Ongoing assessment of vital signs are completed as indicated for your patient. It is mandatory to review the ViCTOR graph at least every 2 hours or as patient condition dictates to observe trending of vital signs and to support your clinical decision making process. Less than 6 months use digital thermometer per axilla. Assess any respiratory distress.
Whether that behaviour makes any sense in that context? Whether the behaviour was adaptive or dysfunctional? Whether a change is needed? If the nurse has to interview the patient she should select a private place, free from noise and distraction and interview should be goal directed.
This is particularly important when the patient is unable to provide reliable information because the symptoms of the psychiatric illness. She should gather Information from other information sources, including health care records, nursing rounds, change- of shifts, nursing care plans and evaluation of other health care professionals.
Nursing Diagnosis After collecting all data, the nurse compares the information and then analyses the data and derives a nursing diagnosis.
A nursing diagnosis may be an actual or potential health problem, depending on the situation. A nursing diagnostic statement consists of three parts: Health problem Contributing factors Defining characteristics The defining characteristics are helpful because they reflect the behaviour that are the target of nursing intervention.
If a patient is making statements about dying, he is isolative, anorexic, cannot sleep and wants to die.
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Then the nursing diagnosis can be- Helplessness, related to physical complaints, as evidenced by decreased appetite and verbal cues indicating despondency. Outcome Identification The psychiatric mental health nurse identifies expected outcomes individualised to the patient.
Outcomes should be mutually identified with the patient, and should be identified as clearly as clearly and determine the effectiveness and efficiency of their interventions.
Before defining expected outcomes, the nurse must realize that patient often seek treatment with goals of their own. These goals may be expressed as relieving symptoms or improving functional ability.
Clarifying goals is an essential step in the therapeutic process. Therefore the patient nurse relationship should be based upon mutually agreed goals.
Once the goals are a greed on they must be stated in writing. Goals should be written in behavioural terms, and should be realistically described what the nurse wishes to accomplish within a specific time span. Example of short term goals: At the end of the two weeks patients will stay out of bed and participate in activities At the end of the one week patient will sleep well at night.
At the end of the one week patient will eat properly and maintain weight. The planning consists of:Introduction.
The nursing process is an interactive, problem-solving process. It is systematic and individualized way to achieve outcome of nursing care.
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