5 Moments of Hand Hygiene:

1.​ Before touching a patient

2.​ Before performing a clean or aseptic procedure
3.​ After body fluid exposure
4.​ After touching a patient
5.​ After touching a patient's surroundings

Hand Washing and Drying:

●​ Wash hands for 15-20 seconds.
●​ Keep hands lower than elbows and point fingers downwards.
○​ This allows water to flow from least (elbows) to most contaminated (fingertips)
areas, and direct microorganisms away from wrists.
●​ Use at least 10 circular motions.
●​ Pat dry starting from fingertips and moving upwards.

Water Temperature:
●​ Use warm water.
○​ Hot water removes protective oils from skin and promotes bacterial invasion.

Alcohol-based Hand Sanitizer:

●​ Rub hands for 15-20 seconds until completely dry.
●​ After using alcohol hand sanitizer 3 times, switch to soap and water.

Nail Care for Hand Hygiene:

●​ No longer than ¼ inch past the fingertips.
●​ No artificial nails.
●​ If nails are dirty, use nails of opposite hand or an orange stick to clean them.

Hand hygiene breaks the Chain of Infection by interrupting the Mode of Transmission.

Purpose of Bathing:
●​ Removes oil, perspiration, dead skin cells, and some bacteria.
●​ Stimulates circulation (brings more blood and nutrients to the skin).
●​ Provides a sense of cleanliness and comfort.
●​ Perfect time for nurse to assess skin integrity while bathing.
○​ Be sure you accurately and precisely document any abnormalities noted.

Bathing Guidelines:
●​ Head-to-toe approach (leave perineal area for last).
 ●​ When giving a bath, rub distal to proximal to help improve blood flow back to the heart
(venous return) and stimulate circulation.
●​ Bathing order:
○​ 1) Face
○​ 2) Arms & Hands
○​ 3) Chest & Abdomen
○​ 4) Legs & Feet
○​ 5) Back
○​ 6) Perineum (buttocks last)
●​ Cover the client with a warm sheet, only exposing the area being washed.
●​ Close the drapes.
●​ Assess the client’s abilities and functional level and allow as much independence as
possible. You don’t want to do everything for them!
○​ Semi-Dependent: requires help from another person
○​ Moderately Dependent: requires help from another person + equipment or device
○​ Totally Dependent: does not participate at all in activity; needs complete assistance
●​ Not everyone practices the same hygiene preferences, so make sure you assess this
first because bathing should be based on client preferences and established routines.
●​ Ensure the room and water temperature (105°F - 110°F) are comfortable.
●​ Offer to let client void before bathing (water can stimulate the urge to void).
●​ Always dry the skin thoroughly after bathing to prevent bacterial growth and irritation.
●​ Document the type of bath, assistance, and any skin protection measures you took.
●​ Be flexible; allow patients to bathe at a time that works best for them.

Types of Bathing:
●​ Complete Bed Bath
○​ Wash everywhere.
●​ Partial Bed Bath
○​ Only wash the hot spots.
●​ Self-Help Bed Bath
○​ Patient participates as much as possible with minimal assistance.
●​ Sitz Bath
○​ On the toilet. Sitting in warm water to help relieve discomfort and promote healing
in the perineal and rectal areas.
●​ Chair Bath
○​ Sitting in a shower or by the sink.
●​ Sink Bath
○​ Standing at a sink with a basin.
●​ Bag Bath
○​ No-rinse cleaner solution.
●​ Shower
○​ Requires MD order if patient has sx (symptoms) for fall risk.
●​ Therapeutic Bath
○​ MD order needed (e.g. hot tubs).
●​ Towel Bath
○​ Warm, moist towel.
Lifespan Considerations in Bathing
●​ Infants:
○​ Sponge baths, then immediately dry and wrap to get warm.
○​ Infant’s ability to regulate body temperature has not fully developed.
○​ Newborns’ bodies lose heat readily.
●​ Children:
○​ Encourage participation as appropriate for developmental level.
○​ Closely supervise in the bathtub and never leave them unattended.
●​ Adolescents:
○​ Assist adolescents in choosing deodorants and antiperspirants.
○​ Secretions from newly active sweat glands react with bacteria on the skin,
causing a pungent odor.
●​ Older Adults:
○​ Aging can decrease the protective function of the skin and cause fragile skin, less
oil and moisture, and a decrease in elasticity.
○​ Avoid excessive uses of soap.
○​ Moisturize the skin immediately after bathing.
○​ Avoid excessive powder because it causes moisture loss and is a hazardous
inhalant.
○​ Cornstarch should be avoided because in the process of moisture it breaks down
into glucose and can facilitate the growth of organisms.

