Nursing Practice Assessment Chapters 7-10

Care provider

Perform holistic assessments (physical, psychosocial, cultural, spiritual)

Develop individualized nursing care plans

Implement direct care safely and competently

Evaluate outcomes and revise care plans

Care coordinator

Delegate tasks appropriately to LPNs and APs

Prioritize client needs using clinical judgement

Communicate with interdisciplinary team members

Organize workload to ensure safe, efficient workflow

Client advocate

Protect patient rights and wishes

Facilitate access to resources or referrals (social work, PT, home health)

Support informed consent and shared decision-making

Educator 

Teach clients about conditions, medications, lifestyle changes, and discharge plans 

Use teach-back to confirm understanding

Leader and manager

Supervise care delivered by team members

Identify and address safety concerns

Support new staff and promote quality care

Low staffing levels & high workload

Risk of missed care

Delegation challenges

Must ensure scope of practice and competency before delegating care 

Time management

Crucial in order to complete priorities

Communication barriers

Shift report

Interdisciplinary communication

Client acute changes

Require rapid reprioritization 

Ethical dilemmas

End-of-life

Autonomy

Confidentiality

Safety concerns

Fall risks

Medication errors

Infection control

Resource limitations

Equipment 

Support staff 

Maslow’s hierarchy of needs: Physiological

Airway, breathing, circulation, vitals, fluids, elimination, pain

Maslow’s hierarchy of needs: Safety

Falls, infection, mental health safety

Maslow’s hierarchy of needs: Love/belonging

Support, emotional needs

Maslow’s hierarchy of needs: Esteem

Body image, confidence

Maslow’s hierarchy of needs: Self-actualization

Growth, autonomy

ABCDE Method

A- Airway (obstruction, choking, respiratory distress) 

B- Breathing (oxygenation, rate/effort, pulse ox) 

C- Circulation (perfusion, shock, CO, bleeding) 

D- Disability 

E- Exposure

Nursing process

Assess, diagnose, plan, implement, evaluate

Acute vs chronic

Acute problems > chronic

Sudden deterioration > stable condition

Unexpected vs expected 

New changes require faster intervention

Organizing care among a group of clients: Things to use first

Priority-setting frameworks

Time management

Delegation

Organizing care among a group of clients: Perform highest priority tasks first

Assess unstable or high-acuity patients

Administer time-sensitive medication (insulin, antibiotics)

Perform safety-focused interventions early (fall-risk precautions)

Delegate stable tasks to LPN/AP appropriately

Cluster care to reduce unnecessary client interruptions

IDEAL discharge planning framework

I- Include client and family. Engage them in every step of planning 

D- Discuss key areas (meds, follow-up, warning signs). Review medications. Describe what life at home will be like. Highlight warning signs and problems. Explain test results. Make follow up appointments. 

E- Educating in plain language. Repeat important points. Use teach-back 

A- Assess understanding. Ask client to repeat instructions 

L- Listen to concerns and preferences. Adjust plan based on client-specific needs 

ISBAR purpose

Used for handoff, calling a provider or transferring care

ISBAR

I- Introduction (name, role)

S- Situation (why are you calling)

B- Background (relevant history, data)

A- Assessment (what you think is happening)

R- Recommendation (what you need)

SOAP purpose

For documentation 

SOAP

S- Subjective (what the client is reporting)

O- Objective (vitals, labs, physical findings)

A- Assessment (nursing interpretation, priority problem)

P- Plan (interventions, medications, monitoring)

QI

Continuous process aimed at improving safety, outcomes, and efficiency

Focuses on systems, not individuals

Uses data to identify gaps and test individuals

QI Core Concepts

Performance measures (falls, CAUTI rate, medication errors) 

Benchmarking (comparing to best practice) 

Root cause analysis (RCA) after adverse event

Evidence-based practice 

QA

Reactive, problem-driven measures to improve client outcomes and improve healthcare delivery

Actions to promote quality improvement

Identify recurring problems (high fall rates)

Participate in audits and QI committees

Report incidents

Follow standardized protocols
Engage in continuing education

Communicate safety concerns immediately

Participate in PDSA (plan, do , study, act)

Plan-Do-Study-Act Model: Plan 

Identify need for change

Develop strategic plan to initiate the change 

Plan-Do-Study-Act Model: Do

Take steps to initiate the change

Plan-Do-Study-Act Model: Study

Review the results

Summarize the findings

Plan-Do-Study-Act Model: Act

Accept the change 

Adapt the change 

Abandon the change 

Make revisions and repeat the cycle 

Purpose of incident reports

Document unusual events (falls, medication errors, equipment failure)

