Personal zone
18in-4ft
Intimate zone
0-18inches
Social zone
4-12ft
Public zone
12 ft or greater
Consent zone
Mouth wrists feet
Vulnerable zone
Face neck front of body
Intimate zone sensitivity
Genitalia
Rectum
Nursing process
Assessment Nursing diagnosis Planning Implementation Evaluation
Physical assessment
IAPP Inspection Auscultation Palpation Percussion
Inspection
look Listen Touch Smell Taste
Nursing intervention
Tells how often
Tells how much
Includes assessment
Individualized
Planning
Write goals and actions
Goals
Pt will experience__________ AEB
1.
2.
3.
Need to be realistic
Individualized
Futuristic
Short term goals
Few hours or days describe specific behavior that can be validated
Validated
Subjective and objective
AEB
As evidenced by
Long term goal
Weeks or months
Broad statement
Aimed at resolution and or prevention
GOALS
Specific Measurable Appropriate Realistic Timely
Data
Gather Cluster Validate Prioritize Needs