N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide Assessment: Actual or Potential Problems Organize data from the assessment to develop a problem list A patient with recent abdominal surgery is at risk of developing respiratory problems. Nursing Diagnosis Develop the appropriate nursing diagnoses for the identified problems. There may be more than one diagnosis for an identified problem. At risk for ineffective airway clearance, RT impaired ability to cough from incision pain, AEB shortness of breath and shallow respirations. Planning: Goals and Outcomes Define what the expected outcomes for the patient will be. There may be more than one goal for each diagnosis. The patient will demonstrate the ability to deep breath and cough within six hours after surgery. Nursing Interventions Define the interventions that will be used to move the patient towards the expected outcomes. There will typically be more than one intervention for each outcome. Teach the patient to splint the abdominal wound during coughing exercises. Teach the patient how to use the incentive pirometer. Encourage the patient to use the incentive spirometer every two hours while awake. Encourage the patient to cough after each use of the incentive spirometer. 1.4 Implementation/Intervention When the patient’s plan of care has been developed, the implementation phase of the nursing process begins. During this phase the patient, nurse, and the rest of the healthcare team begin the execution of the plan of care. The execution of the plan involves: • Constant assessment and reassessment of the patient: As the plan is implemented, the nurse will use focused and ongoing assessments to determine whether or not the patient needs assistance and whether or not the patient is moving towards the goal and expectedoutcomes. • Implementation of the nursing interventions: When any intervention is done with the patient, the nurse must determine if there was a response and if the response was a positive or negative one. If the intervention elicits a negative response, the intervention will either be changed or deleted from the plan. • Delegation of interventions to other team members: The performance of some nursing interventions may be delegated to other members of the healthcare team. Delegation of tasks does not relieve the nurse of accountability for the care provided. When the nurse makes the decision to have another member of the team perform an intervention, it is critical that the nurse understand: o The specific interventions that each role can perform: Can the person legally do the task? If not, the task cannot be delegated to that person. o The capabilities of the team member: Has the person been trained to do the task? If not,

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