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.
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.
