N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide

Pain, acute Protection, impaired Self-care deficit, bathing/hygiene Self-neglect

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©2017 Achieve Test Prep • Skin integrity, impaired or risk for impaired • Tissue integrity, impaired These diagnoses may be related to: • Chronic or acute disease processes • A breakdown in the patient's primary defenses that provides a portal of entry for a microorganism • Inadequate defenses provided by the patient's normal immune response, particularly any diseases or process that cause immunosuppression • Invasive procedures (tube or catheter insertion, surgery, etc.) that may involve a break in the skin or mucous membranes • Trauma • Environmental exposure to pathogens • Poor nutrition • Medications Planning The planning phase of the nursing process includes: • Prioritization of nursing diagnoses: Using the diagnoses from the analysis phase, the nurse and patient should establish the priority using Maslow's hierarchy and the patient's perception of his needs. • Establishing goals or expected outcomes: Goals or outcomes that might be appropriate are: o The patient will show no signs or symptoms of local or systemic infection. o The patient's vital signs will be within normal limits. o The patient will show no signs of skin breakdown. If skin breakdown exists, this goal might be changed to indicate that skin breakdown will be resolved. o The patient's hygiene practices will be maintained or improved. o Teaching and education goals should be appropriate to the patient's or caregivers' needs. In particular, teaching should include information about the particular pathogen causing any infection, how the disease is transmitted, the antibiotic or other medications the patient is taking, and any preventative measures the patient or caregiver can use to prevent infection or disease. • Identification of nursing interventions that will help a patient achieves the goals. Appropriate interventions for biological safety might include: o The principles of medical asepsis must be applied consistently. This includes hand washing for every person, every time, before and after a contact with the patient. o Routine cleaning of the patient's environment with appropriate cleaning supplies must also be included in medical asepsis. Page 98 of 135