Nursing_Fundamentals_Catalogue

KEY FEATURES

• 78 Clinical Skills linking applied nursing skills to effective clinical practice, each featuring: –– An overview of each skill, containing rationales to help understand how and why the skill is performed –– A focus on therapeutic relationships and patient considerations, reminding students that the patient is central to care provision –– Equipment checklist –– A step-by-step approach, clearly explaining how to perform each skill –– Critical decision points, alerting students to critical steps to ensure quality and safety in patient care –– Competency checklist, providing a valuable tool for assessment, including the five-point Bondy Rating Scale –– Reflection opportunity at the end of each competency checklist to encourage learning

Monitoring vital signs: using a priMary survey approach for patient assessMent 17

S K I L L 2 3 - 3

The five-point Bondy Rating Scale

assessing the radial and apical pulses

Delegationconsiderations pulsemeasurement canbedelegated to enrolled nurses who are informedof: • patient historyor riskof irregularpulse • frequencyofpulsemeasurement • theusual reportable levels for thepatient • theneed to report any abnormalities. Equipment • stethoscope (apicalpulseonly) • Watchwith secondhandor adigitaldisplay • pen,observation chart • alcohol swab

Therapeutic relationshipandpatient considerations • confirmspatient identity • gainspatient consent • initiates communicationby introductions and clarificationofpatient’s immediate needs and problems • identifies how the skillwill affect thepatient • Discussesprocedurewith thepatient to clarify understanding • provides reassurance • assessespatient knowledge and expectations and ensurespatient understanding • Wherenecessary,provides further clarification • explains actions andpotentialdiscomfort at all stagesofprocedure certain conditionsplacepatients at riskofpulse alterations.heart rhythm canbe affectedby heart disease, cardiac arrhythmias,onsetof sudden chest painor acutepain from any site, invasive cardiovascular diagnostic tests, surgery, sudden infusionof large volumeof intravenous fluid, internalor external haemorrhage and administrationofmedications that alterheart function. RATIONALE

Thefive-pointBondyRating Scale is auseful tool for assessingprofessional competency and, subsequently, the amountof supervisionneeded to successfullymaster thenursing skills included in thisworkbook.The scale is also auseful indicator of students’ ability to carryout these skillswith accuracy, safety and satisfactory effect.

Scale label

Score Standardofprocedure

Qualityofperformance Levelofassistance required

no supporting cues required

Proficient Confident expedient

Independent 5

safe Accurate Achieved intendedoutcome Behaviour is appropriate to context safe Accurate Achieved intendedoutcome Behaviour is appropriate to context

requiresoccasional supportive cues

Proficient Confident reasonably expedient

supervised 4

Proficient throughoutmost ofperformancewhen assisted

requires frequent verbal and occasionalphysicaldirectives in addition to supportive cues

Assisted

3

safe Accurate Achievedmostobjectives for intendedoutcome Behaviourgenerally appropriate to context safeonlywithguidance not completely accurate Incomplete achievementof intendedoutcome unsafe unable todemonstratebehaviour Lackof insight intobehaviour appropriate to context

STEPS

1. Determine the frequencyofmonitoring the radialor apicalpulse: a. considerpreviousmedical conditions for alterations in apicalpulse.

unskilled Inefficient

requires continuous verbal and frequentphysicaldirective cues requires continuous verbal and continuousphysical directive cues

Marginal

2

unskilled unable todemonstrate behaviour/procedure

Dependent

1

X notobserved www.edcan.org/pdf/edCanFactsheetCAt.pdf Publishedwithpermission fromsLACK Incorporated Adapted fromKnBondy 1983Criterion-referenceddefinitions for rating scales in clinical evaluation. JournalofNursingEducation 22(9):376–382. 0

physical signs and symptomsmay indicate alteration in cardiac function.

b. assess for signs and symptomsof altered cardiacoutput such asdyspnoea, fatigue, chest pain,orthopnoea, syncope,palpitations (person’s unpleasant awarenessofheartbeat), jugular venousdistension,oedemaofdependentbody parts, cyanosisorpallorof skin.

2. assess for factors thatnormally influence apical pulse rate and rhythm:

allows for accurate assessmentofpresence and significanceofpulse alterations.

a. age

acceptable rangeof heart rate changeswith age (see table23-5 † ).

b. exercise

physical activity requires an increase in cardiacoutput that ismetby an increasedheart rate and stroke volume.

c. position changes

heart rate increases temporarilywhen changing from lying to sittingor standingposition.

† see Potter andPerry’sFundamentalsofNursing 5e.

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