Nursing Fundamentals Review

The Nursing Process

• Importance
    - Crucial for guiding thinking during nursing school.
    - Aids in test-taking scenarios and clinical situations.
    - Must be familiar with the steps to be effective.

• Steps of the Nursing Process (ADPIE)
    - Assessment
      - Data gathering stage.
      - Involves observing patients, analyzing lab results, checking vital signs, and overall behavior.
    - Diagnosis
      - Focus on nursing diagnosis, not medical diagnosis.
      - Identifies the primary problems that nurses need to address.
      - Recommendation to acquire a nursing diagnosis handbook for formulating diagnoses.
    - Planning
      - Setting patient-centered SMART goals.
      - SMART Goals Defined
        - Specific: Clearly defined goals.
        - Measurable: Able to track progress quantitatively.
        - Attainable: Realistic for the patient.
        - Realistic: Achievable within the resources available.
        - Timely: Defined timeframe for goal achievement.
      - Shift focus on goals from the nurse to the patient (e.g., "The patient will…").
      - Review of examples of poorly written vs. SMART goals recommended.
    - Implementation
      - Also called the intervention stage; the action phase.
      - Steps taken include administering medications, providing oxygen, performing wound care, etc.
      - Emphasizes that this comes after completing the prior steps sequentially.
    - Evaluation
      - Evaluates the success of the interventions.
      - Questions to consider: Did pain improve? Are oxygen levels stable?
      - If outcomes are negative, return to assessment to reevaluate the situation.

Interdisciplinary Team Members

• Overview
    - Various professionals work together for holistic patient care.

• Key Roles
    - Provider
      - Examines, diagnoses, and treats patients.
      - Can be a physician (MD, DO), physician's assistant (PA), or nurse practitioner (NP).
      - Important to understand distinctions for nursing exams.
    - Occupational Therapy (OT)
      - Helps patients with activities of daily living (ADLs).
      - Example: Assistance with feeding themselves.
    - Physical Therapy (PT)
      - Focuses on muscle strengthening and improving mobility.
      - Works on range of motion and physical rehabilitation.
    - Speech-Language Pathologist (SLP)
      - Assists with speech disorders and swallowing difficulties (dysphagia).
      - Conducts swallow studies and therapies for enhancing swallowing abilities.

SBAR Communication

• Definition of SBAR
    - A standardized communication method to ensure information clarity among healthcare professionals.
    - Components include:
      - Situation
        - Describe the patient situation concisely.
        - Example: "The patient is here for this diagnosis."
      - Background
        - Provide relevant patient history and context.
        - Example: Historical factors leading to hospital admission.
      - Assessment
        - Share observations and clinical assessments (e.g., vital signs, ABGs).
        - Example: Patient experiencing difficulty breathing, oxygen saturation in the high 80s.
      - Recommendation
        - Offer recommendations or seek guidance.
        - Example: Request an order for administering oxygen via non-rebreather mask or inquire for alternative suggestions.

Continuity of Care

• Concept of Continuity of Care
    - Essential for delivering effective care during admission, transfers, and discharge.

• Key Actions at Admission
    - Confirm patient's advanced directive status (e.g., full code vs. DNR).
    - Assess allergies.
    - Determine fall risk.
    - Conduct a swallow examination pre-scheduling any diet intake.
    - Perform a comprehensive head-to-toe assessment.
    - Discharge Planning
      - Begins immediately upon admission, aiming for the patient's return home.

• Transfer Processes
    - Provide a report using SBAR to the accepting nurse.

• Discharge Education
    - Key information to communicate includes:
      - Diet and activity restrictions.
      - Changes to medications and instructions on their usage.
      - Scheduling and details of follow-up appointments.
      - Contact information for the healthcare provider, particularly if it was a new provider during hospitalization.

• Medication Reconciliation
    - Critical to review and compare patient medication lists:
      - Identify medications to stop, continue, or initiate.
      - This process is essential at admission, during transfers, and at discharge to ensure patient safety.

Summary

• Overview covers the nursing process, interdisciplinary team members, SBAR communication, and ensuring continuity of care.

• Emphasizes importance for nursing practice and patient-centered care.

• Encouraged to provide feedback and personal experiences in the comments for better engagement in nursing education.