Fundamentals of Nursing: Clinical Skills Workbook (eBook)

Geraldine Rebeiro, Damian Wilson (Autoren)

eBook Download: PDF | EPUB

2012 | 2. Auflage
352 Seiten
Elsevier Health Sciences (Verlag)
978-0-7295-8116-5 (ISBN)

Infos

The Fundamentals of Nursing: Clinical skills workbook will support Potter & Perry's Fundamentals of Nursing 3rd edition in 2012 by providing a separate clinical skills workbook, accompanied by a suite of Australian clinical skills videos.
The workbook features the nursing skills from the text, accompanied by an overview at the beginning of each skill set and supported by clinical skill competency check lists aligned with the National Competency Standards for the Registered Nurse.
The Bondy rating scale has been incorporated to provide clearly defined levels of competency and an opportunity for reflection is included at the end of each skill to encourage meaningful learning.
A suite of clinical skills videos are available online to support the workbook. Ideal for viewing in class, the videos also provide students with a valuable tool for revision prior to assessment.

• The trusted Step-by-Step approach for all skills as used in Potter and Perry's Fundamentals of Nursing, 4th ANZ edition by Crisp, Taylor, Douglas and Rebeiro
• Competency checklists aligned to the National Competency Standards for the Registered Nurse for Australia and New Zealand
• The Bondy rating scale provides a valuable tool for assessment
• Accompanied by a suite of Australian nursing clinical skills videos via the Evolve platform

      11 NEW skills including 8 health assessment skills:

• Skill 27-1 Abdominal health assessment
• Skill 27-2 Musculoskeletal health assessment
• Skill 27-3 Cardiovascular health assessment
• Skill 27-4 Respiratory health assessment
• Skill 27-5 Neurological health assessment
• Skill 27-6 Mental Health
• Skill 27-7 Body systems assessment
• Skill 41-2 Pain health assessment

Textauszug

Health assessment and physical examination

Overview

Health assessment is essential and fundamental knowledge for registered nurses. Health assessment involves the systematic collection of subjective and objective data from the patient and analysis of these data to make clinical judgements about the patient’s health status.

The process of collecting data for health assessment is often described as invisible and continual. Nurses are continually observing their patients to collect data in order to make the necessary clinical judgements regardless of where they are—hospital, clinic, community, home or residential long-term care. Assessment is the first step of the nursing process, and learning to effectively collect information systematically and comprehensively from patients about their health for assessment and clinical judgements is crucial to making accurate clinical decisions about patient treatment and care.

As the only healthcare professionals with patients 24 hours a day, seven days a week, nurses are usually the first to detect and respond to changes in a patient’s condition at the bedside. Nurses are reliant on their health assessment knowledge and skills in order to identify life-threatening complications for the patient, as well as to detect subtle and overt changes that represent deterioration in the patient’s condition. Registered nurses save lives and improve the health outcomes of their patients through early recognition and nursing actions as a result of continuing assessment on a daily basis. Hence it is important that students learn to develop, practise and consolidate skills to conduct systematic and comprehensive health assessments, through the collection of a health history and physical examination of the patient. It is vital that nurses listen to their patients and inspect and examine them in a systematic and comprehensive way.

This chapter provides students with the opportunity to develop the knowledge, skills and techniques for conducting health assessments using a systems framework approach. The skills addressed include assessment of the abdomen and gastrointestinal tract (27-1), assessment of the musculoskeletal system (27-2), assessment of the cardiovascular and peripheral vascular systems (27-3), assessment of the respiratory system (27-4), mental state assessment (27-5) and assessment of central nervous system and level of consciousness (27-6).

SKILL 27-1   Assessment of the abdomen and gastrointestinal tract

DELEGATION CONSIDERATIONS

Assessment of the abdomen and gastrointestinal (GI) tract may be undertaken by enrolled nurses under the guidance of the registered nurse.

• Ensure review of the anatomy and physiology of the GI system.

• Ensure that hand hygiene is performed and personal protective equipment is worn when appropriate.

