NEEDS APPROACH

1. OXYGEN (Respiratory & Cardiovascular)

 Patent airway Coughing exercise and deep breathing
 Position (semi/high fowlers) ABG’s (O2 saturation)
 V/S Sputum collection
 Adequate ventilation Encourage to avoid smoking& drinking
 Suction airways Administer humidified O2 as ordered
 Chest physiotherapy Pulse oximeter for O2 saturation
 Capillary refill Record and report abnormalities

2. NUTRITION (Gastrointestinal)
 Types of diet (high protein, CHO, Low fibre) Monitor pulse rate as K+ affects heart rate

 Likes and dislikes of foods Daily weights

 Dietician to determine food preparation NG feeds
 Mouth care before & after meals IV fluids for NPO clients
 Small frequent meals (prn) Charting of liquid diets
 NPO status (graduated fluids/IV) Record and report abnormalities
 Adequate hydration (2000 mls/days) Dentition
 Strict intake and output Environmental stimulation
 Ensure that diarrhea pt. gets plenty Assist client with meals prn
fluids and low fibre diet

3. REST, COMFORT & ACTIVITY (Muscular-Skeletal)

Rest
 Total bed rest (prn) Quiet environment (turn off light)
 Position (semi/fowlers) Total/assisted bed bath
 Group nursing activities

Comfort
 Back rub/administer analgesics Clean, smooth bed linen
 Assist with ambulation
 Diversional therapy (relaxation technique e.g. TV, radio, tapes, stories)

Activity
 Encourage bedridden clients should be encouraged to dangle feet, before sitting out of bed
 ROM exercise active/passive (promotes tissue circulation & oxygenation)
 Avoid applying pressure to painful joint

4. SAFETY (Neurology & Integumentary)

 Reality orientation
 Ensure things are within client reach
 Ask family members to sit with the client
 Administer wound care as ordered/aseptic technique
 Nurse dangerously ill client near nurses’ station
 Use of signs e.g. NPO, wet floors, dietary restrictions
 Hand washing before and after contact with patient
 Keep child away from other children with infection
 Administer meds as ordered and monitor effects
& side effects
V/S
Ensure bed rails are in place
Educate client on disease process
Check client frequently
Skin care plan
Monitor IV and hydration status
Turn client 2 hourly and pressure care
Obtain and evaluate lab results
5. SEXUALITY
 Explore fears and anxiety
 Explore interest, activity, attitude and knowledge regarding sexual function
 Assess stage of adaptation of the individual [and partner] to the loss (stages of grief)
 Encourage individual to discuss concerns
 Encourage questions and dispel myths
 Explain the need for the individual to share concerns with partner
 Discuss contraceptive methods and abstinence
 Refer to support group/therapist
 Teach physical and psychological benefits of regular physical activity

6. ELIMINATION (Genitourinary)
 Offer and remove bedpan
 Strict intake and output charting
 Record characteristics (amount, colour, odour)
 Perianal care – teach females and family clients to clean from front to back
 Hand washing after
 Catheter care
 Provide privacy

7. PSYCHOSOCIAL
 Allay fears & anxiety
 Allow client to verbalize feelings
 Establish rapport to gain trust
 Reassure client
 Empathise with client
 Encourage family visit, also from spiritual advisor and significant persons
 Recommend support group
 Use soft tone of voice

Love and Belonging

 Help client to realize their sense of worth
 Encourage visits by social worker
 Ensure privacy
 Help build client self esteem and confidence
 Tell client about alternative methods of doing things
 Encourage and support clients
 Show interest in client
 Provide information to client as necessary

Trust
 Answer questions honestly
 Teach husband/wife how to care
 Do not give false hope
 Exercise confidentiality – when in doubt refer client