Nursing Process

 What are the parts of a nursing diagnosis? Know how to write an appropriate Nursing Diagnosis
o 1.) Diagnostic label (What is the problem?; potential or actual)
o 2.) Etiology (What is the probable cause?)(related to)
o 3.) Defining characteristics (What evidence leads you to 1 & 2?) (As Evidenced By)
o
 Know the steps of the Nursing Process
o 1.) Assessment: gather information about client’s condition
o 2.) Nursing Diagnosis: identify client’s problems
o 3.) Planning: set goals of care & desired outcomes & identify appropriate nursing actions
o 4.) Implementation: perform the nursing actions identified in planning
o 5.) Evaluation: determine if goals met & outcomes achieved
 What is different about a risk diagnosis?  How is a risk diagnosis written?
o Exposure to factors increasing chance of developing certain conditions, risk for infection, risk for falls
o A risk diagnosis is not evidenced by signs & symptoms b/c the problem has not yet occurred; rather nursing
interventions are aimed towards prevention
o A “risk diagnosis”: 2 parts!
 NANDA Diagnostic label: risk for deficient fluid volume
 Evidenced by risk factors of: increased intestinal losses (vomiting and diarrhea) and increased fluid intake
 Write it like this:
 Risk for deficient fluid volume as evidenced by risk factors of increased intestinal losses
(vomiting and diarrhea) and decreased fluid intake
 How to prioritize nursing diagnoses
o ABC
o Safety
o Airway
o Breathing
o Circulation
 Know how to establish MEASURABLE PATIENT CENTERED outcomes
o Measurable criteria is used to evaluate goal achievement. The overall goal is the opposite of nursing diagnosis
o Example: Patient will achieve improved pain control by 1400 on 10/19 (overall goal) a.e.b.:
 Patient will rate pain < 3 on a scale of 0-10
 Verbalize 2 nonpharmacological methods that provide pain refief
 What is the difference between nursing assessments and nursing interventions?
o Nursing assessment
 Gathering data
 Sorting/ organizing collected data
 Documenting data
o It is the gathering of data, the NANDA; on the other hand, nursing interventions is what the nurse does to achieve
their desired outcomes.
 Understand application of the steps of the Nursing Process
o Assessment: 1st step of nursing process; 3 processes: 1. Gathering data, sorting/collecting data, documenting the
data.
 Primary source of data is the patient
 Secondary sources of data are family, friends, healthcare providers, and medical record
 Subjective/Objective data
 Comprehensive ones are guided by databases
 Databases are different depending on the setting
o Diagnosis: 2nd part of nursing process
 Diagnostic Label (What is problem/cause)
 Etiology (What is the probable cause) = RELATED TO
 Defining Characteristics (What evidence leads you to 1 & 2) = AS EVIDENCE BY
o Planning: 3rd part of nursing process
 Goals and expected outcomes
 Establishing priorities
 Nursing actions
 Establishing goals
 Set priorities
  Interventions
 These actions are documented as your PLAN OF CARE
o Implementation: 4th part of nursing process
 When the plan of care is put into action
 When the nurse performs the interventions
 Remember assessment is ongoing! Patient condition changes! Revision of the Nursing Care of Plan is
ongoing
 Direct vs Indirect (delegation) care
o Evaluation: 5th part of nursing process
 Addresses whether established goals are met
 Should directly address the goal statement and the expected outcomes NOT the nursing interventions
 If goal and expected outcomes are met, either continue or establish a new goal
 If goal is unmet, modify either the goal or interventions

Sterile Technique- Wound Care- Dressings- Warm & Cold Therapy- Pressure Injury
Prevention and Care

Sterile Technique:

