Nursing Fundamentals: Essential Skills for Quality Patient Care

Nursing Fundamentals: Documentation, Infection Control, Patient Hygiene, Vital Signs Assessment, Communication in Healthcare

Nursing fundamentals are the essential knowledge and skills that every nurse should possess to provide quality care to patients. This article will focus on five key subtopics within nursing fundamentals: documentation, infection control, patient hygiene, vital signs assessment, and communication in healthcare.

Documentation

Documentation is a critical aspect of nursing practice, as it helps ensure accurate and thorough records of patient care. Proper documentation includes:

• Minimum Data Set (MDS): A federally mandated assessment tool used in skilled nursing facilities to track a patient's goal achievement and coordinate the efforts of the healthcare team to optimize the resident's quality of care and quality of life.
• Narrative note: A type of documentation that chronicles all of the patient's assessment findings and nursing activities that occurred throughout the shift.
• Nontherapeutic responses: Responses to patients that block communication, expression of emotion, or problem-solving.
• Therapeutic communication: The purposeful, interpersonal information transmitting process through words and behaviors based on both parties' knowledge, attitudes, and skills, which leads to patient understanding and participation.
• Verbal communication: Exchange of information using words understood by the receiver.

Infection Control

Infection control is a fundamental nursing skill that helps prevent the spread of infection among patients. Key aspects include:

• Monitoring vital signs: Assessing a patient's temperature, pulse, respiration rate, and blood pressure for signs of infection.
• Personal protective equipment (PPE): Wearing gowns, eyewear, face shields, gloves, and masks to prevent the spread of infection.
• Aseptic technique: Following strict procedures to prevent contamination during invasive procedures or care of open wounds.
• Standard precautions: Applying universal precautions to all patients to prevent the spread of infection.
• Transmission-based precautions: Implementing additional measures when a patient has or is suspected of having an infectious disease.

Patient Hygiene

Patient hygiene is essential for maintaining health and preventing infection. Nurses should promote:

• Daily bathing: Ensuring patients receive regular baths to maintain cleanliness and skin integrity.
• Oral care: Providing assistance with brushing teeth or using mouthwash to prevent oral infections.
• Perineal care: Performing appropriate perineal care for patients with urinary or fecal incontinence.
• Hand hygiene: Encouraging patients to wash their hands frequently and demonstrating proper handwashing techniques.
• Moisturizing dry skin: Applying lotions or creams to prevent dry, cracked skin that can increase the risk of infection.

Vital Signs Assessment

Assessing vital signs is a crucial nursing task that helps detect early signs of infection or other health issues. Nurses should be proficient in taking and interpreting temperature, pulse, respiration rate, and blood pressure measurements.

Communication in Healthcare

Effective communication is essential for delivering high-quality patient care. Nurses should:

• Use therapeutic communication techniques: Encouraging patients to explore feelings, problem-solve, and cope with medical conditions and life events.
• Adapt communication to meet patients' needs: Assessing each patient's preferred method of communication and adapting accordingly.
• Provide feedback: Ensuring patients understand the information provided and addressing any misunderstandings or concerns.
• Collaborate with healthcare team members: Communicating effectively with other healthcare professionals to coordinate patient care.

In conclusion, nursing fundamentals encompass a wide range of knowledge and skills that nurses must master to provide quality care to patients. By focusing on documentation, infection control, patient hygiene, vital signs assessment, and communication in healthcare, nurses can ensure the highest level of care for their patients.