Adult In-Patient Services (Nursing Unit) - Part 3

Prof (Col) Dr R N Basu

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• Standards of practice

• The standard of practice describe:

• A competent level of nursing care and demonstrated by critical thinking model known as the nursing process

• Nursing process includes:

• Assessment

• Diagnosis

• Outcome identification

• Planning

• Implementation, and

• Evaluation

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• Standard 1 : Assessment

• The registered nurse collects patient data and information relative to the healthcare consumer’s health or the situation`

• Standard 2 : Diagnosis

• The registered nurse analyses the assessment data to determine actual or potential diagnosis, problems, or issues

• Standard 3 : Outcome Identification

• The registered nurse identifies expected outcomes for a plan individualised to the healthcare consumer or the situation

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• Standard 4 : Planning

• This standard is explained is more detail

• The registered nurse develops a plan that prescribes strategies to attanexpected, measurable outcome

• Competencies:

• Develops an individualised, holistic, evidence-based plan in partnership with the healthcare consumer and interprofessional team

• Establishes the plan priorities with the healthcare consumer and interprofessional team

• Advocates for responsible and appropriate use of interventions to minimise unwarranted or unwanted treatment and/or healthcare consumer suffering

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• Prioritises elements of the plan based on the assessment of the healthcare consumer’s level of risk and safety needs

• Includes evidence-based strategies in the plan to address each of the identified diagnoses, problems, or issues.

• These strategies may include but are not limited to:

• Promotion and restoration of health

• Prevention of illness, injury, and disease

• Facilitation of healing

• Alleviation of suffering, and

• Supportive care

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• Incorporates an implementation of pathway that describes steps and milestones

• Identifies cost and economic implications of the plan

• Develops a plan that reflects compliance with current statutes, rules and regulations, and standards

• Modifies the plan according to the ongoing assessment of the healthcare consumer’s response and other outcome indicators

• Documents the plan using standardized language or terminology

• A format for nursing care plan is given in the next slide

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• Patient: Mr Susanta Basu.Care Plan by: Sr Thomas, RN

• Date: 20 July 2021

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INTERVENTION1. Provide a quiet

environment and limit visitors during acute phase as indicated

2. Pace activity for patients with reduced activity

3. Assist patient to assume comfortable position for rest and sleep

NURSING DIAGNOSISActivity intolerance RT exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing and dryness

OUTCOMES & EVALUATION- No reports of dyspnoea

_ Vital signs within normal range

• Similarly a 4-column or 5-column format can be used

• A 4-column format may include four steps of assessment and 5-column format shall include 5 steps

• These steps may be:

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4-Step Nursing Process 5-step Nursing process

1. Nursing Diagnosis2. Goals and Outcomes3. Interventions4. Evaluation

1. Assessment2. Diagnosis3. Outcomes4. Interventions5. Evaluation

• Standard 5: Implementation

• The registered nurse implements the identified plan

• Competencies

• Partners with the healthcare consumers to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner

• Integrates interprofessional team partners in implementation of the plan through collaboration and communication across the continuum of care

• Demonstrates caring behaviours to develop therapeutic relationship

• Provides culturally congruent, holistic care that focuses on the healthcare consumer and addresses and advocates for the needs of diverse population across the life span

• Uses evidence-based interventions and strategies to achieve the mutually identified goals and outcomes specific to the problem or needs

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• Integrates critical thinking and technology solutions to implement the nursing process to collect, measure, record, retrieve, trend, and analyse data and information to enhance nursing practice and healthcare consumer outcomes

• Delegates but retains the accountability for care, safety, quality and observing legal framework

• Documents implementation and any modifications including changes or omissions of the identified plan

• Standard 6 : Evaluation

• The registered nurse evaluates progress toward attainment of goals and outcomes

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• The six standards of practice of nurses are the core standard needed for delivery of nursing care

• In addition to these six standards the ANA has also enunciated other standards

• These additional standards are required for their role performance

• These standards include:

• Standard 7 : ETHICS

• Standard 8 : Culturally Congruent Practice

• Standard 9 : Communication

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• Standard 10 : Collaboration

• Standard 11 : Leadership

• Standard 12 : Education

• Standard 13 : Evidence-based Practice and Research

• Standard 14 : Quality of Practice

• Standard 15 : Professional Practice Evaluation

• Standard 16 : Resource Utilisation

• Standard 17: Environmental Health

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• NNABH requirement pertaining to Nursing Practice Standards are:

• AAC 4d: Initial assessment of day-care and in-patients includes nursing assessment, which is done at the time of admission and documented

• COP 6: Nursing care is provided to patients in the organisation in consonance with clinical protocols

• PSQ 2 h: There is an established process in the organisation to monitor and improve the quality of nursing care

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• Fundamental Nursing Skills

• Nurses are required to provide patient care that is safe, effective, efficient and timely

• Even a neophyte nurse is expected to have certain fundamental skill sets

• This is in order that she can adopt the standards of nursing practice to discharge her duties.

