Maslow's Hierarchy of Needs
(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self
... [Show More] Esteem, (level 5) Self Actualization
Assessment of Comfort Level
ask patient if they are comfortable
If they have physcial discomfort, assess level of pain and plan intervention
if it's mental discomfort, have them describe the nature of the stress
Interventions to prevent impaired comfort
anticipate which patient may experience them and provide preplanned interventions
pain
5th vital sign
cutaneous pain
superficial pain usually involving the skin or subcutaneous tissue
visceral pain
pain originating in the internal organs and is non localized
deep somatic pain
ligaments, tendons, bones, blood vessels, nerves
radiating pain
starts at an origin but spreads to other locations
referred pain
pain that is felt in a location other than where the pain originates
phantom pain
pain or discomfort felt in an amputated limb
Assessment of Elimination
-take patient history
-monitor frequency, amount , and consistency
Interventions to prevent changes in elimination
adequate nutrition and hydration
Interventions for patients with changes in elimination
-Monitor pt for signs of fluid and electrolyte imbalance
-adults experiencing urinary incontinence require frequent toileting
-Patients with short term urinary retention require one or more catherization
stress incontinence
involuntary urine loss with physical strain, sneezing, or coughing
urge incontinence
loss of large amounts of urine accompanied with a strong urge to urinate
overflow incontinence
small amounts of urine leak from a full bladder
functional incontinence
the person has bladder control but cannot use the toilet in time
unconscious incontinence
loss of urine when the person does not realize the bladder is full and has no urge to void
intake
-measured in mLs
-everything liquid
output
stools and urine
Assessment of Fluid Balance
-health hx
-monitor vitals especially pulse rate and quality
-assess skin and mucous membrane for dryness and decreased turgor
Interventions to prevent fluid and electrolyte imbalance
drink 8 glassess of water a day and eat a balanced diet
Interventions for fluid imbalance
fluid deficit: replace fluids
fluid overload: restrict fluid
Assessment of gas exchange
-health hx and assess patients breathing efforts and pulmonary function test
interventions to prevent decreased gas exchange
teach infection control and to stop smoking
interventions for someone with decreased gas exchange
having them sit up
Assessment of mobility
ROM, gait and activity tolerance
Interventions to prevent immobility
-determine who is at a higher risk
-teach patients to do ROM every 2 hours
Drinking fluids to prevent DVT
-evaluate need for assitive device
Interventions for immobility
-passive ROM
-reposition patients every 2 hours
-keep patient skin clean and dry
Assessment for sensory perception
-conduct a health hx and determine factors for any sensory loss and perform cranial nerve test
Interventions to prevent loss of sensory perception
-annual screening
-use of protective devices
Interventions for those with sensory perception loss
-encourage compliance with medications
-use of corrective devices
-visually impaired need guide dogs and those who can't hear need hearing devices
Assessment for Gas exchange
-assess RR, O2 sat, breathing pattern
-collect sputum culture and ABG
-pulmonary function test
Interventions to Promote Gas exchange
-proper handwashing to avoid getting sick
-stop smoking
-vaccinations
Interventions for those with decreased gas exchange
-determine underlying issue
-administer O2
-pulse oximeter
-position patient in semi-fowlers position
-deep breathing
Assessment of perfusion
-complete family and patient hx
-ID symptoms of decreased central perfusion such as dyspnea and syncope and dizziness and cyanosis
Interventions to promote perfusion
-stop smoking
-annual checks
Interventions for those with decreased perfusion
-educate on medication importance
Assessment of Immunity
-health hx
-assess weight
-wound healing
-allergic responses
-organ dysfunction [Show Less]