 Know the principles of sterile technique (surgical asepsis)   

o All items within a sterile field must be sterile.
o A sterile barrier that has been permeated by punctures, tears or moisture must be considered contaminated.
o Once a sterile package is open, a 1-inch border around the edge is considered unsterile.
o Tables draped as part of a sterile field are considered sterile only at table level.
o Any question or doubt whether an item is sterile, the item is considered unsterile.
o Sterile people or items contact only sterile areas; Unsterile people or items contact only unsterile areas.
o Movement around and in the sterile field must not compromise or contaminate the field.
o A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated.
o A sterile object or field becomes contaminated by prolonged exposure to air; stay organized and complete any
procedure as soon as possible.
  Know the steps to prepare and maintain a sterile field
o Prepare
 Open outermost flap away from body first, keeping arm outstretched and away from the sterile field.
 Open side flaps, one at a time keeping arms to side and not over sterile surface
 Grasp outer border of last flap and open towards your body last. Careful to stand away from the sterile
package.
 Tips: No leaning over the sterile field! Sterile items must be waist level or higher. Drape is sterile only at
table level.
o Maintain
 Sterile field is prepared immediately before the sterile procedure
 Never turn backs on a sterile surface (work facing the sterile field)
 Do not lean over a sterile area or place an unsterile arm or item over the sterile field
 Arms and Hands remain above the waist
 Even when discarding items drop from waist high
 Do not let sterile hands migrate below waist level
 Lift up materials, do not drag over edges of containers
 Keep all sterile surfaces dry
 Stay organized and perform efficiently minimizing time that contamination can occur
 If contamination occurs at any time, stop and correct the situation immediately
 When in doubt whether something is sterile, consider it contaminated
  Know how to pour a sterile solution into a container on a sterile field
o Verify solution
o Check expiration
o Palm label
o Removed lid in upright position or discard if single use
o Pour without splashing
o Do not pour over sterile field
o Pour with nonsterile bottle outside of field
o Move your position or angle to avoid contamination
o Do not pour across or reach across sterile field
  Know the steps required to apply sterile gloves   
o Safe glove selection (Assess for latex allergy)
o Obtain proper size for hands
o Place on clean and dry surface at waist level.
o Open carefully not touching the inside of the wrapper or gloves.
o Avoid touching wrapper (inside too) after gloves are donned.
o Do not attempt to smooth down one-inch border with hands.
o Do not remove wrapper from surface after gloves applied! 
o More information
 Perform hand hygiene
 Remove outer glove package wrapper by carefully separating/peeling sides
 Grasp inner package and lay on clean, dry, flat surface at waist level. Open package keeping gloves on
inside of surface wrapper
 Identify right and left glove. Glove dominant hand first
 With thumb and first two fingers of nondominant hand, grasp glove for dominant hand by touching only
inside surface or cuff
 Carefully pull glove over dominant hand, leaving a cuff and being sure that cuff does not roll up on wrist.
Be sure thumb and finger are in proper spaces
 With gloved dominant hand, slip fingers underneath cuff of second glove
 Carefully pull second glove over fingers of nondominant hand
 After second glove is on, interlock hands together and hold away from body above waist level until
beginning procedure

Wound Care and Irrigation:

