| Nurses are trained to learn and apply patient | | | | mother gleans a sense of security now that she has |
| assessment skills. These skills are the cornerstone of | | | | been instructed in the correct method of breast |
| being a proficient nurse. The knowledge and | | | | feeding. The nurse must plan the goals that the client |
| procedures for developing these skills are learned in | | | | is to achieve around the clients ability. For instance, |
| the first two years of nursing school and honed in | | | | the goal that a client will walk normally after two |
| clinical as the student nurse takes on a greater | | | | days of having knee surgery is unrealistic, in the |
| patient load. The "Standards of Care" that are the | | | | sense that the client's knee will not be completely |
| basis of nursing include the following: | | | | healed. However, the goal that the client will be able |
| Standard 1. Assessment | | | | to demonstrate the correct use of crutches, would |
| In an assessment the nurse must use all of his or her | | | | be more realistic. This goal is also measurable, since |
| senses. These include hearing, touching, visual, and | | | | the patient will be in the hospital and the nurse can |
| therapeutic communication. The cephalocaudal | | | | teach and observe a return demonstration. |
| approach is most always used. In other words, | | | | Therefore, the goals or outcomes for the client must |
| assessing a patient from head to toe. The nurse | | | | also be measurable. |
| must self aware to be able to conduct a thorough | | | | Standard IV. Planning |
| assessment. Data collection forms the basis for the | | | | The planning standard is designed around the clients |
| next step in standards of care which is diagnosis. A | | | | activities while in the hospital environment. Therefore |
| nurse must have all the necessary equipment, such | | | | the nurse must plan to teach and demonstrate tasks |
| as a scale, tape measure, thermometer, | | | | when the patient is free to learn. This would involve |
| sphygmomanometer, a stethoscope and pen light. | | | | administering pain medication prior to learning to walk |
| The setting is also very important in doing an | | | | with crutches or waiting until after a patient has |
| assessment. If a client is nervous or anxious they | | | | finished a meal before teaching on how to use a |
| may not be as willing to answer questions that the | | | | syringe. The atmosphere should be conducive for the |
| nurse asks or to be examined. Obtaining a quiet | | | | client to learn. |
| environment is not always possible, especially in an | | | | Standard V. Implementation |
| emergency situation. Therefore, the nurse must be | | | | This standard requires that the nurse put to the test |
| very observant, and try to get as much pertinent | | | | the methods and steps designed to help the client |
| data as possible to formulate an nursing diagnosis For | | | | achieve their goals. In implementation, the nurse |
| example, when doing an assessment on a client that | | | | performs the actions necessary for the client's plan. |
| is complaining of severe stomach pain, asking them | | | | If teaching is one of the goals then the nurse would |
| what foods they last ate would give the nurse more | | | | document the time, place, method and information |
| pertinent information than asking them how many | | | | taught. |
| brothers or sisters they have. | | | | Standard VI. Evaluation |
| Standard II. Diagnosis | | | | Evaluation is the final standard. In this step the nurse |
| A nursing diagnosis is not a medical diagnosis. A | | | | makes the determination whether or not the goals |
| medical diagnosis would be the medical condition of | | | | originally set for the client have been met. If the |
| "Diabetes". Whereas, a nursing diagnosis would be, | | | | nurse concludes that the goal or goals have not been |
| "Altered Tissue Perfusion", related to decreased | | | | met, then the plan has to be revised and |
| oxygenation of tissues as evidenced by a pulse | | | | documented as such. Goals therefore should be |
| oximetry of 92% , secondary to the medical | | | | timely and measurable. If the client's goal was to use |
| condition of "Emphysema". A nursing diagnosis is a | | | | crutches successfully, and the client was able to |
| formal statement that relates to how a client reacts | | | | perform a repeat demonstration for the nurse, then |
| to a real or perceived illness. In making a diagnosis | | | | the goal was met. |
| the nurse attempts to formulate steps to assist the | | | | The above standards are the cornerstone of the |
| client in alleviating and or mediating how they respond | | | | nursing profession. These standards take time and |
| to real or perceived illness. | | | | experience to learn and to implement. Experience is |
| Standard III. Outcome Identification | | | | the best teacher, and a nurse should continuously |
| In this process the nurses uses the assessment and | | | | strive for excellence in their care of patients, and |
| diagnosis to set goals for the patient to achieve to | | | | recognizing how to help patients achieve a higher |
| attain a greater level of wellness. Such goals may | | | | level of physical and emotional wellness. |
| simply be that the patient now comprehends the | | | | Learn more about nursing education at The NET |
| regime of testing their blood sugar, or perhaps a new | | | | Study Guide. |