Bathing Special Populations

●​ Dementia:
○​ Be patient.
○​ Come prepared with all supplies.
○​ Offer distractions (music, TV).
○​ Warn them of actions (what you are doing and where you will touch).
○​ If distressed, return later and only wash the essential areas.
●​ Older Adults:
○​ Older adults produce less sebum, so avoid daily bathing to prevent dryness and skin breakdown and
○​ Moisturize immediately after bathing.

Perineal Care
●​ Privacy
●​ Gloves
●​ Waterproof pad
●​ Wash with warm water and soap
●​ Rinse and dry
●​ Female:
○​ Dorsal recumbent position (lies on back with knees bent and feet flat on the
ground).
 ○​ Spread labia with one hand to clean between folds.
○​ Use different sections of washcloth for each stroke.
○​ Wipe from front to back.
●​ Male:
○​ Supine position (flat on back).
○​ Clean the penis starting with the meatus downward in circular motions.
○​ Clean the scrotum carefully.
○​ If uncircumcised, gently retract the foreskin for cleaning.

General Guidelines of Skin Care:

●​ Intact skin is the body’s first line of defense.
●​ Always dry skin thoroughly because bacteria thrive in warm, moist environments.
●​ The degree to which the skin protects the underlying tissues from injury depends on the
general health of the cells, the amount of subcutaneous tissue, and the dryness of skin.
●​ Skin sensitivity is greater in infants, young children, and older adults. Check the need for
hypoallergenic products.
●​ Body odors are caused by resident skin bacteria acting on body secretions.

Dry Skin:
●​ Bathe less frequently.
●​ Use mild or no soap, and rinse well.
●​ Increase fluid intake.
●​ Humidify air.
●​ Use moisturizing creams and lotions. Best time to moisturize is after a bath/shower.
●​ Cold causes vasoconstriction which can inhibit blood flow to the skin.

Rashes:
●​ Tepid bath to relieve itching (pruritis).
○​ Hot causes vasodilation which can make itching worse!
●​ Avoid scratching.
●​ Avoid clothing that is irritating or causes excessive perspiration (sweating), such as
polyester and wool.
●​ Keep area clean with mild soap.

Acne:
●​ Wash face using hot water.
●​ Avoid oily creams or cosmetics that block ducts.
●​ Never squeeze or pick at the lesions because it can increase the potential for infection
and scarring.
Foot Care:
●​ Inspect feet daily for redness, swelling, or breakdown.
●​ Keep feet from getting dry (dry = risk for breakdown) but avoid putting lotion between the toes (breeding
●​ Change socks daily
●​ Wear comfortable, well-fitting shoes that do not rub.
●​ Do not walk barefoot at all.
●​ Exercise feet daily to improve circulation.
●​ Avoid constriction (tight pants, crossing the legs, etc.).
●​ Don’t let feet get too cold (causes vasoconstriction and poor perfusion).
●​ Cut or file nails straight across.

