Nursing Process, SBAR, & Continuity of Care

Up first is the nursing process. And I cannot stress to you how important this is for you to know for all of nursing school. It is going to help you to guide your thinking. It's going to help you in test-taking scenarios. It's going to help you in clinical. You've got to be comfortable with the nursing process. So what is it? Well, we remember the steps with the acronym SPAR. ADPIE, which stands for Assessment, Diagnosis (Nursing Diagnosis), Planning, Intervention, and Evaluation. So, we talk about this on this card. There's a lot of information here. It's bold and red. You're going to want to know it. I promise. But Assessment is what we start with first. This is data gathering, so looking at my patients, their lab results, their vitals, how do they seem, how are they acting. All of that is assessment. Then we move on to Diagnosis. This is a nursing diagnosis, not a medical diagnosis. So this is going to be what I identify as being their primary problem that I as the nurse need to help correct. So this is very important. And if you are not used to writing nursing diagnoses, I would definitely recommend that you get a nursing diagnosis handbook to help you learn how to formulate those. Then we move on to the Planning stage. And in the planning stage, this is where we start setting Goals for our patients. But these aren't just any goals. These are SMART goals. SMART standing for Specific, Measurable, Attainable, Realistic, and Timely. And when you write a goal, you need to make sure that it is all of those things. Remember this is also patient-centered. So, "The patient will blah, blah, blah." Not, "The nurse will." This is the patient's goal. The nurse may be able to help them. But they are not the focus of the goal. So we're focusing on the patient. We have here a poorly-written goal, and then a SMART goal. I would very much recommend you look at this to see the difference there. And then we move on to Implementation. You may have heard this called intervention, as well. This is the doing stage. At this point, I'm doing something. Maybe I'm giving a medication. Maybe I'm applying oxygen. Perhaps there's some sort of wound care going on. All of these things are happening in the implementation stage. This is where we are actually doing something to our patient. Pay attention that this comes way down the line, after we've done those first steps. Very important to know what order we follow. And then at the very end, I'm going to evaluate. Did my interventions work? Is my patient's pain better? Is their oxygen better? Do they say they're feeling better? All of that is good information. And if not, if they're not doing better, then we need to go back to assessment and reassess and start over. Just make sure you understand, we go in order and we always start by assessing. Moving on to card number 43. Here we are talking about the interdisciplinary team members. There are a lot listed here. I'm not going to go over all of them. But a few to mention would be the nurse, doctor, pharmacist, physical therapist, and occupational therapist. These are all members of the team who work together to provide comprehensive care to our patients. Key members I want to highlight for you to know. The provider is the person who examines, diagnoses, and treats the patient. So this could be a physician, an MD, a DO. This could be a physician's associate, a PA. This could be a nurse practitioner, an NP, right? There's lots of different ways to be a provider. So you will hear this in your nursing exams, to report to the provider. Because not every provider is a physician. Then we have occupational therapy and physical therapy. Now occupational therapy is going to help your patients with their activities of daily living. So learning how to feed themselves again, for instance, would be the job of the OT. The physical therapist, the PT, is going to help with things like muscle strengthening, improving mobility, range of motion, that sort of stuff. They work very closely together. But they have a different job. And then one that I really want to point out here, and you'll notice it is bold and red on this card, is speech-language pathologist. So an SLP can help your patients with things like speech impediments. But they can also help when your patient has dysphagia -- GIYA -dysphagia, difficulty swallowing. So they can perform swallow studies. And they can help with therapies for your patient to improve their swallowing ability. So if your patient has dysphagia, you want to be working with an SLP. Okay. So next up on card number 44, we are talking about SBAR communication. This is going to be kind of the gold standard for communicating with other healthcare professionals, be that other nurses or a provider. This is going to help us to organize what we have to say and to make sure that we get all the information across that we need to. So SBAR stands for situation, background, assessment, and recommendations. So it's going to be, "Here's the situation. I've got this patient. They're here for this diagnosis." And I'm moving on to the background. Now here's why they came in. This is the relevant history. And now I'm moving on to the assessment. "When I went in there, I saw that he was having a really hard time breathing. His sats are in the high 80s right now. He just doesn't look very good." I'm going to give them whatever my assessment data is, right, ABGs, that sort of thing. And then we move on to recommendation, "I'd like an order to give him 15 L per minute by non-rebreather. Is that acceptable, or do you have something else that you'd like to recommend?" So either I can provide a recommendation, "This is what I would like," or I can say, "Do you have a recommendation for how to proceed?" Either way, SBAR helps to guide that flow and make sure that we are providing all relevant data. Okay. So, card 45, we're talking about continuity. Care. This is how we can provide the best care for our patients from their admission, any time they are transferred, either within the same facility or to different facilities, and discharge. So you'll see here, we have a lot of stuff to go over. There are key points and everything like that, so pay attention to this part. It's pretty important. At admission, I need to confirm my patient's advanced directive status. "Are you a full code? Are you DNR?" Gotta know it, right? I need to assess their allergies and determine their fall risk. I should also do a swallow examination to make sure that my patient is able to swallow before they ever have anything to eat or drink. And I'm going to do my head-to-toe assessment at this point. Very important to know, discharge planning begins at admission. From the time my patient walks into that hospital, we need to be thinking, how do we get this patient home? Because the hospital is no place for a sick person, right? Nobody wants to be in the hospital. There are pathogens, disruptions, and poor sleep. The best place for my patient is going to be at home or wherever they reside, so we need to start thinking about their discharge planning at admission. Now, when we do a transfer, we're going to provide a report to the nurse who will be accepting the patient using that SBAR communication. And also, at discharge, this is going to be very important that we educate our patients when they are being discharged from the hospital about any sort of diet and activity restrictions, any changes to their medications and how they should be taking them, what their follow-up appointments are, when and where and with whom, and give them the contact information for their provider. Maybe they didn't see this provider before being in the hospital. It's important that they know who to be able to call. Now, there is a key point here that I really want to make sure that you pay attention to. A key point is medication reconciliation, meaning going over the patient's full list of medications, what should be stopped, what is new, what's continuing, should be done at admission, transfer in the same unit or to another unit, and upon discharge. We also want to provide our patients with that full medication reconciliation information at discharge so that they have it updated for their own use. Alright. So that is it for the nursing process, the interdisciplinary team, SBAR communication, and continuity of care. I know that was a lot, but it's all super, super important information. So if you liked that review, please go ahead and like this video, and if there's anything that you want to leave me in the comments about how you remember things or a funny story, I always want to hear that, so please do! My next video is going to be covering hospital-acquired infections and proper... Hand hygiene is very important for fundamentals. So be sure to subscribe to the channel so you're the first to know. