intervention

 Intervention -3Types

1- Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision

2- Dependent ( Physician initiated )-nursing actions requiring MD orders

3- Collaborative- nursing actions performed jointly with other health care team members

planning

Nursing Planning

*Third step of the Nursing Process

*This is when the nurse organizes a nursing care plan based on the nursing diagnoses. 

*Nurse and client formulate goals to help the client with their problems

*Expected outcomes are identified

*Interventions (nursing orders) are selected to aid the client reach these goals.

Intervention- Types of goals 

-Short term goals

-Long term goals

-Cognitive goals

-Psychomotor goals

-Affective goals

 Intervention -3 Types

1- Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision

2- Dependent ( Physician initiated )-nursing actions requiring MD orders

3- Collaborative- nursing actions performed jointly with other health care team members

diagnosis

Nursing Diagnosis:
A statement that describes actual or potential health  problems that can be prevented or resolved by independent 
nursing intervention

NANDA Definition: (North America Nursing Diagnosis
Associate)
-Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual 
and potential health problems/life processes.

-Nursing Diagnosis “provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”


Difference Between Nursing and Medical  Diagnosis 
Nursing Diagnosis- statement used to
describe the client’s actual or potential response to a health problem that a nurse is licensed and competent to treat i.e.-Impaired skin integrity, Risk
for Infection, etc.

Medical Diagnosis-physician’s clinical
judgment of the disease- i.e. diabetes mellitus, give insulin, 1800 caloric diet and moderate exercise.

Diagnosis is the second phase of the
nursing process.
- Analyze data
- Identify health problem and risk.
- Identify the characteristic of nursing problem.
- state nursing diagnosis in concise way and precisely


It contains three parts:
Problem:
1) Identifies unhealthy response
2) Indicates what should change

Etiology:
1) Identifies causative or contributing factors
2-suggests nursing interventions

Sign and symptom: redness, cyanosis, loss of appetite.

It called PES system.

Example:
problem
Etiology
Sign
Ex: Anxiety related to Fear of death manifested by patient
verbalization.
Ex: Activity intolerance related to obesity manifested by
body weight 140 KG.

assessment

Nursing: is a unique and complex science, and caring art, combined with the scien-

tific sciences such as chemistry, anatomy, physiology, biology, pharmacology…etc.

Nurses are increasing responsibilities that involve not only caring but also assessment , diagnosis, and implementation with patients to treat, prevent, educate and assist patients. 

The Nursing Process: It is a logical plan that helps nurses give good care to the patient and avoid mistakes, 

involves 

1. Assessment (collect information)

2. Diagnosis (analysis information, know problem)

3. Planning (manage the problem)

4. Implementation (putting plan into action)

5. Evaluation (check output)

Nursing Assessment : Is the systematic and continuous collection, organization, validation, 
documentation of data.

*First step of the Nursing Process

*Gather Information/Collect Data

Types of assessment 

1-Initial

• Shortly after contact with patient

• Most facilities have specific time-frames 

• Establishes database for development of plan

2-Focused

• Gathers data about specific problem

• May be part of initial assessment, but more often is not

3-Emergency

• Identifies life-threatening problems

4-Time-Lapse

• Compares current to previous data

Assessment collect data

-Nursing Interview (history)

-Physical Examination 

-Lab results.

-Review records and literature

Nursing health history:
Biographic data:
- Client name, address, age, sex, marital satus, occupation,
religious, assurance, Date and time of history.

Chief complain:
- The answer given to question "what brought you to the
hospital?
- The chief complain should record in own patient word.
Ex: my stomach hurts or I have come for my regular check up

History of present pain:
a-Location.
b-Radiation.
c-frequency
d-Timing and duration.
e-Quality and quantity.
f-Factors aggravated or alleviated.
g-Associated symptoms


Past History:
a-Immunization.
b-Childhood illness( measles, mumps,
streptococcal infection and rheumatic fever).
c-Allergy ( drug, egg, animals and insect).
d-Surgeries
e-Hospitalization.
f-Medication ( aspirin, laxatives, antihypertensive)

Family history:
a-Risk factor certain disease
b-Cancer, hypertension. Angina, bleeding tendency. 

