NURSING FUNDAMENTALS

office ambience

assessment

the first step in the nursing process in which the nurse gathers information from the client through interviews. physical exams, and observation. involves obtaining subjective (client’s reasons for visiting, usually physical s/s) and objective (nurse’s observations or measurements of a client’s condition). unexpected findings should be further assessed and reported accordingly.

analysis

the second step in the nursing process involving analyzing data collected during assessment using clinical judgement then collaborating with the client to develop a plan of care

planning

third step of the nursing process involving the nurse using problem-solving and decision-making skills to prioritize care, outcomes, and goals. involves collaboration and EBP.

implementation

the fourth step of the nursing process involving carrying out interventions that have been established using clinical judgements to monitor the clients progress towards their goals.

evaluation

the fifth and final step of the nursing process involving the ongoing evaluation of effectiveness and achievability of the goals as well as the need for adjustment of the interventions. updates to plan of care are made as needed.

code of ethics for nurses

outlines rules for nurses about client privacy, nursing conduct, and nursing behaviors to protect clients and the profession.

evidence based practice (EBP)

process of using evidence from credible resources to guide nursing interventions and judgement.

nurse practice act

state specific rules and regulations to guide nursing care delivery

novice

students and new nurses with no experience. cannot draw on their own judgement and struggle to decide which tasks are the most relevant.

advanced beginner

able to recognize patterns and recurrent situations though remembering and following rules can be hard. needs clinical support from staff.

competent

able to prioritize tasks by drawing on past experiences. may not be as fast as experienced nurses but still have mastery in multiple areas. recognize patterns faster.

proficient

able to understand bigger picture/desired outcomes of situations, improving decision making. also able to respond and adapt to changing situations.

expert

have extensive experience and knowledge to draw from. have a new level of self confidence and trust within their intuitive sense of a situation.

care provider

role to provide knowledgeable and compassionate care to promote health and address illness. nurse has a focus on all aspects of health and serves as an advocate for patients. nurse also practices professionalism and culturally competent care.

case manager

role to work with the client, the family, and the health care team to ensure a client receives all needed services. creates a plan of care that will meet the needs of the whole client along with coordinating the client’s educational needs in relation to care. essentially making sure a client has what they need in order to be fully prepared to be discharged from the care facility

researcher

role of the nurse to utilize research to provide evidence-based care. helps to assure clients are receiving the best care possible. develops nursing knowledge by conducting research and publishing the results.

educator

role to educate clients to increase their knowledge, empowering them to make informed decisions and manage their own self-care.

leader

role to use social influence to inspire and empower individuals. encourages effective communication, relationship building, and striving towards clear paths and goals.

manager

assigned leadership role, formally responsible for a team of nurses. manages staff and ensures quality of care delivered. also responsible for hiring, scheduling, and evaluating.

change agent

brings innovation for improvement through knowledge, critical thinking, objectivity, and practice. facilitates change (ex: new equipment or a new way of care). role filled by ALL nurses.

nursing competencies

knowledge, attitudes, values, and skills nurses are expected to know to provide safe care

advocacy

support, protect, and promote the rights, health, and safety of the client. speaking up for and defending those who are vulnerable or who cannot do so themselves

change management

help to bring about change with a goal to constantly improve the staff workflow and client outcomes, listen to needs of staff and address concerns.

communication

involves intentional listening, compassion, and demonstrating individual clients respect via culturally competent care. also encompasses documentation as well.

collaboration

respectful communication and sharing of ideas, policy, practices, and research with peers and interprofessional team members so as to provide quality professional care.