Purpose: To establish a database about the clients response to health concerns or illness and the ability to manage health care needs.
Identify health problems, risk & strengths
Formulate diagnostic statements
Purpose: To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions. To develop a list of nursing and collaborate problems.
Formulate goals/desired outcomes
Select nursing interventions
Write nursing interventions
Purpose: To develop an individualized care plan that specifies client goals/desired outcomes, and related nursing interventions.
Reassess the client
Determine the nurses need for assistance
Implement the nursing interventions
Supervise delegated care
Document nursing activities
Purpose: To assist the client to meet desired goals/outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning.
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to clients goals/outcomes
Draw conclusions about problem status
Continue, modify, or terminate the clients care plan
Purpose: To determine whether to continue, modify or terminate the plan of care.
systematic, rational method of planning and providing individualized nursing care.
performed within specified time after admission
ongoing process integrated with nursing care
during any physiological or psychological crisis
time lapses reassessment
several months after initial assessment
AKA symptoms, verified only by the person affected
"i feel weak all over"
"i feel sick to my stomach"
AKA signs can be seen
rapid involuntary rhythmic eye movement
instrument for examining the interior of the ear
Low set ears are associated with:
Straighten ear canal of an adult by pulling the pinna:
up and back
adventitious breath sounds
occur when air passes through narrowed airways or airways filled with fluid or when pleural linings are inflamed.
soft-intensity, low pitched "gentle sighing sound created by air moving through smaller airways
moderate intensity and moderate pitched blowing sounds created by air moving through larger airway
high pitched, loud, harsh sounds created by air moving through the trachea