Nursing Process and Health Promotion

Study Notes

Nursing Process

Assessment: Collect patient information through observation, interviews, and physical assessment.
Diagnosis: Analyze, validate, and cluster patient data to identify problems.
Planning: Prioritize nursing diagnoses and create realistic, measurable, and patient-focused goals with specific outcomes to evaluate progress.
Implementation: Initiate nursing interventions and treatments to help the patient achieve goals.
Evaluation: Assess patient responses to interventions, determine their effectiveness, and modify the plan of care as needed. For example, "Did the client meet the planned outcomes?" or "Should I modify the outcomes or interventions?".

Goal Setting

SMART Goals: Specific, Measurable, Achievable, Realistic, and Time-based.

Health Promotion

Process of empowering people to improve their health.
Facilitates client control and improvement of general well-being.

Disease Prevention

Primary prevention: Interventions before negative health effects occur (e.g., education, changing risky behaviors, immunizations).
Secondary prevention: Early detection and treatment of preclinical changes to minimize disease impact (e.g., screenings, blood pressure checks, mammograms).
Tertiary prevention: Aims to reverse, minimize, or delay the effects of disease or disability (e.g., rehabilitation, physical therapy, support groups).

Physical Assessment

Subjective Data: What the patient tells you (e.g., "I have a headache").
Objective Data: What the nurse observes (e.g., a blood pressure reading of 120/80).

Delegation

Nurses can assign tasks to nursing assistants (NAs).
Nurses cannot delegate E.A.T to NAs:
- E: Evaluate
- A: Assess
- T: Teach

Client-Centered Care

Provide compassionate, culturally sensitive care that addresses the client's physical, psychological, sociological, spiritual, and cultural needs, preferences, and values.
The client is actively involved in the decision-making process.

Infection Control

Infection Cycle:
- Incubation: Infection enters the host and begins multiplying.
- Prodromal: Client starts experiencing symptoms.
- Acute Illness: Manifestations of the infectious disease become clear and possibly severe.
- Decline: Symptoms begin to decrease as the infection wanes.
- Convalescence: Client returns to normal or a “new normal” state of health.

Isolation Protocols

Include hand hygiene and barrier precautions.
Apply to ALL patients, regardless of diagnosis.
Change Personal Protective Equipment (PPE) after contact with each patient and between procedures on the same patient if exposed to large amounts of blood and bodily fluids.
Clients in isolation are at higher risk for depression and loneliness. Provide support and education to the client and family.

Transmission of Infectious Agents

Airborne: Small particles from the respiratory tract spread through the air (PPE: N95 mask, gloves, gown, negative pressure room, private room).
Droplet: Droplets from the respiratory tract travel through the air (PPE: clean hands and surgical mask).
Contact: Microorganisms move from an infected person to another person (direct or indirect) (PPE: gloves and gown).

Personal Protective Equipment (PPE)

Donning Order: Gown, mask or respirator, goggles or face shield, gloves.
Doffing Order: Gloves, goggles or face shield, gown, mask or respirator, wash hands.

Disease Specific Protocols

Follow specific protocols for different infectious diseases.

Chain of Infection

Infectious Agent or Pathogen: Contaminated objects (microorganisms: bacteria, fungi, viruses).
Reservoir: Site of microorganism growth (e.g., humans, animals, insects, food, water).
Portal of Exit from the Reservoir: Respiratory tract, urine, feces, emesis, skin, blood.
Mode of Transmission: How the infection is spread (e.g., airborne, droplet, contact).
Portal of Entry to the Host: Skin, mucosa, urinary tract.

Description

Explore the key components of the nursing process, including assessment, diagnosis, planning, implementation, and evaluation. This quiz also covers goal setting through SMART criteria and the importance of health promotion and disease prevention strategies.