Subjective: complaints, history, medications, etc currently
Objective: vital signs, fluid intake and output, heigh/weight
Diagnosis
RN's clinical judgment about actual or potential health problems to assist in prioritizing
and planning care
Problem, related to, as evidenced by
Planning
goals and outcomes established and individualized to unique needs
Implementation
carrying out interventions identified such as cardiac monitor or oxygen, medication and
usual policy
anaylse implementation to decide whether desired outcomes have been met;
intervention may need to be reviewed constantly
Basic human needs
oxygen, nutrition, temperature
Oxygen
The client may require supplemental oxygen, this is flammable.
Nutrition
Food left at room temperature or not prepared appropriately leads to nosocomial
infections and foodborne illness
Temperature
Extended exposure to cold causes frostbite and accidental hypothermia. Extended
exposure to heat changes levels of electrolyte causing heatstroke or heat exhaustion
Motor Vehicle Accidents
- Risk is higher among 16-19 year old drivers than any other age group.
, - Risk associated with older drivers are decline in vision, cognitive functioning, and
physical changes
Poison
Any substance that impairs health or results in death when ingested, inhaled, injected,
or absorbed into the body.
Sources of poison in a persons home
medicines, solid or liquids cleaning substance, gases, and vapors
Falls
An event that results in a person coming to rest inadvertently on the ground or floor, a
leading cause of accidental injury deaths worldwide.
Disasters
Natural disasters such as floods, tsunamis, hurricanes, tornadoes and wildfires are a
major cause of death and injury.
Six critical factors of Disaster-preparedness
communication, resources-supplies and assests, safety and security, staff
responsibilies, utilities management, patient clinical and support activities
Transmission of Pathogens
Pathogens and parasites at all times threaten a person's safety; the use of appropriate
hand hygiene can prevent many of these
Vaccinations
Decreases and in some instances prevents the spread of infectious diseases from one
person to another.
personal factors
- organizational culture
- lifestyle
- immobility
sensory, perceptual, or communicative impairment
economic status
knowledge/awareness of safety
Organizational culture
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