Fundamentals session 10:

Here is session 10 already, and this is the second to last class before the final! In this session we focused on care plans, nursing diagnosis, as well as communication. There are common sense tactics for communication, and the care plans will be a skill that improves with time as more and more a written. Happy studying!


Session 10:

Nursing process and Diagnosis

the nursing process has changed over the years

1950’s care cure and core: assessment decision and nursing action

1967 APIE – assessment, planning, implementation, evaluation

  • Discover, delve, decide, do, discriminate

1970 nursing diagnosis is a separate step

APIE additions – Nursing diagnosis, and outcome identification

  • assessment, Nursing diagnosis, and outcome identification, planning, implementation, evaluation
  • discrete 6 step process
  • You will need to be able to verbalize this to your preceptor


  • the initial assessment is very important and sets the baseline of that patient
  • it directs care, and will set the goal for discharge

outcome identification – the goal for discharge

  • realistic client focused goals that are measurable
    • activity or VS goals
  • can be the patient’s goal, said by the patient

Planning – five column plan of care (one problem per plan)

  • Assessment Data
  • Goals
  • Interventions
  • Rational
  • outcome/ replanning


  • it’s what you do to the patient


  • how did the implementation go?
  • Should be measurable


  • Identifies the plan of care
  • a nursing diagnosis provides the basis for selection of nursing interventions
    • pressure ulcer
    • fall risk
  • types
    • Actual – human response to a health problem that is happening right now
      • 1. Diagnostic label must be NANDA approved
      • 2. Related factors – what contributes to the problem
        • Related to…
      • 3. Defining characteristics – observable cues that are related to the problem Dx
        • as evidenced by….
      • EX: impaired physical mobility R/T hip replacement as evidenced by inability to ambulate w/ walker
    • Risk – problems that may develop
    • wellness – we didn’t really go over this
    • possible – or this but may be tested on the NCLEX

Communication in Healthcare Communication on teams

Reporting from nurse to nurse is an art and needs to be practiced

  • develop good habits around the end of shift reports
  • “I don’t know” is not acceptable

reporting to provider

  • make it specific to the person that you are talking to
  • always see and assess the patient before making the call to the physician
  • know the notes associated to the patient

Any information that the patient give to you needs to be shared with the patient

circle of confidentiality is inside the care team

SBAR – know the tool and be comfortable

document read back – RB*1


  • we will be trained in all of these
  • improves patient safety
  • optimises team
  • every voice is heard and empowers everyone on the team
  • focused on the care plan
  • checklists, huddle
  • support team members
  • the Brief is important and comes first
  • huddle can happen at any time, is a specific time sensitive issue
  • debrief after care, what we did well, and what can be improved on

two challenge rule

  • tell the person at least twice before moving up the chain of command

Closed loop communication is crucial


  • this is a area when error can occur at a higher rate
  • clarify and ask questions


  • make sure charting is top notch when the care is not going as planned or there are questions that you are unsure about.
  • watch out for copy forwarding there is a huge chance to make errors
  • use military time
  • avoid vague descriptions
  • be concise, and objective. not subjective

theory of interpersonal relationships

  • do things with the patient, not for the patient
  • positive regard for patient ie, warmth, trust, positive attitude

Nonverbal communication is a huge % of total communication, about 90% or as low as 75%

OARS style motivational interviewing

  • Open ended q’s
  • Affirm
    • make it genuine and your own style
  • Restate
  • Summarize

clarity, going over the big picture


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