Nursing_Fundamentals

Empowering Knowledge

•

Directly aligned to

Potter and Perry’s Fundamentals of Nursing 5e

•

Aligned to the Registered Nurse Standards for Practice, 2016 (AUS)

and

Competencies for Registered Nurses, 2007 (NZ)

•

11 new skills,

including patient handover, making a postoperative bed,

assessment of fluid status, and assessment and management of the

deteriorating patient

•

Three additional skills

(not featured in the main text):

––

Pouching a urostomy

––

Regulating CVC intravenous flow rate

––

CVC dressing change and flush

NEW TO THE THIRD EDITION

Monitoring vital signs: using a priMary survey approach for patient assessMent

Assessing the radialandapicalpulses

DeMonstrates:the ability to effectively and safely assess the radial and apicalpulses

CLINICALSKILLSCOMPETENCY

stanDarD/s (aus):thinks critically and analyses nursingpractice;engages in therapeutic andprofessional

relationships;Develops aplan for nursingpractice;provides safe, appropriate and responsivequality nursing

practice;evaluatesoutcomes to informnursingpractice

DoMain/s (nZ):professional responsibility;Managementof nursing care; interpersonal relationships;

interprofessional healthcare andquality improvement

perforMancecriteria

(numbers indicate theregisterednursestandards forpractice,2016 (aus) and thecompetencies forregistered

nurses, 2007 (nZ))

aus 1.1,1.2, 1.3, 2.1, 2.2, 2.3, 2.5, 2.6, 2.7, 5.1, 5.2, 5.3,6.1, 6.2, 7.1, 7.3

nZ 1.1, 1.2, 1.3, 1.4, 1.5, 2.1, 2.2,2.3, 2.4, 2.5, 2.6, 2.7,2.8, 2.9, 3.1, 3.2, 3.3, 4.1, 4.2

S C A L E

i independent

s supervised

a assisted

M Marginal

D Dependent

COMPETENCYCRITERIA PERFORMANCECRITERIA/EVIDENCE

S A M D

identifies indication/

rationale

confirmspatient identity

Determines need toperformpulsemeasurement

identifies appropriate timing formeasuringpulses

identifies any contraindication tomeasuringpulses

therapeutic relationship

andperson considerations

initiates communicationby introductions and clarificationofpatient’s immediate

needs andproblems

clarifiespatient knowledge andprovides educationwhere necessary

explains actions at all stagesofprocedure

gainspatient consent

educatespatient to relax and not to speakduringprocedure

assessesperson

assessespatient for signs and symptomsof altered stroke volume, such as

dyspnoea, fatigue, chestpain, syncope,palpitations,distended jugular veins,

dependentoedema, cyanosis, skinpallor

assesses factors influencing apicalpulse rate and rhythm (e.g. age, recent

exercise,medications,body temperature, emotional stress, fear, anxiety)

performshandhygiene

performs social handwash

adheres to ‘5moments for hand hygiene’ asoutlinedbyhandhygieneaustralia

Wears appropriateppe

gathers equipment

observation chart andpen

Watchwith second hand

stethoscope (apicalpulseonly)

clean non-sterilegloves if appropriate

prepares equipment

considersprivacy and appropriatenessof setting

cleans earpiecesof stethoscope

cleans stethoscope

testsdiaphragmof stethoscope

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FUNDAMENTALS OF NURSING

CLINICAL SKILLS WORKBOOK

COMPETENCYCRITERIA PERFORMANCECRITERIA/EVIDENCE

S A M D

performs clinicalprocedure

Radialpulse

1. restspatient’s arm across torso

2. places tipsof first two fingersovergroove along radialor thumb sideof

patient’s innerwrist

3. lightly compresses against radius toobliteratepulse then slightly releases

pressure topalpatepulse

4. notesqualityofpulse (e.g.weak, thready,bounding)

Apicalpulse

1. removespatient’sgown to expose chest

2. locatespointofmaximal impulse (pMi): locates angleof louis to locate

second intercostal space (ics) and slides fingersdown left sternum to fifth

ics andmid-clavicular line

3. cleans stethoscope

4. Warmsdiaphragmof stethoscope inpalmof hand for 5–10 seconds

5. placesdiaphragmof stethoscopeoverpMi to auscultates

ands

(lub-dub)

6. counts the numberofs

ands

beats

7. replacespatient’sgown andbed linen

ifpulse is regular, counts for 30 seconds andmultiplies totalby2

ifpulse is irregularorpatient is receiving cardiovascularmedications, counts for

60 seconds

assesses frequency andpatternof irregularity

comparesperipheralpulse ratewith apicalpulse rate, noting anydiscrepancies

compares assessmentwithbaselinedata includingbloodpressure and

associated signs and symptoms (e.g.dizziness)

cleans anddisposesof

equipment appropriately

Disposesofppe in appropriate receptacle

performs handhygiene

cleans and restocks equipment

completesdocumentation Documentsobservation (includingpulse and site used) and associated

assessment/complications

recordspulse ratewithdate and timeof assessment

reports abnormal findings

reflection:

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supervisor:

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stuDent naMe:

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Date:

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