Nursing Care: A Detailed Overview

1. Definition and Philosophy

• Compassion and respect for every person's inherent dignity and worth
• Patient advocacy - protecting rights, safety, and self-determination
• Holistic perspective - treating the whole person (physical, psychological, social, spiritual)
• Accountability - nurses have authority over their practice and are responsible for outcomes

2. The Nursing Process (ADPIE)

A - Assessment

• Subjective data: symptoms, pain, patient history (what the patient reports)
• Objective data: vital signs, physical exam findings, lab values
• Functional assessment: ADLs (activities of daily living), mobility, cognition
• Psychosocial assessment: mental health, support systems, coping
• Social Determinants of Health (SDOH): barriers like food insecurity, transportation, financial constraints, and caregiver availability - now mandated by 2025 Joint Commission National Patient Safety Goals

D - Diagnosis (Nursing Diagnosis)

• Actual diagnosis: "Impaired skin integrity related to immobility"
• Risk diagnosis: "Risk for infection related to invasive line"
• Health promotion diagnosis: "Readiness for enhanced self-management"

P - Planning

• Short-term goals (achievable within hours to days)
• Long-term goals (discharge readiness, rehabilitation targets)
• Care plan development - coordinates all members of the healthcare team

I - Implementation (Interventions)

• Independent: actions within nursing scope alone (repositioning, education, comfort measures)
• Dependent: physician-ordered actions (medications, procedures)
• Collaborative: actions coordinated with other disciplines (PT, dietitian, pharmacy)

E - Evaluation

• Has the goal been met, partially met, or not met?
• Revise the care plan accordingly
• Ongoing and continuous - not a one-time step

3. Core Domains of Nursing Care

Physical / Clinical Care

• Vital signs monitoring: temperature, pulse, respiration, blood pressure, oxygen saturation, pain (6th vital sign)
• Medication administration: 5–10 Rights (right patient, drug, dose, route, time, documentation, reason, response, etc.)
• Wound care: assessment, cleansing, dressing selection, infection surveillance
• IV line care: insertion, patency checks, site monitoring, preventing phlebitis
• Catheter care: urinary catheter hygiene, preventing CAUTI
• Respiratory care: positioning, oxygen therapy, incentive spirometry, suctioning
• Nutritional support: oral feeding assistance, enteral/parenteral nutrition monitoring

Personal Hygiene and Comfort

• Bathing and skin care: daily or as needed; burns patients in particular require intensive, often painful bathing that is both therapeutic and physiotherapeutic (Bailey & Love's Surgery)
• Oral hygiene: prevents ventilator-associated pneumonia (VAP) in ICU patients
• Pressure injury prevention: repositioning every 2 hours, specialty mattresses, skin moisture management
• Pain management: pharmacological and non-pharmacological; assessment tools (NRS, VAS, FLACC)
• Sleep promotion: minimizing disruptions, comfort measures

Mobility and Rehabilitation

• Early ambulation: reduces DVT, pneumonia, deconditioning
• Range-of-motion exercises: passive and active
• Transfer and positioning techniques: preventing falls and pressure injuries
• Splinting and elevation: e.g., burn patients need daily joint mobilization from day one to prevent contractures (Bailey & Love's Surgery)

Psychosocial Care

• Therapeutic communication: active listening, empathy, open-ended questioning
• Psychological support: particularly after major illness/trauma - reactions include intrusion, avoidance, and arousal (Bailey & Love's Surgery on burn patients)
• Patient and family education: disease process, medications, discharge instructions, self-care
• Grief and coping support: adjusting to illness, disability, or terminal diagnosis
• Early psychology involvement in major trauma/illness prevents long-term PTSD

Infection Control

• Hand hygiene: single most effective intervention
• Standard and transmission-based precautions: contact, droplet, airborne
• Aseptic technique: wound care, catheter insertion, IV access
• Surveillance: monitoring for healthcare-associated infections (HAIs)

Patient Safety

• Fall prevention: risk assessment (Morse, Hendrich), non-slip footwear, bed alarms, bed in lowest position
• Medication safety: barcode scanning, double-checks for high-alert medications
• Communication: SBAR (Situation-Background-Assessment-Recommendation) handoffs
• Preventing never events: wrong-site, wrong-patient, retained objects

4. Nursing Care Planning

• Ensures all team members know the patient's needs and planned actions
• Provides a legal record that care was delivered (undocumented care = care not given)
• Guides staff assignment based on patient acuity and required skills
• Tracks progress and supports revisions as the patient's condition changes
• Must now include SDOH screening as of the 2025 Joint Commission standards

1. Nursing diagnosis
2. Related factors / etiology ("related to...")
3. Defining characteristics / evidence ("as evidenced by...")
4. Goals/outcomes (SMART: specific, measurable, achievable, relevant, time-bound)
5. Nursing interventions
6. Evaluation/rationale

5. Specialized Nursing Care Areas

6. Documentation

• Narrative notes / SOAP notes: Subjective, Objective, Assessment, Plan
• Flowsheets: vital signs, intake/output, medication administration records (MAR)
• Electronic Health Records (EHR): standardized documentation, clinical decision support
• Documentation creates the evidence that care was provided and guides continuity

7. Ethical and Professional Standards

1. Practice with compassion and respect for every patient's dignity
2. Primary commitment is to the patient
3. Advocate for patient rights, health, and safety; protect privacy
4. Nurses have authority over their practice and are accountable
5. Duty to self - maintain personal integrity, workplace safety, self-respect
6. Improve the ethical environment of the workplace
7. Advance the profession through knowledge development and professional standards
8. Build collaborative relationships across disciplines
9. Work to promote social justice and eliminate health inequities
10. Participate in global health efforts and promote environmental health

8. Quality and Safety Framework (QSEN)

1. Patient-centered care - respect preferences, values, needs
2. Teamwork and collaboration - function effectively in interprofessional teams
3. Evidence-based practice (EBP) - integrate best evidence with clinical expertise and patient values
4. Quality improvement (QI) - use data to monitor outcomes and improve care processes
5. Safety - minimize risk of harm through system effectiveness and individual performance
6. Informatics - use information and technology to communicate, manage knowledge, and support decision-making

Summary