Life style:
a-Personal habits: tobacco, alcohol, coffee, tea.
b-Diet description: high fat diet. High salt.
c-sleep pattern.
d-Hoppies.

Types of Data

Subjective data: (symptoms, covert data), the client  only client can be described. Such as itching, pain, 
feeling, I feel weak all over.
Objective data: referred to as (signs or overt data)
are detectable by observe or can be measured, it  can be seen, heard. 
l Example Blood pressure reading, pulse, redness,
cyanosis.
l Blood pressure: 90/ 50 mmHg.     

Type of Sources

-Primary Source  : always the patient 
-Secondary Source: family, other health care personnel, medical records, lab reports.

Social data
Family relation ship, friends, support system.
Level of education.
Occupation history (number of days are missed,occupied hazard).
Economic status, how pay in medical care.
Home (safety measurement)

psychological data:
Major stressor, usual coping pattern, communications tyle.

Data collection method:
1. Observing: is the conscious use of the five
senses to gather information.
l Example: flushed face.
2. Interview:
Is a planned communication or conversation with  purpose for example to get or to give 
information or to identify problem.

There are two approaches to interview:
1-The directive interview: is highly structured
and elicit specific information.
2-Non directive interview: the nurse allow the client to control the purpose.

Phases of interview:
- Preparatory phase.
- Introduction phase.
- Working phase.
- Termination phase.

organizing data:
the nurse uses an organized assessment
framework, nursing health history, nursing
assessment etc.

validating data:
is the act double checking to confirm that they are
accurate and actual.
-Example: compare subjective and objective data
to verify the client statement with your observation.
-Feeling hot need with comparing body temperature.

Documentation data.

physical examination:
 Techniques of Physical Assessment:
1) Inspection :
Deliberate visual exam e.g.: flush, cyanosis.
2) Palpation:
gather data with hands via sense of touch feel skin and
underlying tissue to detect/describe: temp, texture,
vibration, pulsation, mass, size, tenderness.
3) Percussion:
Tap body surfaces to produce vibration and sound
4) Auscultation
Listen to sounds produced by body heart, lung , bowel sounds, BP

drug adminstrater

The responsibilities of nurse for drug administration

The six rights of drug administration only that a drug will be administered as prescribed, 

they are: 

1. Right Patient,

2. Right Drug, 

3. Right Dose,

4. Right Route, 

5. Right Time, 

6. Right Documentation.

To remember: Patients Do Drugs Round The Day (PDDRTD)

1. Right Patient 

Nurse must compare the patient's name on the prescription label, the drug order. 

Make sure that they match.

Nurse can avoid a serious mistake if: 

1. Prepare drug for one patient at a time. 

2. Give the drug to the individual as soon as prepare it. 

3. Do not stop to do something in the middle of giving drugs. 

5. Pay close attention at all times when giving drugs. 

2. Right Drug 

In order to be sure that giving the right drug, nurse must:

• Read the drug order carefully.

• Read the drug label carefully & Check the spelling of the drug carefully.

• Look at the drug. If there is anything different about the size, shape or color of the drug, 

call the pharmacist before give it. 

3. Right Dose 

The right dose is how much of the drug nurse will give the patient at one time.

To determine the dose, you need to know the strength of each drug.

Compare the dose on the prescription label, the drug order.

4. Right Route 

The route means site of administration of drug into the body. Most drug is taken into 

the mouth and swallowed (oral route), but others through the skin, rectum, vagina, eyes, 

ears, nose, and lungs, through a g-tube or by injection. 

Compare the route on the prescription label, the drug order.

5. Right Time

It is very important for drug to be given at the time of day that is written on the drug

order. Some drugs must be administered only at very specific times of the day. For other 

drugs, the time of day that you give the drug is less critical. 

For example, some drugs must be given before meals or at bedtime in order to work best. 

drugs must be given within a ½ hour of the time that is listed on the drug order. 

Note: The ½ hour timeframe does not apply to PRN drugs (on need)

PRN=(pro re nata)

Compare the dose on the prescription label, the drug order.

6. Right Documentation

Each time a drug is administered, it must be documented. 

Your documentation of drug administration must be done at the time that you give the 

drug. 

You must complete all of the documentation that is required on the drug log. 

Double check your documentation as soon as you have finished giving drugs

communications

CommunicationSkills 

LearningObjective:

1. Discuss the concept and levelsof communication.

2. Describe the communication model and its importance.

3. Discuss the channels of managerial communication.

4. List the nurse characteristics that promote communication.

Definition

The process in which amessage containing information,ideas, factsis transferred from

a person (sender)to another person (receiver) via anumber of media with the objectivet that the message is received and understood as intended.

Effective communication is important at all times because breakdowns may cause ill

feelings and may result in other negative consequences.

To improve communication skills,nurses must beaware of the messages they aresending

at all times.

Elements of Communication-

The six elements are generally accepted as the basis for communication.

• Message—the content (idea,opinion,or fact) oneperson wishes another person to

receive.

• Encoder (sender)—theperson who initiates communication by placinga message

in aform that is underst and able to the receiver.

• Sensory channel—the means by which amessage is sent.There are 3 primary

(visual,auditory and touch) routes or channels. Sometimes all 3 channels are usedt ogether.

• Decoder (receiver)—the intended receiver of the original message.

• Feedback—the process where by the overall communication is evaluated for

effectiveness.

• Context—the conditions under which communication occurs.

Levels of Communication

Communication occursat various levels-

1. Intrapersonal communication:

Occurs when a person communicates with himself.

E.g.When the individual looksoutside and seesthat it is raining and thinks to

wear arain coat.

2. Interpersonal communication:

Occurs between two people.E.g.facetoface,telephone etc..

3. Small group communication:

Occurs between three or more people interacting with one another.

4. Organizational communication:

Refers to communication between membersof organization,hospital, nursing

unit etc..

5. Public communication:

It involves interaction with largegroupsof people.E.g.when aspeaker

addresses an audience.

6. Mass communication:

Occurswhen a small number of people send messages toalarge number of

audience through the use of some specialized media.E.g.films,television, radio,

newspapers andbooks.

Typesof Communication

1- Verbal-using Verbal-using spoken language

2-Non Verbal-Gesture,posture,Facial expressions, body movement,clothing,

groomingetc..

Communication and the therapeutic relationship-

Nurses are expected touse communications with clients in a manner designed to

promote health.

The interaction with clients should be therapeutic relationships.It require sthe use

of verbal and nonverbal techniques that are focused on client needs.

Nonverbal barriers of Client or Nurse

Physical — Hearing, vision,and cognitive impairment.

Environmental disruptions.

Psychological — Personal perceptions

Personal prejudices

Fear of person, subject,

Lack of interest.

Verbal barriers—

Giving orders

Threatening client

Criticizing, blaming, shaming

Overly praising

Toomuch or too little information

Nurse characteristics that promote communication

1- Showing unconditional positive regard for your client -means accepting

and respecting the client as afellow human being,without imposingany

conditions for that acceptance.

2- Empathy—identifyingclosely with a client because anurse can imagine

herself in the client'ssituation.

3- Authenticity and Genuineness—beingreal or genuine,it requires openness

and sharing of true feelings.

4- Caring—means paying attention for aclient.

5- Active listening—is the act of perceiving what is communicated verbally as

well as nonverbally.

mobility

Mobility &Body Mechanism

Mobility: the ability to move freely, easily,

rhythmically, and purposefully in the environment, is ane ssential part of living.

Normal movement:

Normal movement and stability are the result of an intactm usculoskeletal system, an intact nervous system, andi ntact inner ear structures which responsible for

equilibrium.

Normal body movement involves four basic elements:

body alignment and( Posture), joint mobility, balance, and coordinatedm ovement.

1- Alignment and posture: proper body alignment andp osture bring body parts in to position in a manner thatp romotes optimal balance and function whether the clienti s standing, sitting, or lying down.

