Nurses are trained to learn and apply patient assessment skills. These skills are the cornerstone of being a proficient nurse. The knowledge and procedures for developing these skills are learned in the first two years of nursing school and honed in clinical as the pupil nurse takes on a greater patient load. The "Standards of Care" that are the basis of nursing consist of the following:
Standard 1. Assessment
Nursing
In an assessment the nurse must use all of his or her senses. These consist of hearing, touching, visual, and therapeutic communication. The cephalocaudal advent is most always used. In other words, assessing a patient from head to toe. The nurse must self aware to be able to conduct a suitable assessment. Data collection forms the basis for the next step in standards of care which is diagnosis. A nurse must have all the essential equipment, such as a scale, tape measure, thermometer, sphygmomanometer, a stethoscope and pen light. The setting is also very leading in doing an assessment. If a client is nervous or anxious they may not be as willing to riposte questions that the nurse asks or to be examined. Obtaining a quiet environment is not always possible, especially in an crisis situation. Therefore, the nurse must be very observant, and try to get as much pertinent data as potential to formulate an nursing determination For example, when doing an assessment on a client that is complaining of severe stomach pain, request them what foods they last ate would give the nurse more pertinent facts than request them how many brothers or sisters they have.
Standard Ii. Diagnosis
A nursing determination is not a healing diagnosis. A healing determination would be the healing condition of "Diabetes". Whereas, a nursing determination would be, "Altered Tissue Perfusion", related to decreased oxygenation of tissues as evidenced by a pulse oximetry of 92% , secondary to the healing condition of "Emphysema". A nursing determination is a formal statement that relates to how a client reacts to a real or perceived illness. In making a determination the nurse attempts to formulate steps to aid the client in alleviating and or mediating how they riposte to real or perceived illness.
Standard Iii. Outcome Identification
In this process the nurses uses the assessment and determination to set goals for the patient to perform to attain a greater level of wellness. Such goals may plainly be that the patient now comprehends the regime of testing their blood sugar, or possibly a new mum gleans a sense of security now that she has been instructed in the definite method of breast feeding. The nurse must plan the goals that the client is to perform around the clients ability. For instance, the goal that a client will walk normally after two days of having knee surgery is unrealistic, in the sense that the client's knee will not be wholly healed. However, the goal that the client will be able to demonstrate the definite use of crutches, would be more realistic. This goal is also measurable, since the patient will be in the hospital and the nurse can teach and study a return demonstration. Therefore, the goals or outcomes for the client must also be measurable.
Standard Iv. Planning
The planning suitable is designed around the clients activities while in the hospital environment. Therefore the nurse must plan to teach and demonstrate tasks when the patient is free to learn. This would involve administering pain medication prior to studying to walk with crutches or waiting until after a patient has complete a meal before teaching on how to use a syringe. The atmosphere should be conducive for the client to learn.
Standard V. Implementation
This suitable requires that the nurse put to the test the methods and steps designed to help the client perform their goals. In implementation, the nurse performs the actions essential for the client's plan. If teaching is one of the goals then the nurse would document the time, place, method and facts taught.
Standard Vi. Evaluation
Evaluation is the final standard. In this step the nurse makes the determination whether or not the goals originally set for the client have been met. If the nurse concludes that the goal or goals have not been met, then the plan has to be revised and documented as such. Goals therefore should be timely and measurable. If the client's goal was to use crutches successfully, and the client was able to perform a repeat demonstration for the nurse, then the goal was met.
The above standards are the cornerstone of the nursing profession. These standards take time and perceive to learn and to implement. perceive is the best teacher, and a nurse should continuously strive for excellence in their care of patients, and recognizing how to help patients perform a higher level of corporal and emotional wellness.
Learn more about nursing study at The Net Study Guide.
Nursing instruction - inpatient estimation Skills
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