Nursing_Fundamentals_Catalogue
NEW TO THE THIRD EDITION
• 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
Monitoring vital signs: using a priMary survey approach for patient assessMent 21
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FUNDAMENTALS OF NURSING CLINICAL SKILLS WORKBOOK
Assessing the radialandapicalpulses
COMPETENCYCRITERIA PERFORMANCECRITERIA/EVIDENCE
I
S A M D
S C A L E
DeMonstrates:the ability to effectively and safely assess the radial and apicalpulses CLINICALSKILLSCOMPETENCY
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 1 ands 2 (lub-dub) 6. counts the numberofs 1 ands 2 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)
performs clinicalprocedure
i independent s supervised a assisted M Marginal D Dependent
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
COMPETENCYCRITERIA PERFORMANCECRITERIA/EVIDENCE
I
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 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) performs social handwash adheres to ‘5moments for hand hygiene’ asoutlinedbyhandhygieneaustralia Wears appropriateppe
cleans anddisposesof equipment appropriately
Disposesofppe in appropriate receptacle performs handhygiene cleans and restocks equipment
assessesperson
completesdocumentation Documentsobservation (includingpulse and site used) and associated assessment/complications recordspulse ratewithdate and timeof assessment reports abnormal findings
performshandhygiene
reflection:
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gathers equipment
observation chart andpen Watchwith second hand stethoscope (apicalpulseonly) clean non-sterilegloves if appropriate
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supervisor:
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prepares equipment
considersprivacy and appropriatenessof setting cleans earpiecesof stethoscope cleans stethoscope testsdiaphragmof stethoscope
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