• The skill set is grouped in the following functional areas:

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• Functional Nursing Skill set*

• Breathing

• Assessing an individual’s ability to breath

• Monitoring respiratory rate

• Monitoring peak flow

• Maintenance of an airway

• Monitoring expectorant

• Disposal of sputum/oral secretion

• Obtaining a sputum specimen

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• Administration of oxygen

• Artificial respiration (Rescue breathing)

• Mobilising

• Assessing an individual’s ability to mobilise

• Moving and handling

• Care of an individual who is falling

• Care of an individual who has fallen

• Personal cleansing and dressing

• The skin

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• Personal Cleansing and Dressing (contd.)

• Assessing an individual’s ability to cleanse and dress

• Making a bed or cot

• Disposal of linen

• Assisting individuals with bathing

• Assisting individuals with oral hygiene

• Assisting individuals with eye care

• Facial shaving

• Hair care

• Assisting individuals to dress

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• Maintaining a safe Environment

• Personal safety

• Principles of health and safety at work

• Standard Precautions

• Principles of Asepsis

• Monitoring a client’s pulse

• Monitoring blood pressure

• Responding in the need of cardiopulmonary arrest

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• Administration of medications

• Responding in the need of fire

• Assessing an individuals ability to maintain a safe environment

• Eating and Drinking

• Assessing the individuals nutritional status

• Assisting clients in selecting appropriate meals/fluids

• Monitoring nutritional status

• Monitoring fluid intake

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• Assisting with eating and drinking

• Feeding dependent clients and clients with swallowing difficulties

• Providing first aid to a client who is choking

• Communicating

• Assessing the communication needs of clients

• Responding to telephone calls

• Managing violence and aggression

• Record keeping

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• Dying

• Assessing the dying client

• Communicating with dying clients

• Communicating with dying clients and their relatives

• Signs of approaching death

• Accounting for valuables

• Last offices

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• Eliminating

• Assessing the individuals ability to eliminate

• Assisting clients to use toileting facilities

• Applying/changing a nappy

• Care of an indwelling catheter

• Monitoring urinary output

• Monitoring bowel actions

• Monitoring vomitus

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• Maintaining body temperature

• Normal body temperature

• Methods of temperature measurement

• Assessing an individuals ability to maintain body temperature

• Monitoring temperature

• Strategies to raise or lower body temperature

• Express sexuality

• Maintaining privacy and sexuality

• Assessing individuals to express sexuality

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• Working and playing

• Assessing an individual’s ability to work and play

• Assisting an individuals to select appropriate work activities

• Assisting individuals to select appropriate recreational activity

• Sleeping

• Assessing an individual’s need in relation to sleep and rest

• Monitoring an individual’s sleep and rest patterns

• Assisting individuals to achieve a balance between activity and rest

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• The nursing skills expected of a trained nurse demands a variety of skills encompassing clinical patient care skills, psychosocial skills, communication skills, leadership skills, and administrative skills including nursing documentation skills

• Some of these skills are learnt in nursing schools and others are picked up on the job, over a period of time, as the nurse grows in the profession

• The level of skills attained by a nurse is an important consideration for allocation of duties to a nurse

• Therefore skills assessment is an important aspect of a nurse manager’s responsibility

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• Preceptor

• Clinical skills assessment and continuing nursing skills development, in advanced countries, is usually done by the preceptor

• The preceptor is an experienced registered nurse who shows enthusiasm for teaching nursing profession

• The preceptor assesses the learning needs of the student

• She sets the goal of learning in collaboration with the nurse

• The preceptor’s knowledge of the clinical area and the patient population will help guide students to select relevant goals and outcome

• This Concept has not been adopted in India

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• Nurse managers/educators

• In Indian corporate hospitals, Instead, there are nurse educators and nurse managers

• The number of nurse educators usually is to the tune of 1:150

• Therefore, they cannot teach clinical nursing skills at the bedside

• The job, by implication, has been shifted to the nurse managers (nurse leaders)

• Usually, a nurse manager (nurse leader) is responsible for supervising 30 to 40 junior nurses placed under her

• No formal planned teaching role, usually, is assigned to a nurse manager

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• However, she gains the first hand insight of the skills level and competence of the junior nurses placed under her supervision

• Therefore, she is in the unique position to assess the skill levels of the nurses placed under her supervision

• The format below can be used to assess and record the skills levels of the nurses*

Clinical skills checklistPre- Experience Medical/Surgical, ICU, ED, or Psychiatry

Name of the nurse :__________________ Facility: ________________

Complete the self assessment form below by placing an “X” under the level that most accurately reflects your competency. Share this with your clinical nurse leader

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• Key:

• Level 1: Confident – has experience with ability, requires little orno supervision

• Level 2: Need assistance – has some experience with skill, requiresmoderate supervision

• Level 3: No experience with skills, requires close supervision

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IDENTIFIED SKILLS LEVEL 1 LEVEL 2 LEVEL 3 COMMENTS

BASIC SKILLS

Blood Pressure

BASIC SKILLS Level 1 Level 2 Level 3 Comment

Apical pulse rate, Radial pulse rate

Respirations

Temperature (Oral, Axillary, Rectal

Hand washing

Use of non-sterile gloves

Pain as the 5th vital sign

Skin care

Mouth care

Bathing complete

Bathing partial

Assist with feeding

Bed making occupied 30

IDENTIFIED SKILL Level 1 Level 2 Level 3 Comment

Bed Making unoccupied

Standing scale weight

Bed scale weight

Transfer wheelchair

Transfer chair

Transfer stretcher

Ambulation of client with tubes / equipment

Glucometer

Isolation procedures

Post mortem care

Repositioning using lift (Draw) sheet

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IDENTIFIED SKILL Level 1 Level 2 Level 3 Comment

Repositioning frail client: supine

Repositioning frail client: sidelying

Assisting movement up in bed

NEUROLOGICAL Level 1 Level 2 Level 3 Comment

Glasgow comma scale

Cranial nerve assessment

Motor / sensory function Assessment

CARDIOPULMONARY Level 1 Level 2 Level 3 Comment

Normal heart sounds (S1, S2)

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IDENTIFIED SKILL LEVEL 1 LEVEL 2 LEVEL 3 COMMENT

Peripheral pulses

Oedema assessment

Application of anti-embolism hose

Management of sequential compression boots

Respiratory assessment

Normal breath sounds

Adventitious breath sounds: wheezing

Adventitious breath sounds: crackles (Rales)

Adventitious breath sounds: Ronchi

Pulse oxymetry

Nasal cannula

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Respiratory assessment Level 1 Level 2 Level 3 Comments

Venti (ventury) mask

Partial rebreathing mask

Non-breathing mask

Oral suctioning (Yankauer)

Nasopharyngeal suctioning

Tracheal (Endotracheal suctioning)

Closed (inline) suctioning system

Tracheostomy care

Chest tube care

Sputum collection

Incentive spirometer

12 lead ECG 34

GASTROINTESTINAL LEVEL 1 LEVEL 2 LEVEL3 COMMENTS

Auscultation of Bowel sounds

Abdominal palpation

Measurement of PO / Enteral intake

Calorie counts

Enteral feeding: NGT

Enteral feeding : PEG

Enteral feeding: J tubes

Enteral tube site care

Insertion and placement of NGT

Management of NG suction

Tap water / SSE enema

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GASTROINTESTINAL LEVEL 1 LEVEL 2 LEVEL 3 COMMENTS

Fleet enema

Ostomy care

Fecal bag

Stool specimen collection

Assist with bed pan

GENITOURINARY Level 1 Level 2 Level 3 Comment

Assist with urinal

Urine assessment : appearance

Bladder assessment

Measurement of urine output

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GENITO URINARY LEVEL 1 LEVEL 2 LEVEL 3 COMMENT

Urinary catheter insertion

Urinary catheter removal

Bladder irrigation

Condom catheter (Texas catheter)

Catheter leg bag

Suprapubic catheter care

Nephrostomy tube management

Nephrostomy care

Peritoneal dialysis

Hemodialysis access( Permacath, fistula, graft)

Incontenence care

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MUSCULOSKELETAL LEVEL 1 LEVEL 2 LEVEL 3 COMMENT

Inspection and palpation of muscles and joints

Assessment of ROM : Active and Passive

Neuromuscular assessment of extremity

Neuromuscular assessment of extremity

PSYCHOSOCIAL LEVEL 1 LEVEL 2 LEVEL 3 COMMENT

Therapeutic communication

Developmental assessment across the lifespan

Cultural/spiritual assessment

Teaching and learning assessment

Develop teaching plan

Implement teaching plan 38

Identified skill Level 1 Level 2 Level 3 Comment

MEDICATION

Interpretation of medication order

PO Medicines

Medicines via feeding tube

Eye drops

Eye ointments

Nose drops / sprays

Metered dose inhalers

Topicals

Rectal / Vaginal suppositories

Intradermal (PPD)

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MEDICATION (Contd.) LEVEL 1 LEVEL 2 LEVEL 3 COMMENT

Subcutaneous injections and sites

Intramuscular injections and sites

Reconstituting medication

Mixing two medications in a syringe

Medication safety – high risk

Patient Controlled Analgesia (PCA)

Rational for medication order

Nursing implications for medications

INTRAVENOUS Level 1 Level 2 Level 3 Comment

Assessment of peripheral sites

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