Fundamentals of Nursing
Exam Prep Notes Week 1: The Nursing Process
1. Overview of the Nursing Process
The nursing process is defined as a systematic, step-by-step method for providing care to patients.
Steps Include:
Assess: Collect data regarding the patient’s health status.
Diagnose: Identify the patient’s primary health issue.
Plan: Develop a strategy with specific goals for patient care.
Implement: Execute the planned interventions.
Evaluate: Determine the effectiveness of the interventions and the progress towards the goals.
2. Goal Setting and Planning
Importance of Goal Setting:
Establishing clear goals is vital before creating any care plans.
Plans are only effective when there is a clear understanding of the desired outcomes for the patient.
Utilizing Nursing Diagnosis for Goals:
Nursing diagnoses often provide examples or insights into setting meaningful goals.
Example of Nursing Diagnosis:
For impaired gas exchange (symptoms include wheezing and shortness of breath), potential goals may include:
“Less wheezing.”
“Respiratory rate between 12-20 breaths per minute.”
3. SMART Goals
Characteristics of SMART Goals:
Specific: Objectives must focus on particular issues (e.g., addressing breathing issues rather than unrelated pain).
Measurable: Goals should incorporate quantifiable elements (e.g., “respiratory rate should be between 12-20” rather than vague terms like “normal”).
Attainable: Goals should be realistic and feasible (e.g., aims like curing asthma should be avoided).
Relevant: Goals must be pertinent to the specific diagnosis or problem at hand.
Time-Bound: Define a specific timeframe for when the goals should be achieved (e.g., “to be evaluated within 1-2 hours”).
4. Planning and Interventions
Action Planning to Achieve Goals:
Determine specific actions necessary to reach the established goals.
Types of Nursing Actions:
Independent Actions: Actions that nurses can perform autonomously, such as:
Sitting the patient up.
Educating the patient about health practices.
Dependent/Collaborative Actions: Actions that require orders or team involvement:
Administration of medications.
Providing oxygen (typically requires a doctor’s order).
Example: Sitting a patient upright is considered an independent action, while delivering medications or oxygen usually mandates a physician's directive.
5. Implementation
Act according to the planned interventions and actions.
On-going Assessment: Continuously assess the patient’s condition while implementing the plan.
Documentation: Maintain comprehensive records of all actions taken and the timing of these interventions.
Importance of Documentation: Protects nursing staff and ensures clarity in patient care records.
Delegation of Basic Tasks: Nurses may delegate rudimentary tasks, such as taking vital signs, to trained aides (Patient Care Assistants, Unlicensed Assistive Personnel) but remain accountable for all outcomes.
6. Delegation and Supervision
Delegation Guidelines:
Delegate only safe, straightforward tasks to trained aides and ensure they are comfortable executing them.
Ensure delegation occurs only with stable patients to minimize risks.
Tasks Never to Delegate:
Assessment.
Evaluation.
Teaching (only registered nurses should perform these tasks).
Supervision: Always verify understanding by having aides repeat back instructions to ensure clarity.
7. Evaluation
After implementing interventions, it is essential to evaluate whether the goals were met.
Key Questions:
Did the intervention work?
What evidence supports this assessment?
Goal Assessment:
Determine whether each goal was met, partially met, or not met, and adjust the care plan accordingly.
Example of Evaluation: If a patient's pain level decreases from 10 to 4 after administering morphine, this indicates successful evaluation of care.
8. Prioritization in Care
Maslow’s Hierarchy of Needs: Framework to prioritize patient needs:
Address basic physiological needs first (e.g., breathing, food, fluids, elimination, temperature control).
Then focus on safety needs to ensure patients do not experience harm.
Next, consider love and belonging, self-esteem, and ultimately self-actualization (mental well-being and confidence).
Respect for patients’ immediate needs and preferences, including any dietary or religious considerations is essential.
9. Communication and Documentation
Effective Communication:
Clear communication leads to enhanced patient care and experience. Maintain transparency with patients, families, and the healthcare team.
Importance of Documentation:
Document all aspects of patient assessments, interventions executed, and outcomes observed.
A critical principle: “If it’s not charted, it didn’t happen.”
Therapeutic Communication:
Employ professional communication that fosters trust, demonstrates empathy, and respects the privacy of patients.
10. Professionalism and Handling Aggression
Providing Dignity and Respect:
Treat every patient with dignity, respect, and professionalism.
Supporting Fellow Nurses:
Promote a cooperative environment and address issues of bullying or incivility in professional settings.
Responses to Aggression:
Ensure personal safety; seek assistance from security personnel when necessary.
11. Key Reminders for Exam Preparation
Familiarize yourself with actions defined as independent, dependent, or collaborative.
Understand the limitations of delegation: never assign tasks that require judgment, assessment, or teaching to aides.
Prioritize care using Maslow’s Hierarchy—prioritize physical needs before psychosocial needs.
Documentation of interventions and outcomes is vital and should always be performed.
Recognize that communication is equally important to clinical skills in nursing care.
12. Mnemonic Review
Nursing Process Steps (Mnemonic: ADPIE):
Assess: Collect and analyze patient data.
Diagnose: Identify the main issues affecting the patient’s health.
Plan: Establish goals and plan necessary interventions.
Implement: Carry out the planned interventions.
Evaluate: Assess the effectiveness of interventions and whether goals were met.
13. Setting Goals: SMART Acronym Breakdown
Specific: Establish a clear and concise goal targeting the problem.
Measurable: Incorporate numerical values to assess progress.
Attainable: Set realistic and achievable goals.
Relevant: Ensure alignment with the patient’s specific issues or diagnosis.
Time-Bound: Define a timeline for achieving the set goals.
14. Maslow’s Hierarchy of Needs (Mnemonic: P.S. Love Self-Actualization)
P: Physiological needs (e.g., air, food, water, warmth, rest).
S: Safety needs (e.g., personal security, health safety).
Love: Love and belonging (e.g., relationships, social connections).
Self-Esteem: Recognition and achievement.
Self-Actualization: Reaching individual potential and growth.
Key Reminder: Approach care attentively from lower levels of Maslow’s Hierarchy, starting with physiological needs before moving to higher-level psychological and social needs, as appropriate.
15. Types of Nursing Interventions
Independent Interventions: Actions that do not require a medical order (e.g., patient education, repositioning).
Dependent Interventions: Actions that necessitate a physician’s order (e.g., medication administration, oxygen provision).
Collaborative Interventions: Actions involving coordination with other healthcare team members (e.g., referrals to physical therapy).
16. Delegation Rules (Mnemonic: "DELEGATE SAFE")
When delegating, do not assign actions that involve:
Evaluate.
Assess.
Teach.
Stable tasks (e.g., checking vital signs) can be delegated to trained aides, but tasks requiring judgment, assessments, or teaching should always be performed by RNs.
17. Delegation Steps for Effectiveness
Approach for Delegation:
Right Task: Identify a suitable task for delegation.
Right Person: Ensure the delegated task is suitable for the person assigned.
Right Person (again!): Confirm the person has the proper skills and training.
Direction/Communication: Provide clear instructions and expectations for the task.
Circumstance: Make certain the situation and timing are appropriate for delegation.
18. Key Exam Reminder List
Maintain familiarity with the ADPIE nursing process steps in correct order.
Formulate SMART goals while planning care interventions.
Be mindful of Maslow’s Hierarchy for prioritizing patient needs.
Delegate safely and ensure not to delegate tasks that involve judgment or critical thinking ('EAT').
Document every assessment, action taken, and intervention performed.
Engage in clear and effective communication, both with patients and within the healthcare team.