 Know how to perform a wound assessment (more information on slide 39 in Sterile Technique & Wound Care ppt)
o Location
o Type of wound (i.e., Surgical, Pressure, Trauma)
o Extent of tissue involvement (i.e., Full-thickness or Partial-thickness)
o Type and percentage of tissue in the wound base (i.e., granulation, slough, eschar)
o Wound size (Length X Width X Depth in centimeters)
o Wound exudate (TACCO) Amount: scant, moderate, copious
o Presence of odor
o Periwound area: (Color, temp, and integrity of skin around wound)
o Pain
 Know the difference between wound dehiscence and evisceration
o Dehiscence: separation or splitting open of layers of a surgical wound
o Evisceration: extrusion of viscera or intestine through a surgical wound
 Know how to describe different wound drainage: serous, serosanguineous, sanguineous, purulent
o Serous: clear-like, watery plasma
o Serosanguineous: pink/ pale red drainage; mixture of serous and sanguineous
o Sanguineous: bright red drainage indicating fresh bleeding
o Purulent: thick and yellow, pale green, tan, or brown drainage
 Know how to describe the amount of drainage: copious, moderate, scant
o Copious: wound tissues are filled with fluid that involves more than 75% of the dressing
o Moderate: wound tissues are wet, the drainage involves 25% to 75% of the dressing
o Scant: wound tissues are moist, but there is no measurable drainage
 Know the difference between slough and necrosis
o Slough: Tissue that can be yellow; cream colored; or gray slough, which is usually accompanied by purulent
drainage.
 For patients with a low infection risk, the use of moisture-retentive dressings enhances debridement of the
yellow/slough tissue
 Moisture-retentive dressings may include moist dressings, hydrocolloids, hydrogels, or alginates.
o Necrosis: Black is used to describe necrotic tissue or desiccated tissue such as tendon. It is also related to
gangrenous lesions secondary to peripheral vascular disease.
 Know how to clean a wound
o
 Know how to irrigate a wound
 o Wound irrigation cleans open surgical or chronic wounds such as pressure injuries. Typically, the irrigation on an
open wound involves the use of clean gloves.
o Irrigation involves introducing the cleaning solution directly onto the wound with a syringe, syringe and catheter,
pulsed lavage device, or a handheld shower.
 Perform hand hygiene
 Form cuff on waterproof biohazard bag and place near bed
 Apply gown, mask, goggles as indicated; apply clean gloves and remove old dressing
 Discard old dressing and gloves in biohazard bag. Perform hand hygiene.
 Apply sterile gloves and perform wound assessment
 Expose area near wound only
o Irrigate wound with wide opening:
 Full 35-ml syringe with irrigation solution
 Attach 19-gauge Angio catheter
 Hold syringe tip 2.5 cm (1 in) above upper end of wound and over area being cleaned
 Using continuous pressure, flush wound; repeat steps until solution draining into basin is clear
o Irrigate deep wound with very small opening:
 Attach soft catheter to filled irrigation syringe
 Gently insert tip of catheter into opening about 1.3 m (0.5 in)
 Flush wound using slow continuous pressure
 While keeping catheter in place, pinch it off just below syringe
 Remove and fill syringe. Reconnect catheter and repeat until solution draining into basin is clear
o Clean wound with handheld shower:
 With patient seated comfortably in shower chair or standing in condition allows, adjust spray to gentle
flow; make sure water is warm
 Shower for 5 to 10 minutes with shower head 30 cm (12 inches) from wound
o When indicated, obtain cultures after cleaning with non-bacteriostatic saline
o Dry wound edges with gauze; dry patient after shower
o Remove/dispose of gloves. Perform hand hygiene. Apply sterile gloves. Apply appropriate dressing and label with
time, date, and nurse’s initials
o Remove mask, goggles, and gown
o Dispose equipment and soiled supplies; remove/dispose of gloves. Perform hand hygiene
o Help patient to comfortable position
 Be prepared to document care of a wound
o Record type of wound tissue present in injury, wound measurements, periwound skin condition, character of
drainage or exudate, type of topical agent used, dressing applied, and patient’s response
o Record patient’s understanding through teach-back for reasons for frequent observation and measuring of wound
o Report any deterioration in wound appearance to nurse in charge or health care provider
 Review how to remove staples
o Considerations: Location of incision, any patient allergies, agency policy, and HCP order
o Supplies needed: suture removal or staple removal kit, 4x4 gauze, antiseptic swabs per agency protocol, clean
gloves, biohazard bag, Steri- Strips (adhesive strips), and sharps container
o Adequate lighting for visualization (proper assessment) & Hand Hygiene!
o Incision Assessment: Ensure safe to remove (site well-approximated and healed together without observable
complication?)
o Plan to remove every other suture or staple if order does not specify and check agency policy
o Report any abnormal findings to HCP BEFORE removing
o Removing staples
 Place lower tips of staple extractor under first staple. As you close handles, upper tip of extractor depresses
center of staple, causing both ends of staple to be bent upward and simultaneously exit their insertion sites
in dermal layer
 Carefully control staple extractor
 As soon as both ends of staple are visible, move it away from skin surface and continue until staple is over
refuse bag
 Release handles of staple extractor, allowing staple to drop into refuse bag
 Repeat steps above until all staples are removed
 Review the different types of wound drains
o Serous, serosanguineous, sanguineous, and purulent (listed in a question above)
 Be familiar with assessment techniques for staging pressure ulcers
o Braden Scale for predicting pressure ulcer risk

