General Survey

• Nursing process


  A structured course of action used by nurses to develop, implement, and evaluate the care of their clients
• Nursing process


  • Problem-solving approach used in the provision of care to complex clients
  • Steps remain the same, but ability to move from following the steps as a novice to using clinical judgment, critical thinking, and priority setting as an expert takes time and experience
• Nursing process


  Provides a blueprint for delivering patient-centered care that is holistic and enhances patient outcomes
• PN


  Assists with many of the steps of the nursing process
• RN


  Validates and analyzes the information collected by the PN, plans and initiates the interventions to address the client's health care needs
• PN


  Acts under the direction of the RN and carries out interventions and client care tasks
• Steps of the nursing process


  • Assessment
  • Analysis
  • Planning
  • Implementation
  • Evaluation
• Assessment


  1. Gather information from the client through interview, physical exam, and observation

  2. RN maintains ongoing knowledge of assessment techniques and best practices

  3. PN assists the RN by systematically collecting data, reviewing information about the client, and communicating it to the RN and appropriate members of the health care team
• Subjective data


  Client's reason, usually physical symptoms, for visiting the provider
• Objective data


  Nurse's observations or measurements of a client's health condition
• Assessment requires the use of critical thinking including identifying important data from the information the client shared, obtaining additional data if a problem is identified, and organizing the data according to an established framework
• It is the responsibility of the PN to notify the RN or the client's provider of unexpected findings
• Analysis


  1. RNs analyze the subjective and objective data collected during assessment using clinical judgment

  2. RN collaborates with the client to develop the client's plan of care, identifying both actual and potential problems

  3. RN considers the need for education as well as the client's readiness to learn and any barriers to learning
• Analysis step is outside the scope of practice for the PN
• Planning


  1. Nurse uses problem-solving and decision-making skills to prioritize outcomes and goals and develops interventions to meet those goals

  2. Collaboration between the RN, client, and possibly the family, in which the goals are set and agreed upon by all parties involved

  3. Involves using evidence-based practice (EBP) and current nursing standards

  4. PNs participate in planning by assisting the RN in the development of expected outcomes and interventions and use their problem-solving and decision-making skills
• Implementation


  1. RN carries out the interventions that have been established

  2. RN uses clinical judgments to monitor the client's progress toward achieving their goals

  3. RN provides teaching and coordinates the plan of care with other members of the health care team

  4. RN determines the best approach with the client to promote learning and looks for any potential barriers that might impair learning

  5. PNs complete the implementation phase by providing planned nursing care to accomplish expected outcomes

  6. PNs reinforce client teaching by providing educational materials to the client, allowing time for questions and providing clarification of the initial teaching of the RN
• Evaluation


  1. Nurse evaluates the effectiveness and achievability of the goals and the need for adjustment of the interventions

  2. Continued communication with the client and the health care team will help keep the goals attainable

  3. Nurse documents achieved, revised and new goals, making updates to the plan of care as needed

  4. PNs can compare the actual outcome of nursing care to expected outcomes, assist with updating nursing interventions and maintain communication with the RN regarding any changes that may be needed to the plan of care
• Assessment


  Gather data from the client through interview, physical exam, and observation to make judgments
• Analysis


  Use clinical judgment to evaluate data collected to formulate the client's problems, including actual and potential problems
• Planning


  Use problem-solving and decision-making skills to prioritize outcomes and goals, and develop interventions to meet those goals
• Implementation


  Carry out the interventions that have been established, use clinical judgments to monitor the client's progress towards achieving their goals
• Evaluation


  Assess the effectiveness and achievability of the goals and the need for interventions to be adjusted
• Critical thinking and clinical judgment


  • Contextual awareness
  • Analyzing assumptions
  • Exploring alternatives
  • Using credible sources
  • Reflecting and deciding
• Analyzing assumptions is not part of the critical thinking process for the PN
• Ethical principles


  • Nonmaleficence (do no harm)
  • Beneficence (act to promote the good of the client)
  • Autonomy (client's right to make decisions)
  • Justice (treat everyone fairly)
  • Confidentiality (respect the rights of the client to maintain privacy)
• Nonmaleficence


  Avoiding hurt or harm to others
• Beneficence


  Helping others in a positive manner
• Autonomy


  Having self-control
• Justice


  Being open and fair
• Confidentiality


  Protecting the privacy of others
• Communication skills


  • Demonstrate holistic care, compassion, inclusivity, and professionalism when communicating with clients, their families, and the entire health care team
  • Identify opportunities for health promotion throughout the assessment and collaborate accordingly with the client
• Personal factors


  • Maintain professionalism with all communications
  • Evaluate your own thoughts and feelings to maintain a neutral attitude
  • Reflect on your own biases to allow for easier interactions with clients from various cultures and religions
  • Do not impose your own values on others
  • Practice empathy by putting yourself in the client's situation
  • Cultural competence involves being wholly aware of the various cultures that frequent the institution and providing reasonable accommodations to meet their religious and cultural needs
• Therapeutic communication


  • An approach to communication that is both verbal and nonverbal
  • Introduce yourself and state your title
  • Focus on the person, not the problem
• Some things to avoid while communicating therapeutically include using inappropriate plural pronouns ("we") and assuming
• Therapeutic communication


  An approach to communication that is both verbal and nonverbal
• Therapeutic communication


  1. Introduce yourself and state your title

  2. Focus on the person, not the problem
• Things to avoid while communicating therapeutically


  • Using inappropriate plural pronouns ("we")
  • Assuming the client knows about a health interview or physical
  • Asking personal questions that are not relevant to the situation
  • Giving personal opinions
  • Using automatic responses and false reassurances
  • Relaying disapproval of client statements or health practices
• Verbal therapeutic communication


  • Ask what the client prefers to be called, otherwise address the client by using their surname
  • Ask the client which personal pronouns they use and use gender inclusive terms such as "partner" instead of the terms "husband" or "wife" during interactions
  • Keep questions focused and relevant to the context and situation
  • Ask open-ended questions
  • Redirect the client as needed
  • Engage in active listening
  • Restate the client's view to indicate your understanding
  • Use everyday language and stay away from medical terms as much as possible
  • Keep any emotionally charged conversations for last to ensure you receive any other pertinent information
  • Give positive reinforcement and reassurance without passing judgment or disapproval
• Initial greeting indicating inclusivity


  "Hi, I'm Finn and will be doing an assessment on you today. How would you like me to address you? I use he/him pronouns. Would you like to share yours?"
• Nonverbal therapeutic communication


  • Face the client when speaking and maintain an awareness of personal space
  • Obtain permission from the client when intimate distances are needed such as obtaining an assessment or providing a treatment
  • Use therapeutic touch when appropriate and with the client's permission