Nursing Competencies and Standards

Cognitive Competencies

• Encompass how one processes thinking, judgment, and critical thinking.

Technical Competencies

• Refer to hands-on skills and the ability to use equipment.

Interpersonal Competencies

• Involve relationships with peers and patients.

Ethical Legal Competencies

• Include understanding HIPAA, legal boundaries, maintaining morals, and ensuring privacy.

Nursing Process

• ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation

Standards of Nursing Care

• Apply to everyone equally
• Must adhere to professional standards
• Should be evidence based
• Include demonstrating professional responsibility in care
• Involve things like concept mapping and reflective journaling

Nursing Process: Assessment

• A full assessment involves systemic and continuous collection, analysis, validation, and communication of patient data.

Types of Nursing Assessments

• Initial Assessment: Conducted when a patient is first admitted or at the beginning of a shift
• Focused Assessment: Addresses specific problems. May be part of the initial assessment or routine data collection
• Focused Assessments: Help discern new or overlooked issues.
• Quick Priority Assessments: Rapid and brief assessments like ABC's, evaluating patient safety, and addressing something like a small increase in O2.
• Emergency Assessment: Pertains to life-threatening situations, focusing on ABC's, must be done by aprofessional
• Time Lapsed Assessment: Compares a patient’s current condition to their baseline, reassesses health status, and revises the care plan accordingly.
• Triage Assessment: Quick screening to determine patient prioirity; includes vitals, EKGs, and labs.

Objective Data

• Consists of vital signs, elevated temperature, vomiting, and skin conditions
• Can be directly seen or assessed.

Subjective Data

• Includes pain, dizziness, and nausea
• Relayed by the patient.

Sources of Data

• Patient, family, significant others, patient record, medical history, physical examination and progress notes.

Assessment Methods

• Inspection: Visual observation
• Palpation: Using touch to assess skin, temperature, turgor, texture, moisture, and vibrations within the body
• Percussion: Striking one object against another to produce sound.
• Auscultation: Listening with a stethoscope to hear sounds within the body.
• NANDA statements combine the problem, etiology, and supporting assessment findings/signs and symptoms

Four Types of Outcomes

• Cognitive Outcome: Indicates an increase in patient knowledge
• Psychomotor Outcome: Involves patients achieving new skills (gross or fine motor skills)
• Affective Outcome: Reflects changes in patient values, beliefs, and attitudes
• Physiological Outcome: Relates to physical changes like weight loss or gain.

Evaluating Outcomes

• Cognitive: Asking the patient to repeat information or use learned knowledge.
• Psychomotor: Asking the patient to demonstrate the new skill they learned.
• Affective: Observing patient behavior and conversation to gauge change.
• Physiologic: Using physical assessment skills to gather and compare data.

Evaluative Statements

• Outcome can be fully met, partially met, or note met

Actions Based on Patient Response

• Based on how the patient responds to care, you may need to: Delete/modify the diagnosis/problem, make the outcome more realistic, and change nursing interventions

Documentation

• A written or electronic legal record of all patient interactions
• Contains data related to assessing, diagnosing, planning, implementing, and evaluating patient care.
• Serves as a financial and legal record
• Supports clinical research
• Aids in decision analysis

Characteristics of Effective Documentation

• Consistency with professional and agency standards
• Must be complete, accurate, concise, factual, organized, timely, legally prudent, and confidential.

Elements of Documentation

• Includes: content, timing, format, accountability, and confidentiality.

Policy for Receiving Verbal Orders

• Must be from a provider or NP
• Needs to be documented in the patient's medical record
• Must have accuracy verification through a read-back
• The date and time is noted
• Includes the physician or NP's name and the nurse’s name and initials.
• Confined to urgent situations
• Requires sign-off within 24 hours
• Should be confirmed by another nurse.

Methods of Documentation

• Computerized documentation/Electronic health records (EHRS)
• Problem-Oriented Medical Records: Includes SOAP notes (Subjective, Objective, Assessment, Plan).
• PIE Charting: Includes Problem, Intervention, and Evaluation.
• Focus charting, or charting by exception

Reporting Care

• Change of shift or handoff reports
• ISBARQ (Introduction, Situation, Background, Assessment, Recommendation, Questions)
• Telephone/Telemedicine reports
• Transfer and discharge reports
• Reports to family or significant others
• Incident/variance reports

Change of Shift/Hand-off Reports

• Cover basic patient information: name, room, bed, diagnosis, physicians.
• Review current health status, current orders, and any new orders.
• Point out abnormal occurrences and unfilled orders.

Nursing Informatics (ANA Definition)

• Integrates nursing science with information management and analytical sciences to manage and communicate data, information, knowledge, and wisdom in nursing practice.