 Know how to assess for pressure on dark skinned patients
o Patients with darkly pigmented skin cannot be assessed for pressure injury risk by examining only skin color.
Changes in sensation, temperature, or tissue consistency may precede visual skin changes. Palpate tissue consistency
between area of injury and normal tissue to detect changes. (more information on pg. 994 in skills book)
 Know how to prevent pressure injury
o Routinely assess patients for risk (Palpate tissue consistency in dark skin to detect changes)
o Reposition patients every 1 to 2 hours when in bed
o Float heels off the bed
o Shift position every 15 minutes when in chair.
o Use specialized beds, overlays, and mattresses to redistribute pressure over bony prominences. Consider chair
cushions when seated.
o Clean incontinence episodes promptly
o Minimize friction and shear. Use lift sheets. Raise head of bed no more than 30 degrees (unless medically
contraindicated)
o Adequate nutrition: High protein, adequate calories, vitamins and minerals
 Check labs: CBC, Prealbumin, and Albumin
o Assess and inspect skin at least daily. Note all pressure points; document results
o Establish risk using standardized scale (Braden)
o Factors that increase incidence of PI
 Pressure over bony prominences
 Poorly positioned or Ill-fitting medical devices
 Incontinence
 Shear stress
 Immobility
 Loss of sensory perception
 Malnutrition
 What are some hazards of immobility?

Dressings, Bandages, and Binders:

 Review the different types of dressings, bandages and binders.

o Dressings
 Hydrogel–Provides moisture to wound
 Alginate- Highly absorptive (made of seaweed)
 Foams-Provide absorption and padding (Allevyn)
 Gauze-Use mesh gauze for moist-to-dry dressings or drain sponge for managing drainage (around trach)
  Hydrocolloids-adhesive and molds to body (Duoderm)
o Bandages
 Available in rolls of various widths and materials, including gauze, elastic, webbing, elasticized knit, and
muslin
 Gauze bandages are lightweight and inexpensive, mold easily around body contours, and permit
air circulation to prevent skin maceration.
 Elastic bandages apply compression. Elastic compression to a lower extremity prevents edema by
promoting the return of blood from the peripheral to the central circulation
o Binders
 Abdominal (most common)
 An abdominal binder supports large abdominal incisions that are vulnerable to tension or stress as
a patient moves or coughs.
 Lessens pain in postoperative patients.
 Enhances recovery of walk performance, controlling pain, and improving patient's experience
following major abdominal surgery.
 Know about a wound V.A.C
o Negative pressure would therapy
 Helps to remove drainage away from wound
 Increases circulation, decreases local tissue swelling, increases granulation tissue

 Review how to wrap different types of bandages

o Top: Correct method for bandaging midthigh amputation stump.
 Note that bandage must be anchored around patient's waist.
o Bottom: Correct method for bandaging midcalf amputation stump.
 Note that bandage need not be anchored around waist

Warm and Cold Therapy:

 Know the effects of warm and cold therapy

o Cold = Vasoconstriction = ↓Bleeding, Swelling & Pain
o Heat = Vasodilation = ↓pain
 Identify patients who are at risk for injury with the application of hot and cold therapy
o DO NOT USE HOT OR COLD IF THERE ARE ALTERATIONS IN PERFUSION (i.e., diabetes, peripheral
vascular disease, etc.)

