Reference no: EM133949474
ASSESSMENT:
* 1. Collects data through appropriate physical assessment techniques:
a. Physical assessment demonstrates knowledge of anatomy & physiology.
b. Physical assessment data collection is adapted based on the patient's developmental level.
2. Collects data (subjective and objective) from available resources:
a. All references/resources are appropriate, practice-specific professional journals and texts.
b. Interviewing techniques are used to collect data from the patient.
c. All pertinent diagnostic and screening values are analyzed and noted appropriately to the level of the result.
d. Aware of all current medical and nursing orders for the patient.
e. Continually assesses the patient and environment.
3. Documents assessment data in a clear and organized manner:
a. Adapts documentation to setting/patient. Get expert-level assignment help in any subject.
b. Takes the initiative to document all findings, procedures and assessments
4. Shows evidence of preclinical preparation based on knowledge from nursing physical and behavioral sciences:
a. Conducts individual investigation to expand knowledge base.
ANALYSIS:
1. Clinical decision-making reflects an understanding of the relationships of assessment data to the patient's problem/diagnosis:
a. States relationships among complex or chronic human need interruptions and situational/setting/system variables.
b. Makes decisions on culturally sensitive or contemporary health care issues from an understanding of decision theory and current research.
2. Identifies priorities requiring nursing action based on the assessment and determines reassessment as indicated:
a. Recognizes needed changes in healthcare delivery system [HCDS].
b. Prioritizes individual and HCDS needs to maximize patient outcomes.
* 3. Formulates nursing diagnosis based on assessment data:
a. Used in a chronic or complex human need disruption as indicated.
b. Recognizes nursing's contribution potential to recipients.
* 1. Formulates appropriate and measurable goals for self and patient:
a. States realistic goals for a variety of patients.
b. Considers spiritual, ethnic, socioeconomic, etc. factors in goal setting.
* 2. Plans care in a systematic, logical, organized manner:
a. Plans appropriate level of care according to identified acute care needs.
3. Plans health teaching based on identified learning needs and readiness of patient:
a. Acute care education needs are addressed considering ethnic, socioeconomic, etc. factors
4. Communicates clearly regarding nursing care plan with all appropriate individuals:
a. Coordinates among health care workers and patient in planning for meeting health needs
* 1. Utilizes effective and appropriate verbal/non-verbal communication skills:
a. Adapts communication according to situation, setting, patient, and role function.
b. Approaches patient in a non-threatening, non-discriminatory way.
* 2. Provides direct patient care in a safe, accurate, organized manner:
a. Applies time management concepts.
b. Employs principles of delegation and prioritization.
c. Uses change theory and processes to implement alternatives to previously identified activities, when appropriate.
d. Safely, competently and responsibly implements novice nurse role that incorporates research and theory in accordance with standards of practice.
3. Administers medications safely according to established procedure:
a. Applies principles of medication administration to a variety of settings.
* 4. Communicates accurately, verbally and in writing (charting and reporting):
a. Documentation is clear, accurate and comprehensive and reflects conformance to institutional or other specified protocol.
5. Collaborates with patient/family/health care team and other appropriate individuals:
a. Determines referral sources and accurately and clearly communicates information to promote continuity of care.
b. Supervises and coordinates delivery of patient's care.