Foundations, priorities & vital signs

What nursing isSlides content

The ANA (American Nurses Association) defines nursing as the art and science of caring: protecting, promoting and optimizing health and function; preventing illness and injury; helping healing; easing suffering through compassionate presence; diagnosing and treating human responses; and advocating for individuals, families, groups, communities and populations.

How practice is regulatedSlides content

The model of professional nursing practice regulation answers the who, what, when, where and why of practice, so care is knowledgeable, safe and complete. From the broadest layer to the most personal:

• BON (Board of Nursing): each state's regulatory body. It sets practice rules, approves nursing programs, grants licenses and handles discipline. Here it's the Maryland Board of Nursing, and licensure and renewal rules vary by jurisdiction.
• NCLEX (National Council Licensure Examination): the exam graduates pass to be licensed (NCLEX-RN or NCLEX-PN).
• NLC (Nurse Licensure Compact): one license lets a nurse practice in every state that joined the compact.
• Scope of practice: what a licensed nurse is competent and permitted to do. Standards of care: the minimum care a professional must give, compared with peers of similar education and experience.
• Standards of practice describe competent care using the nursing process; standards of professional performance describe competent professional behavior.
• ACEN (Accreditation Commission for Education in Nursing) and CCNE (Commission on Collegiate Nursing Education) accredit nursing schools.

Organizations and competencies

QSEN (Quality and Safety Education for Nursing)

The knowledge, skills and attitudes every prelicensure student should have. Six competencies:

Your program's organizing frameworkSlides content

Human flourishing (client-centered care), nursing judgment (safety standards and information), professional identity (teamwork and collaboration) and spirit of inquiry (quality improvement and evidence-based practice). Core values: diversity, patient-centeredness, ethics, caring, integrity, excellence and holism.

People who shaped nursing

The first U.S. school of nursing opened in 1872.

The clinical judgment modelSlides content

1. Recognize cues: pick out relevant, important information from different sources
2. Analyze cues: organize and connect them to the client's clinical picture
3. Prioritize hypotheses: rank the possible problems by urgency, likelihood and risk
4. Generate solutions: set expected outcomes and the interventions to reach them
5. Take action: carry out the solutions for the highest priority
6. Evaluate outcomes: compare what happened with what you expected

NGN (Next Generation NCLEX) question typesSlides content

Five stepsSlides content

The nursing process builds the plan of care (POC): how we know what to focus on each shift to restore or improve the client's condition. The whole interprofessional team uses it.

1 · AssessmentSlides content

The nurse collects, organizes and validates data from the health history (interview), the physical assessment, the medical record, and objective and subjective data.

Lab results are part of a full assessment. Values differ between facilities, so this course uses the ATI values, adult ranges only, for the CBC (complete blood count) and CMP (comprehensive metabolic panel). See the CBC/CMP flashcards.

2 · Analysis (nursing diagnosis)Slides content

A nursing diagnosis is a clinical judgment about a person's response to an actual or potential health condition. NANDA-I (North American Nursing Diagnosis Association International) develops and standardizes them. It is not a medical diagnosis.

3 · PlanningSlides content

Generate solutions: set goals and choose individualized, evidence-based interventions. Goals are written in SMART format and can be short or long term.

A measurable goal names an observable behavior and a time frame: "The client will walk 100 feet in the hallway with a walker by the end of the shift." Words like "understand," "feel" or "tolerate better" can't be measured.

Every intervention gets a rationale (the "why"), and it must be evidence based. Example: clean the incision with chlorhexidine every shift as ordered, because chlorhexidine lowers infection risk by reducing bacteria.

4 · Implementation and 5 · EvaluationSlides content

Let's practice: Mr. JonesSlides content

Mr. Jones, 78, came to the emergency department last night after falling and breaking his hip, and had it surgically repaired. The UAP (unlicensed assistive personnel) reports: temperature 39.0 °C (102.2 °F), pulse 122, respirations 16, BP 140/90, pain 4/10.

Which findings are outside the expected range?

Temperature (fever is above 38 °C), pulse (tachycardia is above 100) and BP (140/90 is stage 2 hypertension). Respirations of 16 are within 12–20. A fever with a fast heart rate after surgery needs follow-up and a report to the provider.

Maslow's hierarchy of needsSlides content

ABCDE for acutely ill clientsSlides content

Other ways to set prioritiesSlides content

Triage colors

Rationing: deciding how to use resources that are too scarce to meet every need.

TermsSlides content

• Health promotion: helping people gain control over and improve their health. Tools on the slides: client education, health literacy, supportive environments, public policy, referrals.
• Wellness: a positive state of health, with spiritual, emotional, physical and environmental dimensions.
• Disease prevention: measures that limit exposure to, or the effects of, illness or disease.
• Health education: learning experiences that build knowledge or shape attitudes. Health outcomes: the results of promotion and prevention.

What affects healthSlides content

Levels of preventionSlides content

Time managementSlides content

Plan your day; make lists and prioritize; focus on what's important and limit distractions; delegate safely; take a break when possible; it's OK to say "no"; take care of yourself.

Client assignments divide care among staff by acuity (how complex a client's needs are): direct (specific clients, like 1 nurse to 2 clients in an ICU [intensive care unit]), area (a zone), group (clients grouped by location or acuity) or team nursing (several nurses share the tasks).

Communication toolsSlides content

Discharge planningSlides content

Discharge planning is ongoing: it starts the moment the client is admitted and continues through the whole stay. It decides what support the client needs to move to another facility or home.

Teach-back: the client explains the teaching back in their own words, showing what they understood.

DelegationSlides content

Delegating hands a client care task to another team member who is competent and within their scope. The nurse who delegates stays responsible and accountable for the task being done correctly and on time.