Recording- Reporting- Informatics

Documentation

 Be familiar with legal documentation guidelines

 Be familiar with common record-keeping Forms (Admission History, Flow and Graphic Sheets, Kardex, Standardized Care
Plans, Discharge Summary Forms, Electronic Health Record)
o Admission nursing history forms:
 A nurse completes a comprehensive nursing history form or screen to gather baseline assessment data when
a patient is admitted to a nursing care unit.
o Flow sheets and graphic records:
 Permit concise documentation over time.
 Use a format or system for entry of information, usually every 24 hours.
 May be assigned to a nurse assistant for data entry.
o Kardex:
  A “cardboard flip-over” file kept at the nurses’ station that provides information for daily patient care
needs; it has two parts: an activity and treatment section, and a nursing care plan section. It eliminates the
need for repeated referral to chart for routine information throughout the day. Include the following:
 Basic demographic data (age, religion, etc.)
 Primary medical diagnosis
 HCP’s orders
 Nursing orders/interventions
 Scheduled tests/procedures
 Allergies
o Standardized care plans are computer-generated care plans based on the nursing assessment and customized for the
patient. They are provided for the patient daily.
 Advantages: evidence-based, improve continuity of care. Nurses learn to recognize the accepted
requirements of care for patients
 Disadvantages: may not include unique therapies that some patients need, do not replace your professional
judgment/decision making, need to be updated regularly.
o The discharge summary provides information related to a patient’s ongoing health problems and need for health care
after discharge.
 Includes reason for hospitalization, significant findings, current status of patient, teaching plan
 Emphasizes previous learning by patient/family and care that needs to continue.
o The Electronic Health Record is a longitudinal electronic record of patient health information generated by one or
more encounters in a care delivery setting.
 Sign on your HER using only your password
 Never share, always keep passwords private.
 Only open EHRs for patients you are caring for
 Know and implement agency protocol to correct documentation errors
 Save information as documentation is completed
 Sign off whenever you leave computer
 Know the Social media Guidelines for nurses
o Don’t post about patients
o Don’t post defamatory comments
o Don’t follow patients
o Can be subject to disciplinary action
 Compare and contrast the different charting systems (Narrative documentation, Problem- oriented medical records, SOAP, PIE,
Focus, SBAR, Charting by Exception)
o Narrative documentation
 Story-like format, usually in chronological order; useful in emergency situations when time and order of
events is important
 Replaced by SBAR and focus charting in some settings
o Problem-oriented medical records
 Structured method of documenting narrative that emphasizes a patient’s problems. This method organizes
data using the nursing process, which facilitates communication about patient needs. Data is organized by
problem or diagnosis. Ideally all members of HC team contribute to list to help coordinate and
individualized plan of care with the following sections:
 Patient database
 Problem list
 Plan of care
 Progress notes
o SOAP Documentation
 Subjective
 Objective
 Assessment/Analysis
 Plan
 Logic for SOAP notes is similar to nursing process: collects data about patient’s problems, draws
conclusions, and develop a plan of care
o PIE Documentation
 Problem or nursing diagnosis for the patient
 Interventions or actions taken
 Evaluation of the outcomes of nursing interventions
 Differs from SOAP in that PIE HAS A NURSING ORIGIN, whereas SOAP originates from a NURSING
MODEL
  Differs from SOAP because there are no assessment data in the narrative note. Instead, assessment data is
included in documentation on flow sheets
o Focus charting or DART
 Data
 Action
 Response
 Teaching
 Places less importance on patient problems and focuses on patient concerns such as a sign or symptom,
condition, nursing diagnosis, behavior, significant event, or change in condition. Includes both subjective
and objective data. Saves time because it is easy for caregivers to understand
o SBAR Documentation
 Situation
 Background
 Assessment
 Recommendation
 Concrete approach for framing conversations, especially critical ones that require the nurse’s immediate
attention and action. Allows for an easy and focused way to set expectations for what the team will
