include assessment skills, caring skills, counseling skills, and comforting skills.
Assessment Skills
Before the nurse can determine what care a person re- quires, he or she must determine the client’s needs and problems. This requires the use of assessment skills(acts that involve collecting data), which include interviewing, observing, and examining the client and in some cases the client’s family (familyis used loosely to refer to the peo- ple with whom the client lives and associates). Although the client and the family are the primary sources of infor- mation, the nurse also reviews the client’s medical record and talks with other health care workers to obtain facts.
Assessment skills are discussed in more detail in Unit 4.
Caring Skills
Caring skills(nursing interventions that restore or main- tain a person’s health) may involve actions as simple as assisting with activities of daily living(ADLs), the acts that people normally do every day. Examples of ADLs in- clude bathing, grooming, dressing, toileting, and eating.
TRENDS IN HEALTH CARE AND NURSING
TABLE 1-4
HEALTH CARE NURSING
The most underserved health care populations include older adults, ethnic minorities, and the poor, who delay seeking early treatment because they cannot afford it.
The number of uninsured rose from 37 million in 1995 to 41.2 million in 2002. This figure could exceed 48 million by 2009.
Medicare and Medicaid benefits are being modified and reduced.
Chronic illness is the major health problem.
Disease and injury prevention and health promotion are priorities.
Medicine tends to focus on high technology, which improves outcomes for a select few.
Hospitals are downsizing and hiring unlicensed personnel to perform procedures once in the exclusive domain of licensed nurses for cost containment.
There are fewer primary care physicians in rural areas.
Changes in reimbursement practices have created a shift in decision making from hospitals, nurses, and physicians to insurance companies.
Health care costs continue to increase despite managed care practices (cost-containment strategies used to plan and coordinate a client’s care to avoid delays, unnecessary services, or overuse of expensive resources).
Capitation(strategy for controlling health care costs by paying a fixed amount per member) encourages health providers to limit tests and services to increase profits.
Hospitals, practitioners, and health insurance companies are being required to measure, monitor, and manage quality of care.
Enrollments and numbers of graduates from LPN/LVN and RN educational programs are not keeping pace with projected shortages.
More licensed nurses are earning master’s and doc- toral degrees.
There continues to be a shortage of nurses in various health care settings because of decreased enroll- ments, retirement, attrition, and cost-containment measures.
Hospital employment is decreasing.
Client-to-nurse ratios in employment settings are higher.
More high-acuity clients are in previously nonacute settings such as long-term and intermediate health care facilities.
Job opportunities have expanded to outpatient ser- vices, home health care, hospice programs, com- munity health, and mental health agencies.
C H A P T E R 1 ● Nursing Foundations 13
FIGURE 1-6
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Example of recovery pathway in managed care. (Courtesy of Elkhart General Hospital, Elkhart, IN.) (continued)14 U N I T 1 ● Exploring Contemporary Nursing
FIGURE 1-6
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(Continued).Increasingly, however, the nurse’s role is expanding to include the safe care of clients who require invasive or highly technical equipment. This textbook introduces beginning nurses to the concepts and skills needed to provide care for clients whose disorders have fairly pre- dictable outcomes. After this foundation has been estab- lished, students may add to their initial knowledge base.
Traditionally, nurses always have been providers of physical care for people unable to meet their own health needs independently. But caring also involves the con- cern and attachment that result from the close relation- ship of one human being with another. Nevertheless, the nurse ultimately wants clients to become self-reliant.
The nurse who assumes too much care for clients, like a parent who continues to tie a child’s shoes, often delays their independence.
Counseling Skills
A counselor is one who listens to a client’s needs, responds with information based on his or her area of expertise, and facilitates the outcome that a client desires. Nurses imple- mentcounseling skills(interventions that include communi- cating with clients, actively listening during exchanges of information, offering pertinent health teaching, and pro- viding emotional support) in relationships with clients.