Example: a UAP can take an oxygen saturation reading, so they bring a pulse oximeter into the room.

Other terms from the module

• STAMP (early signs of agitation or aggression): Staring, Tone and volume of voice, Anxiety, Mumbling, Pacing. Tools that measure aggression: the Overt Aggression Scale and the Broset Violence Checklist.
• SBIRT: Screening, Brief Intervention and Referral to Treatment, for risky alcohol and drug use. OUD (opioid use disorder) cascade of care: prevention, identification, treatment, recovery.
• IPEC (Interprofessional Education Collaborative) core values: values and ethics, roles and responsibilities, interprofessional communication, teams and teamwork.
• Nonadherence (noncompliance): not following the plan.

Patient-centered careSlides content

Caring theoriesSlides content

Caring behaviors

• Listening: careful, active, empathetic
• Touch: expressive touch shows compassion. Ask permission first (touching without consent can be battery) and respect cultural preferences
• Being present: show up, listen, don't multitask
• Providing comfort: nonpharmacologic measures for pain and anxiety (warm blankets, fluffing pillows, repositioning, bedtime rituals)
• Showing compassion: know your own feelings before trying to help others

Culturally competent careSlides content

Culturally competent care is evidence-based care that fits the client's cultural values, beliefs, worldview and practices. It helps reduce health care disparities. Don't assume: ask.

• "Do you have any ethnic, spiritual or racial affiliation you identify with?"
• "Do you have any beliefs and practices related to health or illness?"
• "Do you follow any food preferences or prohibitions as part of your culture?"

Cultural awareness (checking your own culture and biases), knowledge (learning about others), skill (assessing accurately), encounters (interacting across cultures) and desire (wanting to connect) build competence. Acculturation is taking on another group's cultural traits.

Communication by generation

Spiritual careSlides content

Spiritual well-being is satisfaction and contentment with who one is and where one belongs in the universe. A spiritual assessment is part of holistic care. Spiritual distress is questioning life's meaning or one's beliefs, or anger at a higher power, shown as despair, anger, uncertainty or fear. Nurses listen and support, and can consult pastoral care (chaplains).

• Palliative care: interprofessional symptom management for chronic or life-threatening illness, keeping the best possible quality of life.
• Medically futile: treatment that can't cure or extend life. Potentially inappropriate treatment: may not be futile but may not fit the client.
• Quality of life: fulfilling the client's own purpose and meaning.

Setting up the interviewSlides content

• Use therapeutic communication: introduce yourself, eye contact as appropriate, ask what the client would like to be called
• Comfort, privacy and confidentiality: a warm, well-lit room, door or curtain closed
• Start with the least invasive tasks: health history and general survey first, then the physical assessment
• Watch nonverbal cues: what is the body language telling you?
• Avoid medical terms ("high blood pressure," not "hypertension"); use an interpreter as needed

The health historySlides content

The four techniquesSlides content

General survey

Physical appearance (age, sex, LOC [level of consciousness], skin color, signs of abuse or distress), body structure (height, weight, symmetry, nutrition, posture), mobility (gait, range of motion), behavior (expression, mood, speech, dress, hygiene, odors) and vital signs.

PulseSlides content

• Rate: beats per minute
• Rhythm: regular intervals
• Strength: the volume of blood the left ventricle pushes out, graded 0 to 4+, with 2+ expected
• Equality: the same on both sides
• Count 30 seconds and double it; count a full minute if irregular.
• Apical pulse: at the apex, 5th intercostal space at the midclavicular line. S1 ("lub") is the mitral and tricuspid valves closing; S2 ("dub") is the aortic and pulmonic valves closing.
• Pulse deficit: apical rate minus radial rate. A difference means beats aren't reaching the periphery.

TemperatureSlides content

The balance between heat the body makes and heat it loses.

Factors: hormones, exercise and activity, dehydration, illness, injury, recent food or drink, smoking, environment and circadian rhythm.

RespirationsSlides content

One inspiration plus one expiration is one breath. Count 30 seconds and double it; a full minute if abnormal. Factors: age, sex, pain, anxiety, smoking, body position, medications, neurologic injury, illness and how well the blood carries oxygen.

Oxygen saturationSlides content

Blood pressureSlides content

The force of circulating blood on the vessel walls, in mm Hg, written systolic/diastolic. Systolic: the peak pressure when the heart contracts. Diastolic: the pressure while the heart relaxes and fills. BP = cardiac output × systemic vascular resistance, so anything that changes either one changes BP. Cardiac output = stroke volume × heart rate.

• Cuff too small or narrow → falsely high. Too large → falsely low.
• Pulse pressure = systolic minus diastolic: 140/90 → 50.
• Equipment: sphygmomanometer (BP cuff) and stethoscope; Korotkoff sounds are the sounds of blood through the partly squeezed artery.

Orthostatic (postural) hypotension

BP drops and the heart rate rises to compensate when the client moves from lying to sitting or sitting to standing: a systolic drop of 20 mm Hg or more, or a diastolic drop of 10 or more, within 1–3 minutes. The client feels dizzy and may faint. Causes include dehydration, hypotension, heart failure and nervous system disorders. Have the client change positions slowly and protect them from falls.

What pain isSlides content

"An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." Pain threshold: the point where a stimulus is felt as pain. Pain tolerance: how much the client is willing to accept.

Words clients use: aching, throbbing, stabbing, pounding, sharp, gripping, dull, tearing, radiating, cutting, burning, scalding.

Assessing painSlides content

FLACC scaleSlides content

A nonverbal way to assess pain in any client who can't tell you about it. Score each of the five categories 0–2 for a total of 0–10.

Treating pain

Routes: PO (by mouth), IM (intramuscular), IV, PR (per rectum), topical.