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 student nurse takes on a greater patient load. The
“Standards of Care" that are the basis of nursing include the following:
Standard 1. Assessment
In
an assessment the nurse must use all of his or her senses. These
include hearing, touching, visual, and therapeutic communication. The
cephalocaudal approach 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 thorough assessment. Data collection forms the basis for the
next step in standards of care which is diagnosis. A nurse must have
all the necessary equipment, such as a scale, tape measure,
thermometer, sphygmomanometer, a stethoscope and pen light. The setting
is also very important in doing an assessment. If a client is nervous
or anxious they may not be as willing to answer questions that the
nurse asks or to be examined. Obtaining a quiet environment is not
always possible, especially in an emergency situation. Therefore, the
nurse must be very observant, and try to get as much pertinent data as
possible to formulate an nursing diagnosis For example, when doing an
assessment on a client that is complaining of severe stomach pain,
asking them what foods they last ate would give the nurse more
pertinent information than asking them how many brothers or sisters
they have.
Standard II. Diagnosis
A nursing diagnosis is
not a medical diagnosis. A medical diagnosis would be the medical
condition of “Diabetes". Whereas, a nursing diagnosis would be,
“Altered Tissue Perfusion", related to decreased oxygenation of tissues
as evidenced by a pulse oximetry of 92% , secondary to the medical
condition of “Emphysema". A nursing diagnosis is a formal statement
that relates to how a client reacts to a real or perceived illness. In
making a diagnosis the nurse attempts to formulate steps to assist the
client in alleviating and or mediating how they respond to real or
perceived illness.
Standard III. Outcome Identification
In
this process the nurses uses the assessment and diagnosis to set goals
for the patient to achieve to attain a greater level of wellness. Such
goals may simply be that the patient now comprehends the regime of
testing their blood sugar, or perhaps a new mother gleans a sense of
security now that she has been instructed in the correct method of
breast feeding. The nurse must plan the goals that the client is to
achieve 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 completely
healed. However, the goal that the client will be able to demonstrate
the correct 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 observe a return demonstration. Therefore, the goals or
outcomes for the client must also be measurable.
Standard IV. Planning
The
planning standard 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 learning to walk with crutches
or waiting until after a patient has finished a meal before teaching on
how to use a syringe. The atmosphere should be conducive for the client
to learn.
Standard V. Implementation
This standard requires
that the nurse put to the test the methods and steps designed to help
the client achieve their goals. In implementation, the nurse performs
the actions necessary for the client’s plan. If teaching is one of the
goals then the nurse would document the time, place, method and
information 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 experience to learn and to implement.
Experience is the best teacher, and a nurse should continuously strive
for excellence in their care of patients, and recognizing how to help
patients achieve a higher level of physical and emotional wellness.
Learn more about nursing education at The NET Study Guide.
The
nursing entrance test study guide provides nurses the assistance they
need with the nursing entrance test. The nursing study guide helps
nurses. Visit http://www.thenetstudyguide.com for more information.