Line of gravity: an imaginary vertical line drawn throught he body s center gravity pass through the point at which

all of the body mass is centered.

2- Balance: mechanisms of equilibrium (sense of balance)

3- Coordination: balance, smooth, purposeful movement,

it's the result of the proper functioning of the nervess systems

4- Range of motion (ROM): is the maximum movementt hat is possible for that joint. It varies from one person too ther by genetic makeup, developmental patterns,

presence and absence of disease and the amount ofp hysical activities in which the person normally engageW hen a person is inactive, the joints are pulled into a

flexed position, if the tendency is not counteracted withe xercise and position changes, the muscle permanently

shorten, and the joint becomes fixed.

Types of joint movement are:

Flexion: decreasing the angle of the joint.

Extension: increasing the angle of the joint.

Hyper extension: further extension of the joint.

Abduction: movement of the bone away from the midline of the body.

Adduction: movement of the bone toward the midline oft he body.

Rotation: movement of the bone around its center axis

Circumduction : movement of the distal part of the bone

in a circle while the proximal end remain fixed .

Eversion : turning the sole of the foot outward bym oving the ankle joint .

Inversion: turning the sole of the foot inward by movingt he ankle joint.

Pronation : moving of the bones of the forearm so thatt he palm of the hand face the body .

Supination : moving of the bones of the forearm so that

the palm of the hand faces upward when held in front of

the body .

Activity & Exercis

Daily Living Activity (DLAs): activities which carried out during a routine day independently including the following (DLAsDLAs)

*Eating

*Dressing/

grooming

*Bathing

*Toileting

*Ambulating

*Transferring

*Cooking

*Housholding

*Shopping

Isotonic exer cise (dynamic): are those in which them uscle shortens to produce muscle contraction and activem ovement, such as, running, walking, cycling, ADLs,

and active exercise.

Active Exercise: Is isotonic exercise in which the clientm oves each joint in the body through its complete range of movement.

Passive Exercise: another person move each of thec lient joint through its complete range of movement, its hould be performed only when the client is unable to accomplish the movement actively. The movements hould be systematic, and the same sequence should bef ollowed during each exercise

Effects of Immobility on Body Systems

The most obvious signs of prolonged immobility are often manifested in the musculoskeletal system. Clients

experience a significant decrease in muscular strength and agility whenever they do not maintain a moderate

amount of physical activity. In addition immobility also affects the cardiovascular, respiratory, and urinary and psychoneurologic system .Nurses needs to understand these effects and encourage client movement as much as possible.

1. Musculoskeletal system:

Disuse osteoporosis: demineralization process take place in the bones calcium, the bones became spongy and may gradually deform and fracture easily

Disuse Atrophy: unused muscles atrophy (decrease in size), losing most of their strength and normal function
Contracture: it's permanent shortening of the muscles which limiting joint mobility, its effect the tendons, ligaments and joint capsules such as (foot drop, external hip rotation) Stiffness & pain: as the bone demineralization excess calcium may deposit in the joints contributing to stiffness and pain

2. Cardiovascular System:

Diminished cardiac reserve : decrease mobility create an imbalance in the autonomic nerves system ,increase heart rate , rapid heart rate reduce diastolic pressure ,coronary blood flow and capacity of heart respond to any dbecause, because of that the person may experience tachycardia with minimal exertion

Increased use of Valsalva maneuver : (Valsalvamaneuver)refer to holding the breath and straining against a closed glottis , client hold their breath when move up in bed ,sit on bedpan ,which buildup pressure on the large veins of thorax to interfere with the return blood flow to the heart and coronary arteries ,when exhales sudden blood flow reach the heart causing tachycardia and cardiac arrhythmia

Interstitial edema: when the venous pressure is great,

some serous of the blood is found out of the blood into the interstitial spaces surrounding the blood vessel,causing edema is most likely occur around the sacrum or heels of client who sits up in bed or in feet and and lower legs of a client who sits in a chair. Poor blood flow to the

heart case more pooling and more susceptible to injury than normal tissue.

Thrombus formation:

Thrombophlebitis: a clot take is loosely attached to an inflamed vein wall caused by:

1- Impaired venous return to the heart.

