Read the example scenario

Nursing procedures

Skills demonstrated:

Isabella throughout her practice learning experience demonstrated a broad understanding of mental and emotional distress to empathise with and support Olivia.

As a student nurse under supervision, Isabella had accessed and read Olivia’s health records, this helped to inform her of Olivia’s history. In addition to this, it safeguarded Isabella and prevented re-traumatising Olivia within the therapeutic relationship. Isabella was then able to help Olivia feel comfortable in talking about difficult topics, but it did not always have to be the focus of the conversation.

Isabella listened to and considered Olivia’s needs and her complex family dynamics and seeing her regularly enabled Isabella to monitor how she was progressing with her care plan and talk about anything else that she wanted to discuss.

Meeting Olivia in person on a regular basis, Isabella was able to observe her physical wellbeing, and monitor for dehydration, hypotension and low blood glucose.

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages:

1.1 mental health and wellbeing status
1.1.1 signs of mental and emotional distress or vulnerability
1.1.2 cognitive health status and wellbeing
1.1.3 signs of cognitive distress and impairment
1.1.4 behavioural distress-based needs
1.1.6 signs of self-harm and/or suicidal ideation

2. Use evidence-based, best practice approaches to undertake the following procedures:

2.1 take, record and interpret vital signs manually and via technological devices
2.6 accurately measure weight and height, calculate body mass index and recognise healthy ranges and clinically significant low/high readings
2.9 collect and observe sputum, urine, stool and vomit specimens, undertaking routine analysis and interpreting findings
2.10 measure and interpret blood glucose levels

3. Use evidence-based, best practice approaches for meeting needs for care and support with rest, sleep, comfort and the maintenance of dignity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

3.1 observe and assess comfort and pain levels and rest and sleep patterns
3.4 take appropriate action to ensure privacy and dignity at all times
3.5 take appropriate action to reduce or minimise pain or discomfort
3.6 take appropriate action to reduce fatigue, minimise insomnia and support improved rest and sleep hygiene.

4. Use evidence-based, best practice approaches for meeting the needs for care and support with hygiene and the maintenance of skin integrity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

4.1 observe, assess and optimise skin and hygiene status and determine the need for support and intervention

5. Use evidence-based, best practice approaches for meeting needs for care and support with nutrition and hydration, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

5.1 observe, assess and optimise nutrition and hydration status and determine the need for intervention and support
5.2 use contemporary nutritional assessment tool
5.4 record fluid intake and output and identify, respond to and manage dehydration or fluid retention

6. Use evidence-based, best practice approaches for meeting needs for care and support with bladder and bowel health, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

6.4 assess bladder and bowel patterns to identify and respond to constipation, diarrhoea and urinary and faecal retention

9. Use evidence-based, best practice approaches for meeting needs for care and support with the prevention and management of infection, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

9.3 use effective aseptic, non-touch techniques

9.6 use evidence-based hand hygiene techniques

9.8 safely use and dispose of waste, laundry and sharps

References
Smith GB, Redfern OC, Pimentel MA, Gerry S, Collins GS, Malycha J, Prytherch D, Schmidt PE, Watkinson PJ. The National Early Warning Score 2 (NEWS2). Clin Med (Lond). 2019 May;19(3):260. doi: 10.7861/clinmedicine.19-3-260. PMID: 31092526; PMCID: PMC6542226.

Troels Thim, Niels Henrik Vinther Krarup, Erik Lerkevang Grove, Claus Valter Rohde & Bo Løfgren (2012) Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach, International Journal of General Medicine, 5: 117-121, DOI: 10.2147/IJGM.S28478