot and Nail Care
- Teach patient and family that nails should be cut straight across. May need to get a referral if no one available to cut nails.
- Show close attention to the feet and nails of the diabetic patient and the elderly.
- If feet and nails are in bad condition, notify doctor so a consult can be ordered with a podiatrist.
Patient’s Room Environment
- Maintaining comfort: temperature, noise, lighting, ventilation, odors.
- Beds:
- Features: raising, adjusting, side rails.
- Clean, comfortable, and safe.
- Bed making:
- Occupied.
- Unoccupied.
Evaluation
- Evaluate during and after each intervention.
- Observe for changes in patient’s behavior.
- Consider the patient’s perspective.
- Often it takes time, repeated measures, and a combination of interventions for improvement.
- Expected outcomes met?
- Patient’s expectations met?
- Ask questions to determine appropriate changes to interventions.
Safety Guidelines
- Communicate clearly with team members.
- Incorporate patient’s priorities.
- Move from the cleanest to less clean areas.
- Use clean gloves for contact with nonintact skin, mucous membranes, secretions, excretions, or blood.
- Test the temperature of water or solutions.
- Use principles of body mechanics and safe patient handling.
- Be sensitive to the invasion of privacy.
