Nursing Fundamentals Study Notes

Writing in Nursing

  • Preferred format: APA (despite not writing in this format)

  • Nurses coordinate patient care activities.

Care Coordination

  • Promotes cooperation and information sharing among healthcare providers and the patient care team.

  • Requires teamwork, communication, and patient involvement.

  • Key Components:

    • Information literacy

    • Evidence-based practice

    • Patient-centered care

  • 4 Steps of Care Coordination: Establish responsibility, communicate, assist with transitions of care, assess needs and goals.

Chain of Command

  • Authority structure in healthcare settings.

  • Ensures efficient communication and problem resolution.

  • Levels: Nursing Assistants, Staff Nurses, Charge Nurse, Nursing Supervisor, Assistant DON, Director of Nursing, Administrator.

Prioritization of Care

  • Determine which patients need immediate care.

  • Consider life-threatening situations and patient safety.

  • Ask: Is this life-threatening?

Delegation in Nursing

  • Assigning responsibilities to qualified individuals.

  • Five Rights of Delegation: Right task, person, circumstance, communication, supervision.

  • Tasks to avoid delegating: sensitive tasks, high-risk decisions, tasks needing personal expertise, tasks with legal restrictions.

RN vs. LPN Responsibilities

  • RN: Initial assessments, care plans, care for unstable patients, intravenous meds, delegates.

  • LPN: Reinforces teaching, stable patient care, other supportive tasks.

  • Emphasizes clinical judgment and decision making.

Nursing Process (ADPIE)

  1. Assessment: Data collection (objective/subjective).

  2. Diagnosis: Identify health problems and nursing diagnoses.

  3. Planning: Prioritize diagnoses, set SMART goals, and determine interventions.

  4. Implementation: Perform nursing actions aligned with the care plan.

  5. Evaluation: Assess progress and modify as needed.

Vital Signs Assessment

  • Normal ranges for temperature, pulse, respiration, and blood pressure specified.

  • Early warning signs detected through vital signs monitoring.

Documentation

  • Essential for communication and legal records in healthcare.

  • Key principles: clear, concise, correct, complete (4 C’s).

  • Importance of factual records for patient care and reimbursement.

Communication in Nursing

  • Involves verbal, written, and nonverbal methods.

  • Critical thinking helps overcome biases.

  • Adjust communication methods to patient needs, especially for sensory impairments.

Health Promotion and Disease Prevention

  • Focus on individual and community health management.

  • Levels of prevention: primary, secondary, tertiary.

Immunization Guidelines

  • Specific schedules and recommendations for various vaccinations based on age and health status.

  • Requires informed consent and allergy checks before administration.