Nursing: Core Concepts and Foundations

• Fundamentals of nursing provide the foundational knowledge and skills required for competent nursing practice.
• Encompasses a broad range of concepts, including patient-centered care, safety, communication, and ethical practice.

Core Concepts

• Patient-centered care emphasizes the individual needs, preferences, and values of each patient.
• Holistic care considers the physical, psychological, social, cultural, and spiritual dimensions of the patient.
• Evidence-based practice integrates the best available research evidence with clinical expertise and patient values to guide nursing care.
• Safety is paramount in nursing practice and involves minimizing the risk of harm to patients and healthcare providers.
• Quality improvement focuses on continuously improving the processes and outcomes of healthcare delivery.
• Communication is essential for effective collaboration with patients, families, and other healthcare professionals.
• Ethics guides nursing practice and involves upholding moral principles such as autonomy, beneficence, non-maleficence, and justice.

The Nursing Process

• The nursing process is a systematic, problem-solving approach to providing patient care.
• Consists of five distinct but interrelated phases: assessment, diagnosis, planning, implementation, and evaluation.

Assessment

• Assessment involves the systematic collection of data about the patient's health status.
• Data can be obtained through various methods, including interviews, physical examinations, and review of medical records.
• Subjective data are information provided by the patient, such as symptoms, feelings, and perceptions.
• Objective data are observable and measurable signs, such as vital signs, physical assessment findings, and laboratory results.

Nursing Diagnosis

• Nursing diagnosis involves analyzing the assessment data to identify actual or potential health problems.
• It differs from medical diagnosis, which focuses on identifying the disease or pathology.
• A nursing diagnosis statement typically includes three parts: the problem, the etiology (related factors), and the defining characteristics (signs and symptoms).

Planning

• Planning involves developing a plan of care that addresses the patient's identified nursing diagnoses.
• Goals and outcomes are established to provide direction for nursing interventions.
• Nursing interventions are specific actions that nurses perform to achieve the desired patient outcomes.
• The plan of care should be individualized, realistic, and based on evidence-based practice.

Implementation

• Implementation involves putting the plan of care into action.
• Nursing interventions are carried out, and the patient's response is monitored.
• Interventions may include direct care, teaching, counseling, and collaboration with other healthcare professionals.
• Documentation of nursing interventions and patient responses is essential.

Evaluation

• Evaluation involves assessing the effectiveness of the plan of care in achieving the desired patient outcomes.
• Data are collected to determine whether the goals have been met.
• The plan of care may be revised based on the evaluation findings.
• Evaluation is an ongoing process that ensures the plan of care remains relevant and effective.

Basic Nursing Skills

• Vital signs assessment includes measuring temperature, pulse, respiration, and blood pressure.
• Hygiene includes bathing, oral care, and skin care to maintain cleanliness and prevent infection.
• Safe patient handling involves using proper techniques to move and transfer patients to prevent injury.
• Medication administration requires knowledge of drug actions, dosages, routes, and side effects.
• Wound care includes assessing and cleansing wounds, applying dressings, and monitoring for signs of infection.
• Infection control practices, such as hand hygiene and standard precautions, are essential to prevent the spread of infection.

Communication Skills

• Therapeutic communication involves using verbal and nonverbal techniques to establish a trusting relationship with the patient.
• Active listening involves paying attention to the patient's verbal and nonverbal cues and providing feedback.
• Empathy involves understanding and sharing the patient's feelings.
• Open-ended questions encourage the patient to provide more information.
• Closed-ended questions elicit specific information.
• Nonverbal communication includes body language, facial expressions, and tone of voice.

Safety

• Patient safety is a priority in nursing.
• Fall prevention involves assessing patients for risk factors and implementing measures to prevent falls.
• Medication safety includes verifying medication orders, administering medications accurately, and monitoring for adverse effects.
• Infection control practices, such as hand hygiene and isolation precautions, are essential to prevent the spread of infection.
• Risk management involves identifying and mitigating potential hazards in the healthcare environment.

Ethical Principles

• Autonomy is the right of patients to make their own decisions about their healthcare.
• Beneficence is the obligation to do good and act in the best interests of the patient.
• Non-maleficence is the obligation to do no harm.
• Justice is the principle of fairness and equality in the distribution of healthcare resources.
• Fidelity is the obligation to keep promises and be loyal to the patient.
• Veracity is the obligation to be honest and truthful.

Legal Considerations

• Nurses are responsible for practicing within the scope of their licensure and adhering to state and federal laws.
• Negligence is the failure to exercise the standard of care that a reasonably prudent nurse would exercise in similar circumstances.
• Malpractice is professional negligence that results in injury to the patient.
• Informed consent is the process of obtaining the patient's agreement to a medical procedure or treatment after providing full disclosure of the risks, benefits, and alternatives.
• Confidentiality is the obligation to protect the patient's privacy and maintain the confidentiality of their medical information.

Health Promotion

• Health promotion involves educating patients about healthy behaviors and lifestyle choices to prevent disease and promote well-being.
• Nurses play a key role in health promotion through education, counseling, and advocacy.
• Health promotion interventions may include teaching about nutrition, exercise, stress management, and disease prevention.

Documentation

• Accurate and complete documentation is essential for providing safe and effective patient care.
• Documentation should be objective, factual, and timely.
• Electronic health records (EHRs) are increasingly used in healthcare settings to document patient care.
• Documentation serves as a legal record of the care provided and can be used for communication, quality improvement, and research.

Cultural Competence

• Cultural competence is the ability to provide care that is sensitive to the cultural beliefs, values, and practices of diverse patient populations.
• Nurses should be aware of their own cultural biases and stereotypes and strive to provide culturally appropriate care.
• Cultural assessment involves gathering information about the patient's cultural background, beliefs, and practices.
• Culturally sensitive communication involves using language and behaviors that are respectful and appropriate for the patient's culture.

Professionalism

• Professionalism involves adhering to ethical principles, maintaining competence, and demonstrating accountability for one's actions.
• Nurses are expected to maintain a professional demeanor, dress appropriately, and communicate effectively with patients, families, and colleagues.
• Continuing education is essential for maintaining competence and staying up-to-date with the latest advances in nursing practice.
• Advocacy involves supporting and defending the rights of patients and promoting their well-being.