Diabetic Foot Care:

●​ Increased risk for infection due to high blood sugar.
○​ Bacteria thrive in this environment.
●​ Increased risk for infection due to neuropathy (poor sensation and feeling in lower extremities).
○​ They need to have routine inspection and foot care.
○​ If they get minor scrapes or cuts, they may not notice them, which predisposes them to infection.
●​ Poor foot care can put them at high risk for lower extremity amputations.
●​ Try to file nails instead of cut.

Oral Care:
●​ Brush teeth thoroughly after meals and at bedtime.
●​ Floss daily.
●​ Foam swabs are used to clean the mouths of dependent clients.
●​ Begin brushing teeth around 18 months.
●​ Dental checkup every 6 months with fluoride treatment.
●​ If providing oral care to an unconscious client, lay them on their side and ensure suction
is available to prevent choking aka aspiration.
●​ Avoid lemon glycerin swabs because they irritate and dry out the oral mucosa and can
decalcify teeth.
●​ Ensure adequate intake of nutrients, particularly calcium, phosphorus and vitamins, A, C,
D, and fluoride.
●​ Avoid sweet foods and drinks between meals.
●​ Eat coarse, fibrous foods (e.g. raw veggies).

Hair Care:
●​ Assess for hair related conditions.
○​ Hair loss
○​ Lanugo (thin hair)
○​ Ticks
 ○​ Pediculosis (lice)
○​ Scabies
○​ Hirsutism
●​ Excessively matted or tangled hair could indicate lice.
●​ Look for nits at the base of the scalp.
●​ Use oil for tangled hair.
●​ Older adults are more susceptible to temperature drops so it’s important to use warm
water when shampooing their hair and dry hair promptly.
●​ Use a safety or electric razor and shave in the direction of the hair growth.
●​ Do not shave patients who are on blood thinners. If you must, use an electric razor.

Eye Care:
●​ Wipe from inner to outer canthus to prevent particles and fluid from draining into the
lacrimal duct.
●​ Rinse with clean, tepid water if dirt or dust get into eyes.
●​ Regular eye examinations, especially after 40, to detect problems such as cataracts and
glaucoma.

Ear Care:
●​ For adults, examination requires you to pull the pinna up and back to visualize the ear
canal structures.
●​ Avoid cotton tipped swabs because they push cerumen back further into the canal.

Hearing Aid Care:

●​ Remove your hearing aids at night.
●​ Open the battery doors all the way, or change them every night.
●​ Use a dry tissue to gently wipe the outer part of the hearing aid.
●​ Keep them away from extreme heat or cold.
●​ Do not wear hearing aids while applying makeup or hair products.
●​ Keep hearing aids and batteries away from children and pets.
●​ Schedule a checkup every 3-6 months.
●​ Do not clean with water or alcohol. Only use a dry wipe.
●​ If you remove a hearing aid, turn it off or batteries will continue to run.

Seizure Precautions
●​ Before a seizure:
○​ Pad the side rails.
○​ Keep oral suction equipment at the bedside.
 ●​ During a seizure:
○​ Stay with the client and call for assistance.
○​ Do not restrain the client.
○​ If the client is not in bed, lower them to the floor and pad the surroundings.
○​ Turn client to lateral position if possible.
○​ Clear the area of objects that could cause injury.
○​ Loosen any restrictive clothing.
○​ Do not put anything in the client's mouth.
○​ Provide oxygen and suction as needed.
○​ Prepare seizure medications.
○​ Time and record the seizure movements for reporting to the MD.
○​ Document the seizure promptly after it occurs

Universal Fall Precautions:

1.​ Familiarize the client with the environment.
2.​ Teach-back method for using the call light.
3.​ Keep call light within reach.
4.​ Personal possessions should be easily accessible.
5.​ Handrails should be in the room, bathroom, and hallway.
6.​ Bed in low position and locked.
7.​ Ensure the patient wears non-skid, well-fitting footwear.
8.​ Nightlights to improve visibility.
9.​ Keep the floor clean and dry.
10.​Ensure uncluttered areas.