To understand the client’s perspective, the nurse uses therapeutic communication techniques to encourage ver- bal expression (see Chap. 7). The use of active listening
(demonstrating full attention to what is being said, hearing both the content being communicated and the unspoken message) facilitates therapeutic interactions. Giving clients the opportunity to be heard helps them to organize their thoughts and to evaluate their situation more realistically.
When the client’s perspective is clear, the nurse pro- vides pertinent health information without offering specific advice. By reserving personal opinions, nurses promote the right of every person to make his or her own decisions and choices on matters affecting health and ill- ness care. The role of the nurse is to share information about potential alternatives, allow clients the freedom to choose, and support the final decision.
While giving care, the nurse finds many opportunities to teach clients how to promote healing processes, stay well, prevent illness, and carry out ADLs in the best pos- sible way. People know much more about health and health care today, and they expect nurses to share accu- rate information with them.
Because clients do not always communicate their feel- ings to strangers, nurses use empathy(intuitive aware- ness of what the client is experiencing) to perceive the client’s emotional state and need for support. This skill differs from sympathy(feeling as emotionally distraught as the client). Empathy helps the nurse become effective in providing for the client’s needs while remaining com- passionately detached.
Comforting Skills
Nightingale’s presence and the light from her lamp com- municated comfort to the frightened British soldiers. As a result of that heritage, contemporary nurses understand that illness often causes feelings of insecurity that may threaten the client’s or family’s ability to cope; they may feel very vulnerable. It is then that the nurse uses comfort- ing skills(interventions that provide stability and security during a health-related crisis) (Fig. 1-7). The nurse be- comes the client’s guide, companion, and interpreter.
This supportive relationship generally increases trust and reduces fear and worry.
As a result of one woman’s efforts, modern nursing was born. It has continued to mature and flourish ever since. The skills that Nightingale performed on a very grand scale are repeated today during each and every nurse–client relationship.
FIGURE 1-7
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This nurse offers comfort and emotional support.(Copyright B. Proud.)
Stop • Think + Respond BOX 1-2 Identify which of the following nursing actions is an assessment skill, caring skill, counseling skill, and comfort- ing skill: (a) the nurse discusses with a family the progress of a client undergoing surgery; (b) the nurse provides information on advanced directives, which allows a client to identify his or her end-of-life decisions; (c) the nurse asks a client to identify his or her current health problems;
(d) the nurse provides medication for a client in pain.
CRITICAL THINKING E X E R C I S E S
1. Explain the reason that Congress enacted the Nurse Re- investment Act.
2. Name four types of skills that all nurses perform when caring for clients.
C H A P T E R 1 ● Nursing Foundations 15
16
2
Chapter Nursing
Process
W O R D S T O K N O W
actual diagnosis assessment
collaborative problems concept mapping critical thinking data base assessment diagnosis
evaluation focus assessment goal
implementation long-term goals nursing diagnosis nursing orders nursing process objective data planning
possible diagnosis risk diagnosis short-term goals signs
standards for care subjective data symptoms
syndrome diagnosis wellness diagnosis
L E A R N I N G O B J E C T I V E S
On completion of this chapter, the reader will
● Define nursing process.
● Describe six characteristics of the nursing process.
● List five steps in the nursing process.
● Identify four sources for assessment data.
● Differentiate between a data base assessment and a focus assessment.
● Distinguish between a nursing diagnosis and a collaborative problem.
● List three parts of a nursing diagnostic statement.
● Describe the rationale for setting priorities.
● Discuss appropriate circumstances for short-term and long-term goals.
● Identify four ways to document a plan of care.
● Describe the information that is documented in reference to the plan of care.
● Discuss three outcomes that result from evaluation.
● Describe the process of concept mapping as an alternative learning strategy for student clinical experiences.
INthe past, nursing practice consisted of actions based mostly on common sense and the examples set by older, more experienced nurses. The actual care of clients tended to be limited to the physician’s medical orders. Although nurses today continue to work interdependently with physicians and other health care practitioners, they now plan and implement client care more independently. In even stronger terms, nurses are held responsible and accountable for providing client care that is safe and appro- priate and reflects currently accepted standards for nursing practice.