2- Hyper coagulation of the blood.

3- Injury to vessel wall.

*Thrombus: clot, which breaks loose form the vein wall to enter the general circulation.

*Embolus: an object that moved from its place to another

causing obstruction of circulation such s (pulmonary.

Cerebral, Renal embolism

3. Respiratory System:

Decreased respiratory movement:

In a recumbent, immobile client the ventilation of the lungs limited because the abdominal organs push against the diaphragm, restricting the lay movement and making

it difficult to expand, and over all muscle atrophy also affects the respiratory muscles.

These changes produce shallow respiration & reduce vital capacity (the maximum amount of air that can be exhaled after a maximum inhalation).

Pooling of respiratory secretion:

Inactivity allows secretions to pool by gravity interfering with normal gas exchange, the ability to cough up secretion may also be hindered by loss of respiratory muscle tone, dehydration which thickens secretion & sedation that depress the cough reflex. All that lead of poor oxygen fun retention of carbon d oxide in the blood causing respiratory acidosis which is left at disorder.

Atelectasis: when ventilation is decreased pooled secretions Accumulate in a dependent area of a bronchiole and effecting block it and the combination of decreased surfactant (ability of the alveoli to remain open) and blockage of a bronchiole with mucus can causes collapse of the lung lobe.

Hypostatic pneumonia : pooled secretions provide excellent media for bacterial growth, upper respiratory infection can evolved rapidly to sever infection of the lower respiratory trait penumbra caused by static secretion which severely impair oxygen-carbon d oxide exchange in the alveoli.

4. Metabolic system:

Decrease metabolic rate :

Basal metabolic rate : is the minimal energy expended for the maintenance of these produce from the physical andc hemical process of the body.

In immobile person the basal metabolic rate andg astrointestinal motility as the energy requirement of the

body decrease.

Negative nitr ogen balance:

In active person a balance exists between protein synthesis (anabolism) & protein breakdown (catabolism).

Immobility increase catabolism (muscle mass release snitrogen) so more nitrogen is excreted than is ingested leading to negative nitrogen balance which effecting thee ssential building of muscle & tissue& for wound healing.

Anorexia : loss of appetite occurs because of the decrease metabolic rate. Negative calcium balance: Greater amount of calcium loss from bones .The absence of weight-bearing & stress on the

musculoskeletal structure is the direct cause of the calcium loss from bones.

5. Urinary system:

Urinary stasis : immobilization cause overall decrease in muscle tone so the bladder empting is not as complete

Renal Calculi: In mobile person calcium remain dissolved because calcium & citric acid are balanced in acid urine. In immobile person the balance not longer maintain the urine become more alkaline so the calcium salts precipitate out as crystals to from renal calculi. The stone usually develop in the renal pelvis & pass through the ureters into the bladder causing pain bleeding

& sometime obstruction of the urinary tract

Urinary retention: accumulation of urine in the bladder.

Urinary infection: static urine provides an excellent medium for bacterial growth.

6. Gastrointestinal system:

Constipation : decreased peristalsis overall muscle weakness affects the abdominal & perineal muscle usedin defecation. When the stool becomes very hard more strength is required to expel it. Excessive used of the valsalva maneuver by straining at stool, this effort increase intra-abdominal & intrathoracic pressure which cause stress on the heart & circulatory system.

7. Integumentar y system:

Reduce skin turgor : the health of the dermis & subcutaneous tissue can affect by shifting in body fluids between the fluid compartments & skin atrophy.

Pressure ulcers (skin breakdown): caused by poor blood flow &diminishes supplement of nutrients to specific

area.

8. Psychoneurologic system:

The participation of the immobile client in the life event comes narrow so, time perception & problem-solving,

decision making abilities may deteriorate as a result of lack of intellectual stimulation, in addition to that loss of control & stress of illness increase client's anxiety.in defecation. When the stool becomes very hard more strength is required to expel it. Excessive used of the valsalva maneuver by straining at stool, this effort increase intra-abdominal & intrathoracic pressure which cause stress on the heart & circulatory system.