Fire Considerations

RACE (discovery of fire):

1.​ Rescue: Remove persons from immediate danger.
2.​ Alarm: Alert others and emergency services.
3.​ Contain: Close doors to contain fire and smoke.
4.​ Extinguish: Extinguish fire or evacuate if necessary.

PASS (using fire extinguisher):

1.​ Pull the pin.
2.​ Aim at the base of the fire.
3.​ Squeeze the handle.
4.​ Sweep from side to side.
Poisoning:
●​ Call poison control if a child ingested.
●​ Call 911 if a child is unconscious.
●​ Never make a child vomit, only spit.

Bed-Making & Safety:

●​ Wear gloves, and possibly a gown if the situation warrants it.
●​ Hold soiled linens away from your body and place them directly in a bin.
●​ Draw sheet must be under patient for pulling up in bed and transferring.
●​ Call light within reach.
●​ Side rails up, but be careful about the cognitive status of your patient.
○​ Sometimes putting side rails up can contribute to falls if the patient is confused
and tries to climb over them.
●​ Never put more than 3 rails up because 4 raised rails could be considered a restraint.

Proper Lifting:
1.​ Plan your lift.
2.​ Ask for help.
3.​ Widen you base.
4.​ Bend your knees.

Logrolling:
●​ Move the patient's whole body as a unit.
●​ Prevents spinal cord injury.

Restraints:
●​ Protective devices used to limit the physical activity of a client or a body part. There are
three types:
○​ Physical restraints (e.g. bed rails, handcuffs)
○​ Chemical restraints (e.g. sedatives, antipsychotics)
○​ Seclusion (e.g. isolation rooms)

Indications for Restraint Use:

●​ Only be used as a last resort after less restrictive interventions have proven ineffective to
protect the client, staff, or others from harm.
●​ The two main situations for restraint use are:
 ○​ Nonviolent, non-self-destructive behavior (e.g. pulling out IVs or ventilator
tubing).
○​ Violent, self-destructive behavior (e.g. harm to self, staff, or others).

Restraint Order Parameters:

●​ Primary Care Physician (PCP) Order must include:
1.​ Reason for restraint.
2.​ Specific time frame (nurses may remove restraints earlier if behavior warrants it).
3.​ Type of restraint needed.
●​ PRN (as needed) orders are not allowed for restraints.
●​ Orders must be renewed every 24 hours.

Restraint Application Guidelines:

●​ Informed consent must be obtained from family/PCP.
●​ Never ask the patient permission prior to restraining them.
●​ MD must lay eyes on the patient within 1 hour after applying a physical restraint.
●​ Restraints should be applied so the client can still move as freely as possible while
remaining safe.
●​ Do not impede circulation.
●​ 2 fingers should be able to fit in between restraints.
●​ Pad bony prominences to prevent injury.
●​ Tie restraints securely, but ensure the knot will not tighten when pulled.
●​ Never tie restraints to the side rails of the bed. Tie to a non-moveable part of the bed.
●​ Remove and assess restraints every 2 hours.
●​ Continuous monitoring of clients in restraints is required.
●​ Regularly assess the skin condition and the need for restraints.
●​ Never raise more than 3 side rails on a bed (raising 4 rails constitutes a restraint).

To prevent orthostatic hypotension, always let the patient dangle their feet first before getting up.
Positions
●​ Sim’s
○​ enema
○​ access rectum or vagina
●​ Supine
○​ lumbar puncture
○​ avoids hip flexion
○​ prevents headache and leakage of spinal fluid
●​ Prone
○​ promotes extension of the hip joint
○​ used with ARDS patients
●​ Fowler’s
○​ increases venous return
○​ allows lung expansion
 ○​ after thyroid surgery
●​ Trendelenburg
○​ increase blood return to the heart
●​ Lithotomy
○​ childbirth

Crutches:
●​ Crutches are 6 inches away from feet.
●​ Hand grips are at hip height.
●​ Arm makes a 30° angle when holding crutches.
●​ Pads of the crutches are 1.5” to 2” below the axilla, which is about 2-3 fingers.
●​ Don’t lean on pads of crutches. Keep all of your weight on the hand grips.

4-Point Gait:
●​ Move one at a time.
●​ right crutch, left foot, left crutch, right foot

3-Point Gait:
●​ Patient is non-weight bearing on one side.
●​ Move both crutches forward at the same time, and then swing the uninjured leg forward
to meet them.

2-Point Gait:
●​ Both legs are on the ground.
●​ Move one crutch and the opposite leg forward at the same time, then the other crutch
and leg forward together.
●​ right crutch and left foot, left crutch and right leg

Swing-to Gait:
●​ Both crutches are moved forward. Swing both legs forward to the same spot.

Swing-through Gait:
●​ Both crutches are moved forward. Swing both legs forward past the crutches

Cane:
●​ Hand grip is at wrist height.
●​ Arm makes a 30° angle when gripping the cane's handle.
●​ Cane is always placed on strong side of body.
●​ Cane is moved at the same time with the weaker leg, then followed by the strong leg.
Walker:
●​ Used following a loss of function or surgical procedure for patients who are weak or tend
to lose their balance because it offers a broad base of support.
●​ Hand grips are at wrist height.
●​ Arm makes a 15-30° angle when holding the hand grips of a walker.
●​ Move the walker 4-6” first, then the weaker side.

Mobilization Assistive Devices

●​ Walking on the ground, the weaker leg always moves first.
●​ Going up the stairs, the strong leg goes first.
●​ Going down the stairs, the weak leg goes first.

Prioritizing Nursing Care with ABC’s:

●​ Airway: Airway obstruction
○​ Throat swelling
○​ Foreign objects
○​ Food
●​ Breathing: Respiration/ventilation issues
○​ Inadequate oxygenation
○​ Difficulty breathing
○​ Nasal flaring
●​ Circulation: Blood flow & tissue perfusion issues
○​ BP (blood pressure)
○​ HR (heart rate)
○​ Cyanosis (bluish skin)
○​ Pallor (pale skin)
○​ Pulses

The Nursing Process: ADPIE

1.​ Assessment
2.​ Diagnosis
3.​ Planning
4.​ Implementation
5.​ Evaluation
Assessment
Primary Data Sources:
●​ Obtained during patient interview.
●​ Comes directly from the patient.
●​ Patient is the best source of information about their conditions, feelings, and what they
have done to address their concerns before seeking professional health care.

Secondary Data Sources:

●​ Support people (family)
●​ Patient’s chart
●​ Medical records
●​ Labs
●​ Vital signs
●​ Healthcare professionals
●​ Hand-off report
●​ Literature

Collecting Data:
●​ Gathering information about a client's health status.
 ●​ Must be systematic and continuous.
●​ Past history and current problem.
●​ Database contains all information about a client.
●​ Uses observation, inspection, auscultation, palpation, percussion.

1.​ Inspection: use your eyes

2.​ Palpation: pressing, touching
3.​ Percussion: tapping on a surface
4.​ Auscultation: ears, listen with stethoscope

Data Collection Methods:

●​ Observing
●​ Interviewing
●​ Examining

Stages of an Interview:
●​ Orientation
○​ establish the patient’s trust
○​ tell them what to expect
○​ Think about what questions to ask
●​ Working
○​ ask the questions
●​ Termination
○​ say goodbye and always thank the patient

Direct Interview:
●​ Nurse calls the shots, while the patient just answers questions.
●​ Nurse establishes a purpose.
●​ Nurse controls the interview.
●​ Used when time is limited (e.g. emergency).

Nondirective Interview:
●​ Mostly used in behavioral and psych.
●​ Nurse establishes rapport.
●​ Client controls the purpose, subject matter, and pacing of the interview.

Close-ended Questions:
●​ “Did you drink alcohol tonight?”
●​ Restricted to a yes or no answer.