Used for QI, not punishment

Not part of the medical record

Should include objective, factual information only

Purposes of the health record

Communication among providers

Legal documentation

Biling and reimbursement

Research, education, auditing

Components of the Health Record

Admission data

Provider orders

Nursing assessments 

Medication administration record (MAR) 

Nursing notes 

Lab/diagnostic results 

Interdisciplinary notes 

Discharge instructions 

Type of documentation in the health record

Narrative notes

SOAP/ADPIE

Flow sheets (vitals, I&O)

MAR

Care plans

HER

Incident reports

Guidelines for accurate documentation

Document promptly, accurately, and factually

Use objective language (what you see, hear, feel, smell)

Avoid judgmental terms (lazy, noncompliant)

Use proper spelling, grammar, and approved abbreviations

Never chart ahead

Correct errors with one line through, “error,” and initials

Things to include: Time and date, signature and credentials, interventions and responses

Legal considerations in health record documentation

Medical record in a legal document 

Must meet facility and regulatory requirements 

Incomplete or inaccurate documentation increases liability 

If it’s not documented, it’s considered not done 

Only chart for yourself, not others 

Protect access (avoid sharing passwords) 

HIPPA protects all identifiable patient information, including:

Name, age, DOB

MRN

Diagnoses, treatments

Photos

Room number

Anything that can identify a patient

Measures to protect confidential patient information

Log out of EHD each time

Access only records necessary for you job

Avoid discussing patients in public spaces

Store papers with PHI securely

Dispose of PHI in shredding bins

Verify caller identity before giving information

What to use instead of the abbreviation U?

Unit

Mistaken for 0 or 4 

What to use instead of the abbreviation IU?

International unit

Mistaken for IV

What to use instead of the abbreviation QD/QOD?

Daily/every other day

Mistake for each other

What to use instead of the abbreviation Trailing zeros (0.5)? 

Write 5 

What to use instead of the abbreviation no leading zeros .5 mg?

Write 0.5 mg

What to use instead of the abbreviation MS, MSO4?

Write morphine sulfate

Can mean multiple things

What to use instead of the abbreviation MgSO4? 

Write magnesium sulfate

Client-centered focus

Care decisions are based on client’s preferences, culture, goals, and values

Client/family are active partners in planning, implementing, and evaluating care

Shared goals

All members agree on a common goal

Goals are measurable and updated as client needs change

Mutual respect and role clarity 

Each team member understands their own scope and responsibilities 

Appreciation for different knowledge and contributions 

Prevents role conflict and improve efficiency 

Professional interdependence

Team members rely on one another’s expertise

Promotes safe transitions, reduce duplication, and prevents gaps in care

Effective communication

Timely, accurate, and respectful exchanges

Use standardized tools (ISBAR)

Coordination of care

Joint planning and shared decision-making

Include referrals, handoffs, discharge planning, consults, case management

Trust and psychological safety 

Team members must feel safe to speak up about concerns 

Supports quality improvement and reduces errors 

ISBAR communication

Use for handoff, reporting changes, contacting provider

Team STEPPS tools 

Call-outs (verbalize critical information quickly) 

Check-backs (confirm understanding) 

Huddles/debriefs (short meetings used to plan or evaluate care) 

Documentations and electronic communication

Accurate, timely charting promotes continuity and reduces errors

EHR alerts, messaging, rounds documentation, care plans

Face-to-face or verbal reports

Bedside shift report (maintains safety and client involvement)

Change of shift updates

Consult discussions

Strategies to promote collaboration within the health care team 

Maintain open, respectful communication: Encourage questions, and clarification, address conflict early and professionally, use assertive (not aggressive) communication) 

Promote role clarity (ensure everyone understands their scope) 

Engage in shared decision-making 

Use team huddles and debriefs 

Foster a culture of psychological safety 

Manage conflict constructively 

Nurse’s role in communicating with other health care professionals by reporting

The nurse is the central communicatory between everyone

Responsibilities during reporting: Prepare by reviewing the chart beforehand. Prioritize critical information. Clarify by asking questions about unclear instructions. Advocate (speak up if the plan seems unsafe or unrealistic). Support continuity (ensure the next nurse or team member is fully informed)

Technology in nursing education

Stimulation and virtual learning: Mannequins to support realistic clinical scenarios. Allow safe environment to learn without risking patient harm

Computer based learning: Online modules (ATI). Electronic quizzes and adaptive learning

Mobile technology: Clinical apps (anatomy apps, drug guides). QR codes for accessing procedures and policy manuals