communicate
o Charting by exception (CBE)
 Aims to eliminate redundancy
 Emphasizes abnormal findings
 Identifies trends
 System of documentation that aims to eliminate redundancy and make more concise. Emphasizes abnormal
findings and identifies trends in clinical care. Involves creating a flow sheet that uses a check mark to
indicate normal findings and routine interventions
 Review how to give a Change of Shift Report
o 1.) Use and organized format for delivering report that provides description of patient needs and problems. SBAR
(Situation, Background, Assessment, Recommendation) can be used to organize and streamline report.
o 2.) Identify the electronic patient record using at least 2 identifiers
o 3.) Gather information from documentation sources, NAP report, or other relevant documents
o 4.) Prioritize information on the basis of patient’s needs and problems
o 5.) For each of patient include the following
 S: Situation – patient’s name, gender, age, chief complaint on admission, and current situation
 B: Background Information – allergies, emergency code status (DNRs), medical and surgical histories,
special needs, etc.
 A: Assessment data – objective observations and measurements made by nurse during shift. Include
relevant information reported by patient, family care giver, or health care team members, such as lab data
and test results. Describe education in the teaching plan and patient’s/family caregiver’s ability to
demonstrate learning. Review patient’s progress toward discharge during each change-of-shift report
 R: Recommend – Explanation of priorities to which oncoming nurse must attend, including referrals,
nursing orders, and core measures. Ask staff from oncoming shift if they have any questions regarding
information provided
 Be familiar with Incident Reports
o Any event not consistent with routine operation of a health care unit or routine care of patient
o Examples: patient falls, needlestick injuries, medication errors, or a visitor becoming ill, or if a patient is
administered the wrong medication by a nurse
o Completion of an occurrence report happens when there is an actual or potential patient injury that is not part of the
patient record. Document in the patient’s record an objective description of what you observed, and follow-up
actions taken without reference to it. Reporting helps to identify high-risk trends in nursing care or daily unit
operations that warrant correction. You complete the report even if an injury does not occur or is not apparent. Great
opportunity to improve patient safety.
 Practice writing DART notes (Focus notes)
o
 Know the Official "Do Not Use" list
o DO NOT erase, apply correction fluid, or scratch out errors made while recording. Draw a single line through the
error, write the word “error” above it, and sign your name or initials
o DO NOT write retaliatory or critical comments about patient or care by other health care professionals. Enter only
objective descriptions of patient’s behavior, use quotations for patients’ comments
o DO NOT try to add additional information to a previously made entry. If additional information needs to be added
to an existing entry, write the date and time of the new entry on the next available space, and mark it as an
addendum
o DO NOT rush to complete charting; make sure information is accurate. Correct ALL errors promptly
o DO NOT speculate or guess while making entries, make sure to state the facts. Record ALL the facts, so that the
information is accurate and reliable
o DO NOT leave blank spaces in nurses’ notes. Chart consecutively, line by line; if space is left draw a line
horizontally through it, and sign your name at the end
o Record all entries legibly and in black or blue ink (check institution’s policy). DO NOT chart with a pencil or a felt
tip pen
o DO NOT record “physician made error.” Instead chart that “Dr. Smith was called to clarify order for analgesic.” If
an order is questioned, record that you sought clarification
o Never chart for someone else, only chart for yourself. You are accountable for the information you enter into a chart
o AVOID using generalized terms, or empty phrases such as “status unchanged” or “had a good day” Use complete
and concise descriptions of care
o DO NOT wait until the end of the shift to record important changes that occurred several hours earlier, be sure to
sign each entry. Begin each entry with time, and end with your signature and title
o DO NOT leave a computer screen unattended if you are logged on. Always keep your password to yourself to help
maintain security and confidentiality