Open-ended Questions:
●​ “Can you tell me more about your alcohol history”
OPEN ENDED QUESTIONS ARE ALMOST ALWAYS CORRECT/PREFERRED BECAUSE
YOU ALLOW YOUR PATIENT TO EXPRESS.

AVOID ASKING “WHY” QUESTIONS AND SAYING “IF I WERE YOU…”

4 Types of Assessment:
●​ Comprehensive:
○​ You don't need to have a problem.
○​ E.g. head to toe, annual physical exam
●​ Problem Focused:
○​ Assess the focus, which is the problem/chief complaint/
●​ Emergency:
○​ ABC
●​ Time Lapsed
○​ ongoing assessment
○​ E.g. I gave a patient Tylenol and I will come back a few hours later to recheck
their temperature.

Subjective Data:
●​ Whatever the patient says.
●​ Spoken information or symptoms that are typically difficult to validate.
●​ Gathered during the interview process.
●​ Should always be documented as direct quotes.
●​ Using words that express feelings, concerns, and emotions.
●​ Examples:
○​ Patient stated "I feel nauseous”
○​ Symptoms
○​ Health history
○​ Review of systems which you get at the doctor office and check off your history
and stuff.
○​ Patient said he vomited. The nurse didn't see it.

Objective Data:
●​ What the nurse does.
●​ Can be measured or observed.
●​ The nurse uses her senses of sight, hearing, touch and smell.
●​ This data is obtained through observation, physical exam, labs, or diagnostic test.
●​ Examples:
○​ Vital signs
○​ Lab levels
○​ Patient had lower quadrant pain on palpation.
○​ Wong Baker is objective because the nurse determines the number on the scale
based on what she sees on the patient’s face. “The nurse assessed and
determined pain to be X”
 ○​ Tenderness because even though the patient said ouch the nurse still assessed it
during palpitation.
○​ The nurse SEES the patient vomit.

Types of Distance:
●​ Intimate
●​ Personal
●​ Social
○​ Keep social distance (4-12 feet) from the patient.
●​ Public

ALWAYS ask to touch. If you touch a patient without consent, it is battery.

The nurse should instruct the patient of what needs to be done and then ask the client for
permission. The only exception for this is for restraints.

When documenting, ensure the following:

●​ Record client data.
●​ Record in factual manner without stating interpretations.
●​ Record subjective data with quotes in clients' own words.

Diagnosis

Diagnosis
●​ Organizing and cluster related data and identify the priority nursing diagnoses.
●​ Supporting data includes etiology, signs, and symptoms.
●​ NANDA’s are used by nurses to formulate nursing diagnoses.
 ●​ Formulate diagnosis statements.

Types of Diagnosis
●​ Actual: Diagnosis of a problem that is present at the time of assessment.
○​ Impaired skin integrity related to pressure ulcer as evidenced by wound on the
spine..
●​ Health Promotion: Diagnosis of preparedness to implement behaviors to improve health
condition.
○​ Readiness for enhanced nutrition related to patient’s expressed desire to improve
eating habits.
●​ Risk Nursing: Diagnosis when a problem does not exist.
○​ NO SYMPTOMS IN RISK DIAGNOSIS (no “as evidenced by”)
○​ Risk for infection related to skin integrity.
○​ Risk for falls related to medication.

A nursing diagnosis typically has three parts, structured as:

1.​ Problem (NANDA Diagnostic Label):​

This is the issue or concern that the patient is experiencing. It identifies the patient's
health condition or potential health issue. It's derived from the North American Nursing
Diagnosis Association list of approved diagnoses.​
Example: Impaired Gas Exchange
2.​ Etiology (Related Factors or Causes):​
This describes the underlying cause or contributing factors for the problem. It answers
“Why is this happening?”​
Example: related to alveolar-capillary membrane changes​
The etiology should be something that the nurse can address or influence with
interventions.
3.​ Symptoms (Defining Characteristics):​
These are the signs or symptoms that the nurse observes or the patient reports,
providing evidence that the problem exists. It answers “What are the signs and
 symptoms of the problem?”​
Example: as evidenced by shortness of breath, increased respiratory rate, and cyanosis.

Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by

shortness of breath, increased respiratory rate, and cyanosis.
Nursing diagnosis is a response to the disease (e.g. pain, impaired mobility).
Medical diagnosis is the disease itself (e.g. cystic fibrosis, coronary artery disease).

It is never okay to include a medical diagnosis within a nursing diagnosis. If there is a medical
diagnosis in a nursing statement, the answer is wrong.

Planning
Planning:
●​ Prioritize nursing diagnoses.
●​ Personalize the nursing plan of care.
●​ Identify short-term and long-term goals.
●​ Planning is deliberate, systematic, problem-solving phase of the nursing process
●​ During the planning phase, the nurse refers to the client’s assessment data and
diagnostic statements for direction in formulating goals and determining the nursing
interventions.
●​ A nursing intervention is “any treatment based upon clinical judgement and knowledge,
that a nurse performs to enhance patient/client outcomes.

Components of the planning process consists of the following:

●​ Setting priorities
●​ Establishing client goals/desired outcomes (SMART)
●​ Selecting nursing interventions

SMART Goals:
●​ Specific
●​ Measurable
●​ Attainable
●​ Realistic / Relevant
●​ Time bound
Informal Plan
●​ Exists in the nurses mind, and often not documented.
●​ E.g. repositioning a patient, quick intervention for pain
Formal Plan
●​ A written or computerized plan that is legally documented.
●​ E.g. care plan
Standardized Plan
●​ Pre-designed care plans.
Individualized Plan
●​ Tailored specifically to the patient.
Implementation
Implementation
●​ Carry out the plan.
●​ Nursing interventions.
●​ Interventions can be independent, dependent, collaborative, direct, or indirect.
●​ Care plans include clinical pathways, protocols, and standing orders.
●​ Document the care provided.

Imperative use of:

●​ Cognitive skills
●​ Interpersonal skills
●​ Technical skills

Process of Implementing:
●​ Reassess the client
●​ Determine nurse’s need for assistance
●​ Implement nursing interventions
●​ Supervie delegated care
●​ Document nursing activities

Guidelines of Implementation:
●​ Skills needed to implement: cognitive, interpersonal, and technical
 ●​ Base interventions on scientific knowledge, research, and professional standards of care
(EBP - evidence based practice).
●​ Nurses must understand each intervention, its purpose in the plan of care, any
contraindications and changes in the client’s condition that could affect the client’s
orders.
●​ Adapt activities to the individual client.
●​ Implement safe care.
●​ Provide teaching, support, and comfort.
●​ Be holistic and look at the entire person, not just one aspect of them.
●​ Respect dignity of client and encourage autonomy or self-decision making.
●​ Encourage active participation in care.

Evaluation

Evaluation includes:
●​ Identifying goal/outcome attainment
●​ Determining whether the care plan should be continued, revised/adapted, or
discontinued.

Process of Evaluation:
1.​ Collecting data related to desired outcomes.
2.​ Comparing data with desired outcomes (Goal Met, Partially Met, Not Met).
3.​ Relating nursing activities to outcomes.
4.​ Drawing conclusions about problem status.
5.​ Continuing, modifying, or terminating the nursing care plan.
After administering a pain medication, expected practice is to reassess the pain level
30-60 minutes after giving the med.

Remember Maslow’s:
1.​ Physiological Needs
○​ airway
○​ hydration
○​ nutrition
○​ pain relief
○​ temperature regulation
2.​ Safety and Security
○​ physical safety (e.g. bed rails)
○​ health (e.g. hand hygiene)
3.​ Love and Belonging
○​ family
○​ sense of connection