Technology in nursing practice 

EHR- Digital documentation for assessments, orders, interventions, results 

Bar-code medication administration 

Smart IV pumps 

Telehealth 

Automated dispensing systems (Pyxis) 

Use of technology in providing and documenting client information

EHR

Documentation tools: Flow sheets (assessments, vitals, I&O). Voice recognition documenting

Patient portals (clients can view labs, request refills, schedule appointments)

Secure messaging systems (use for communication between team members)

How health literacy and information management affect client outcomes

Promote safer, more effective, and more equitable care

Low health literacy leads to:

Poor medication adherence

Higher readmission and ED visits

Misunderstanding discharge instructions

Difficulty managing chronic conditions

Increased preventable complications

Ways to improve outcomes through health literacy 

Use plain langugage

Teach-back method 

Visual aids

Cultural competence

Assistive devices 

Effects of poor information management

Missing/inaccurate charting

Lack of documentation during transfers

Missed abnormal results

Inconsistent communication

HIPPA violations

Safe information management strategies

Chart in real time

Verify client identifiers during documentation

Maintain HIPPA

Report abnormal findings immediately

Conventional medicine

Based on biomedical, evidence-based scientific approaches 

Focuses on diagnosing and treating illness using medications, surgery, radiation, technology 

Goal is to cure disease, manage symptoms and restore function

Complementary therapy

Used together with conventional medication

Enhances traditional care and alleviates symptoms

Examples: Acupuncture+chemo for nausea, massage therapy after surgery

Alternative therapy

Used instead of conventional medicine

Replaces traditional treatments

Typically not recommended unless part of a guided treatment plan due to safety concerns

Examples: Herbal therapy instead of antidepressants, special diets instead of chemotherapy

Integrative therapy 

Combination of conventional care and complementary therapies 

Patient-centered and holistic 

Emphazies mind-body wellness, lifestyle, prevention, healing environment 

Examples=Guided imagery+opioids for pain control, anti-inflammatory diet+ medications for arthritis 

Mind-body therapy: Meditation

Reduces stress and BP, promotes emotional regulation

Mind-body therapy: Yoga

Helps with chronic pain, increases relaxation

Mind-body therapy: Guided imagery 

Decreases pain and anxiety 

Mind-body therapy: Deep breathing exercises

Lowers HR and BP

Physical and body-based therapy: Massage

Reduces muscle tensions, improves circulation

Physical and body-based therapy: Acupuncture 

Treats chronic pain, nausea, headaches 

Physical and body-based therapy: Chriopractor

Helps musculoskeletal pain and flexibility

Other nonpharmacologic therapies

Energy therapy-restore energy balance

Relaxation techniques-Music therapy, aromatherapy

Traditional Chinese Medicine (TCM)

Acupuncture, herbal formulations, cupping 

Ayurvedic medicine

India

Diets, herbs, yoga, massage, detoxification

Homeopathy

Uses highly diluted natural substances

For allergies, anxiety, chronic conditions

Naturopathy 

Natural remedies 

Focuses on whole-person  wellness 

Native/indigenous medicine

Herbal medicines, ceremonies, spiritual healing

Focuses on balance between body, mind, spirit, and community

Cranberry

Uses= Preventing recurrent UTIs, promotes urinary health

Physiological response- Inhibits bacteria from adhering to urinary tract walls

Psychological response- Clients may feel more in control of managing recurrent infections

Echinacea

Uses=Shortens duration of cold-flu symptoms, mild immune support

Physiological response-Stimulates immune system function, anti-inflammatory and anti-viral properties

Psychological response-increases sense of wellness and control over illness

Garlic

Uses=Heart health, BP reduction, infection protection

Physiological responses-Lowers cholesterol, anti platelet effects, mild hypertensive effects, antimicrobial

Psychological response-Supports natural approaches to heart health

Ginger

Uses=Pregnancy-related nausea, motion sickness, osteoarthritis pain 

Physiological response-Anti-inflammatory, reduces nausea, improves GI mobility 

Psychological response-natural relief can reduce anxiety related to nausea or pain 

Melatonin

Uses=Insomina, jet lag, shift-work sleep disorder

Physiological response-Regulates sleep-wake cycles, antioxidant effect

Psychological response-Improve sleep with leads to better mood and reduced stress

Peppermint oil

Uses=IBS symptoms, headache relief, nausea reduction

Physiological response-Relaxation of GI smooth muscles, analgesic cooling effect

Psychological response-Aromatherapy benefit, calming, improves focus

St. John’s wort

Uses=Mild to moderate depression, anxiety, and mood support 

Physiological response-Increases serotonin levels 

Psychological response-Improves mood, decreased anxiety