clinical-nursing

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Core competencies

Nursing Assessment:

• Head-to-toe systematic assessment methodology
• Focused assessments based on chief complaint and medical diagnosis
• Neurological assessment: Glasgow Coma Scale (GCS), pupil assessment (PERRLA), level of consciousness, orientation, cranial nerve screening, motor/sensory assessment
• Cardiovascular assessment: heart sounds (S1, S2, murmurs, gallops), peripheral pulses (0-4+ scale), capillary refill, JVD, edema grading (1+ to 4+), telemetry rhythm interpretation
• Respiratory assessment: lung sounds (clear, crackles, wheezes, rhonchi, diminished, absent — by lobe), work of breathing, accessory muscle use, SpO2, oxygen delivery devices and flow rates
• GI assessment: bowel sounds (all 4 quadrants), abdominal palpation, nutritional screening, tube feeding management
• GU assessment: urine output monitoring (normal >0.5 mL/kg/hr), fluid balance, catheter management
• Integumentary assessment: wound assessment (location, size, depth, stage, drainage, wound bed description), Braden Scale for pressure injury risk, skin turgor
• Pain assessment: numeric rating scale, Wong-Baker FACES, FLACC (non-verbal), CPOT (critical care), behavioral pain indicators

NANDA-I Nursing Diagnosis Taxonomy:

• 13 Domains: Health Promotion, Nutrition, Elimination and Exchange, Activity/Rest, Perception/Cognition, Self-Perception, Role Relationships, Sexuality, Coping/Stress Tolerance, Life Principles, Safety/Protection, Comfort, Growth/Development
• Three-part diagnostic statement: Problem (diagnostic label) related to Etiology as evidenced by Defining Characteristics
• Risk diagnoses: Risk for [Problem] as evidenced by Risk Factors (no "related to" or defining characteristics)
• Health Promotion diagnoses: Readiness for Enhanced [Health Pattern]
• Priority setting using Maslow's hierarchy and ABC (Airway, Breathing, Circulation)

NIC (Nursing Interventions Classification):

• 7 Domains: Physiological Basic, Physiological Complex, Behavioral, Safety, Family, Health System, Community
• Intervention selection based on nursing diagnosis, desired outcomes, feasibility, acceptability to patient, and nurse capability
• Independent interventions (within nursing scope) vs. collaborative/dependent interventions (requiring physician order)
• Documentation of intervention, time, patient response, and any modifications

NOC (Nursing Outcomes Classification):

• 7 Domains aligned with NIC domains
• 5-point Likert scale rating (1=severely compromised to 5=not compromised, or 1=never demonstrated to 5=consistently demonstrated)
• Baseline rating at care plan initiation
• Target rating with timeframe
• Outcome measurement at defined intervals

Medication Administration:

• Five Rights: Right patient, Right drug, Right dose, Right route, Right time
• Additional Rights: Right documentation, Right reason, Right response
• High-alert medications: insulin, anticoagulants (heparin, warfarin, DOACs), opioids, chemotherapy, electrolyte concentrates (potassium, magnesium)
• Independent double-check requirements for high-alert medications
• IV compatibility checking, rate calculations, titration protocols
• PRN medication documentation: indication, dose, time, reassessment of effectiveness
• Controlled substance documentation and count procedures

Vital Signs Interpretation:

• Normal adult ranges: T 97.8-99.1°F (36.5-37.3°C), HR 60-100, RR 12-20, BP <120/80 (normal), SpO2 ≥95%
• Pediatric vital sign ranges by age (higher HR and RR in younger children, lower BP)
• Critical values requiring immediate notification: T >104°F or <95°F, HR >150 or <40, SBP >200 or <80, RR >30 or <8, SpO2 <90%
• MAP calculation (MAP = [SBP + 2(DBP)] / 3) — target generally >65 mmHg
• Early Warning Scores (NEWS, MEWS) for clinical deterioration detection
• Orthostatic vital signs: measure supine, sitting, standing — positive if SBP drops ≥20 or DBP drops ≥10 with symptoms