EQUIPMENT

• Stethoscope

• Small pillow for under the knees

• Tape measure or ruler

• Marking pen

• Pen

• Documentation

Reference:

Estes MEZ. Health assessment and physical examination, ed 4. New York: Cengage Learning, 2010.

SKILL 27-2   Assessment of the musculoskeletal system

DELEGATION CONSIDERATIONS

Assessment of the musculoskeletal system may be undertaken by enrolled nurses under the guidance of the registered nurse.

• Ensure review of the anatomy and physiology of the musculoskeletal system for risk factors, specifically the major muscle groups and joints.

• Ensure hand hygiene is performed and personal protective equipment worn when appropriate.

EQUIPMENT

• Tape measure

• Marking pen

• Pen

• Documentation

Reference:

Estes MEZ. Health assessment and physical examination, ed 4. New York: Cengage Learning, 2010.

SKILL 27-3   Assessment of the cardiovascular and peripheral vascular systems

DELEGATION CONSIDERATIONS

Assessment of the cardiovascular system (CVS) and peripheral vascular system (PVS) may be undertaken by enrolled nurses under the guidance of the registered nurse.

• Ensure review of the anatomy and physiology of the CVS and PVS for risk factors.

• Ensure hand hygiene is performed and personal protective equipment is worn when appropriate.

EQUIPMENT

• Stethoscope

• Sphygmomanometer

• Watch with second hand

• Tape measure

Reference:

Estes MEZ. Health assessment and physical examination, ed 4. New York: Cengage Learning, 2010.

SKILL 27-4   Assessment of the respiratory system

DELEGATION CONSIDERATIONS

Assessment of the respiratory system may be undertaken by enrolled nurses under the guidance of the registered nurse.

• Ensure review of the anatomy and physiology of the respiratory system for risk factors.

• Ensure review of the anatomical landmarks of the chest wall.

• Ensure hand hygiene is performed and personal protective equipment worn when appropriate.

EQUIPMENT

• Stethoscope

• Pen

• Documentation

• Watch (with a second hand)

• Portable pulse oximeter

References:

Epstein, O, Perkin, G, Cookson, J, et al. Clinical examination, ed 4. Edinburgh: Mosby, 2008.

Jarvis, C. Physical examination and assessment, ed 5. St Louis: Saunders, 2008.

SKILL 27-5   Mental state assessment

Mental state assessment is a key nursing skill and provides a structured set of observations about the patient’s cognitive and emotional state at a specific point in time.

DELEGATION CONSIDERATIONS

The mental state assessment can be conducted without supervision. Most aspects of the mental state assessment can be carried out as part of routine nursing care, i.e. they can be integrated into other nursing procedures.

Before proceeding:

• review the categories of mental state assessment, and communication skills

• revise the structured format for mental state assessment (BATOMI) (see Box 44-4)

EQUIPMENT

• Mental health assessment uses communication skills and therapeutic use of self

• Consider privacy and appropriateness of setting

SKILL 27-6   Assessment of central nervous system and level of consciousness

DELEGATION CONSIDERATIONS

Assessment of the central nervous system (CNS) may be undertaken by enrolled nurses under the guidance of the registered nurse.

• Ensure review of the anatomy and physiology of the CNS for risk factors

• Ensure review of the Glasgow Coma Scale (GCS)

• Ensure hand hygiene is performed and personal protective equipment is worn when appropriate.

EQUIPMENT

• Penlight torch

• Neurological observation chart

• Pen

References:

Estes MEZ. Health assessment and physical examination, ed 4. New York: Cengage Learning, 2010.

Forbes, H, Watt, EJarvis’s Physical examination and health assessment. Sydney: Saunders Australia, 2012.

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Produkt-Details

• Erscheint lt. Verlag: 10.3.2014
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Pflege ► Ausbildung / Prüfung
• ISBN-10: 0-7295-8116-0 / 0729581160
• ISBN-13: 978-0-7295-8116-5 / 9780729581165