fundamentals skills

8/8/2019 Fundamentals Skills

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Fundamentals Skills Test (MS1) Prep Phase:• Nurse should ensure the environment in which the interviewis to be conducted is private and relaxed• Chairs placed @ right angles about 3-4ft apart• Pt is in bed place chair @ 45 degree angle• Should take no more than 10-15m

Intro phase:• Nurse states name and status and purpose of the interview• Assess patient's comfort and ability to participate• Should take no more than 20m Working Phase:• Gathers all information to form subjective database Types of outcomes:1. Cognitive ~ involve increases in a patient's knowledge; asking a patient

to repeat information or, at a higher level of performance, by asking toapply new knowledge to their everyday situations2. Psychomotor ~ describe the patient's achievement of new skills; demonstrationthe skill3. Affective ~ pertains to changes in patient's values, beliefs, and attitudes and are morecomplex to evaluate. Patient's behavior and conversation can determine whether affectiveoutcomes have been achieved4. Physiologic outcomes ~ physical changes in the patient are the targeted outcome. Thenurse uses physical assessment skills to collect relevant data & compares those withprevious patient data Evaluating:

• Measures how well the patient has achieved desired outcomes• Identify factors contributing to the patient's success or failure• Modify the plan of care, if indicated

Nursing Interventions ~ any treatment based upon clinical judgment and knowledge that anurse performs to enhance patient/client outcomes Dynamic: Although the nursing process is presented as an orderly progression of steps, inreality, there is great interaction and overlapping among the five steps. No one step in theprocess is a one-time phenomenon; each step flows into the next step. In some nursingsituations, all five stages occur almost simultaneously Systematic: each nursing activity is part of an ordered sequence of activities.Moreover, each activity depends on the accuracy of the activity that precedes it andInfluences the actions that follow it Interpersonal: always the heart of nursing is the human being. The nursing process ensuresthat nurses are patient centered rather than task centered Time-lapsed assessment ~ scheduled to compare a patient's current status to baseline dataobtained earlier



Purpose of diagnosing is to identify:• How an individual, group, or community responds to actual or potential health and lifeprocesses• Factors that contribute to or cause health problems (etiologies)• Strengths the patient can draw on to prevent or resolve problems

Concurrent evaluation ~ conducted by using direct observation of nursing care, patientinterviews, and chart review to determine whether the specified evaluative criteria are metRetrospective evaluation ~ use post discharge questionnaires, patient interviews, or chartreview to collect data Goal ~ an aim or an endPatient outcome ~ expected conclusion to a patient health problem, or in the eventof a wellness diagnosis, an expected conclusion to a patient's health expectationExpected outcome ~ used to refer to the more specific, measurable criteria used to evaluatethe extent to which a goal has been met Diagnoses ~ Medical diagnoses identify diseases, whereas nursing

diagnoses focus on unhealthy responses to health and illness.Medical diagnoses describe problems for which the physician directsthe primary treatment , whereas nursing diagnoses describe problemstreated by nurses within the scope of independent nursing practice

Maslow's Hierarchy of Human needs1. Physiologic needs2. Safety needs3. Love and belonging needs4. Self-esteem needs5. Self-actualization needs To be measurable, outcomes should have the following:• Subject• Verb• Conditions• Performance criteria• Target time

A formal plan of care allows nurses to:• Individualize care that maximizes outcome achievement• Facilitate communication among nursing personnel and their colleagues• Promote continuity of high-quality, cost-effective care• Evaluate the patient's responses to nursing care

• Create a record that can be used for evaluation, research, reimbursement, and legalpurposes• Promote the nurse's professional development

Each nursing intervention should include:DateVerbSubjectDescriptive phrase: How, when, where, how often, how long, or how much



Radiation ~ the diffusion or dissemination of heat by electromagnetic waves (body gives off waves of heat from uncovered surfaces)Convection ~ the dissemination of heat by motion between areas of unequal density (anoscillating fan blows currents of cool air across the surface of a warm body)Evaporation ~ the conversion of a liquid to a vapor (body fluids in the form of perspiration andinsensible loss is vaporized from the skin)Conduction ~ the transfer of heat to another object during direct contact (the body transfers

heat to an ice pack, causing the ice to melt) POMR ~ Problem oriented medical recordSOAP ~ Subjective data, Objective data, Assessment, PlanPIE ~ Problem, Intervention, EvaluationDAR ~ Data, Action, ResponseCBE ~ Charting by exceptionOASIS ~ Outcome and Assessment Information Set Core body temperature is normally maintained within a range of 97.00F - 99.50F Criteria ~ measurable qualities, attributes, or characteristics that specify skills, knowledge, orhealth statesCustom ~ sometimes establishes standardsOrders ~ written to address the special needs of the patient Nursing audit: a method of evaluating nursing care that involves reviewing patient records toassess the outcomes of nursing care or the process by which these outcomes were achieved Pulse deficit ~ difference between the apical and radial pulse rates

Respirations ~Normal - 12 - 20 bpm

Tachy - > 24 bpmBrady < 10 bpm BP variations ~Circadian rhythm: normal fluctuations occur during the day

The blood pressure is usually lowest on arising in the morning The blood pressure has been noted to rise as much as 5 - 10 mm Hgby late afternoon, and it gradually falls again during sleepGender : women usually have lower blood pressure than men of the sameage until menopauseBody position: blood pressure tends to be lower in a prone or supine position thanwhen sitting or standing

Medications: oral contraceptives cause a mild increase in blood pressure Sensory deficit: any impairment in sight, hearing, smell, taste, or touchAssess the scene for safety/victim

fundamentals skills

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