The Nursing Experience (page 2)
The best way to find out if nursing is for you is to shadow a nurse. Contact your school of interest and ask if they allow it. High school students can also attend nurse camp at a local college and spend a few days immersed in the nursing experience. Nurse camp allows you to practice on computerized mannequins and use nursing equipment. You'll also get to talk to students and instructors, which gives you a chance to ask questions about your potential career.
- Attend nursing classes taught by nursing faculty.
- Learn about the student experience from nursing students.
- Learn and practice skills in a nursing laboratory.
- Utilize computerized mannequins that simulate real patient illnesses.
- Observe nurses in a hospital unit.
- Find out about nursing specialties.
If time or distance prohibits you from firsthand experience, or if you'd rather read about nursing before jumping in, here is an inside look at the nursing experience. The skills noted here are by no means all-inclusive. They were chosen to give you an insight into the world of nursing, and are intended to give you a brief overview, not to teach you the skill. As they say on television, nurses are professionals—don't try these skills on your own.
As the first component of the nursing process, assessment encompasses a number of skills that let you do some detective work. Nurses assess clients' four domains: physical, psychological, social, and spiritual. Physical health involves basic functions such as breathing, eating, sleeping, and walking, while psychological health involves a person's intellect, self-concept, emotions, and behavior. Social health encompasses the client's relationship with family, friends, coworkers, and society, and spiritual health refers to a person's meaning of life, attitudes toward moral conduct, and belief in a higher power. Nurses consider all these dimensions when performing a comprehensive assessment.
Assessments include both subjective and objective data. Subjective data, also called history, are the symptoms, feelings, perceptions, and other information that the client states and validates. Objective data, also called physical, are the signs directly measured, observed, and felt by the nurse. Nurses need to be able to assess all types of clients, and to modify their assessment to meet the client's age and health status. Children are not just small adults; their bodies are different, and they don't have an adult's level of understanding. Thus, nurses learn skills to both assess children and communicate with them. Older adults require skill modification as well, as do critically ill persons. You need to move faster if a client is in a life-threatening situation, and you need to alter the order of your assessment. Nurses thus learn both assessment skills and assessment modifications. However, before they assess, nurses initiate the nurse-client relationship and discuss confidentiality.
The nurse-client relationship is a helping relationship that differs from social relationships. It focuses on the client, is goal directed, and has defined parameters. The nurse-client relationship begins with the orientation phase, which consists of introductions and an agreement between the nurse and client about their roles and responsibilities. The second phase is the working phase, during which the nurse and client participate together in the client's care. The nurse acts as the client's advocate, caring for his or her physical and emotional healthcare needs. The final phase is termination, which is the closure of the relationship. Here the nurse reviews the client's aspects of care and how they have dealt with physical and emotional responses. Termination is also the time for discharge planning.
Confidentiality requires that client information remain private between the client and the healthcare team. No one else is entitled to the client's information unless the client signs a consent for release of information. Nurses need to tell clients about their right to confidentiality, and they need to avoid discussing clients outside the clinical setting. Telling friends or family about clients violates the client's right to confidentiality and could result in disciplinary action for the nurse.
In respect to confidentiality, nurses are required to adhere to the Health Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA was enacted to ensure health insurance coverage after leaving an employer and to improve the efficiency and effectiveness of health care-related electronic transactions. The Department of Health and Human Services (DHHS) developed the Standards for Privacy of Individually Identifiable Health Information, better known as the HIPAA Privacy Rule. The privacy rule regulates how certain groups or persons can use and disclose individually identifiable health information. The privacy rule:
- grants client patients more control over their own health information, and sets boundaries on the use and release of health records.
- enables patients to make informed choices and to know how, when, and for whom their protected health information is used.
- limits the release of protected health information to the minimum necessary for the purposes of the disclosure.
- establishes safeguards that most healthcare providers must achieve to protect client health information, and allows civil and criminal penalties to be imposed on those who violate the rule.
- allows for disclosure of protected health information for public health, safety, and law enforcement purposes.
Once nurses establish the nurse-client relationship and discuss confidentiality, they are ready to begin assessment (even though nurses actually begin their assessment when they first see and hear the client). Nurses first collect subjective data using therapeutic communication techniques. Communication is a powerful tool, and therapeutic communication techniques are some of the most important skills in a nurse's toolbox.
Examples of Therapeutic Communication Techniques
- Broad opening statements allow clients to set the direction of the interview: "Where would you like to begin?"
- Active listening is more than hearing; it involves the nurse's ability to focus on and decode what the client is saying.
- Open-ended questions require more than a "yes" or "no" answer: "How would you describe your pain?"
- Focusing helps to keep the client on topic: "You were telling me about your heart problem; can you tell me more about it?"
- General leads encourage the client to continue: "And then?"
- Silence may be the best response. It slows the pace of the interview and allows the client to reflect on his or her feelings.
Once nurses establish the relationship and confidentiality, they begin the interview, usually asking about the chief complaint, which is the reason why the client sought healthcare. The nurse then obtains the client's health history, which includes medications, allergies, nutrition, elimination, sleep patterns, hospitalizations, injuries, and family health. Nurses then ask questions about each body system—for example, they will ask about breathing problems and coughing to assess the respiratory system. Since nurses use a multidimensional model, they will also ask about the client's psychological, social, and spiritual health. The main purpose of the history is to focus the physical assessment, but the history also provides insight into the client's healthcare teaching needs, which may include nutritional counseling or smoking cessation.
At some point during or immediately after collecting subjective data, nurses assess vital signs: blood pressure, temperature, pulse, respirations, and what is now called the fifth vital sign, pain, which is discussed later in this chapter. Vital signs reflect the client's overall health and changes can indicate serious illness. Therefore, nurses need to know both technique and interpretation. For example, you need to know how to use different types of thermometers, as well as know that an increase in temperature can signify problems such as infection, increased stress, heat stroke, and some types of cancer. Pulse and respirations are more than just numbers. Did you know there are 17 pulse sites? Both pulse and respiration have characteristics such as rhythm and quality, and respiration characteristics also include depth. A slow pulse (under 60 beats per minute in an adult) is called bradycardia, while a rapid one (greater than 100 beats per minute in an adult) is tachycardia. Dyspnea means difficult breathing.
Blood pressure may be measured directly with a catheter placed in an artery, a measurement monitored by critical care nurses. But most nurses use the indirect and more commonly known method, using a stethoscope and sphygmomanometer (blood pressure cuff). For those people with hard to hear blood pressures, nurses use the Doppler method, an electronic system similar to home blood pressure machines. Blood pressure assessment takes skill. An overly wide cuff can cause a falsely low reading, while a cuff that's too narrow can cause the reading to be falsely high. Readings are typically documented in fraction form, with one number over another. The top number is the systolic blood pressure; the bottom, the diastolic. Normal adult blood pressure is 120/80.
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