Definitions and differences of:
Standards of Nursing Practice
o Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation
Nurse Practice Act
o Laws established in each state in the United States to regulate the practice of
nursing
o Defines the legal scope of nursing practice
o Create a state board of nursing having the authority to make and enforce rules
concerning the nursing profession
Code of Ethics
o Professional values provide the foundation for nursing practice and will guide
your interactions with patients, colleagues, and the public.
o Altruism, autonomy, human dignity, integrity, and social justice
Nursing Process Steps
Assessment
Diagnosis
Planning
Implementation
Evaluation
Teaching
Assessing client’s knowledge – The nurse needs to assess the client’s background level of
knowledge and any barriers to communication. This will guide the treatment plan
Assess knowledge of different treatment options – Check reliable, factual sources for
options that may better assist the patient
, Types of Assessments
Initial – Performed when patient is admitted to gain a baseline of patient
Client Centered – Assess social environment, health literacy, and communication skills
Focused – Gathers data about a specific problem that has already been identified
Time lapsed – Compares a patient’s current status with the baseline data
Subjective vs. Objective Data
Objective data is observable and measurable by someone other than the person
experiencing the symptoms
o Ex. Elevated temperature, moist skin
Subjective data – Information perceived by the patient only
o Ex. Patient reports having a headache
Collecting and Validating Data
The reason for collecting and validating data by multiple personal is to promote safe care
and avoid errors. Validating data is important to ensure the correct information is
documented and the appropriate nursing care is provided
Nursing Assessment
Inspection
o Performing purposeful observations in a systematic manner
Auscultation
o The act of listening with a stethoscope to sounds produced within the body
Percussion
o The act of striking one object against another to produce sound (abdomen and
tympany sound)
Palpation
o Use the sense of touch to assess temperature, turgor, texture, moisture, and
vibrations within the body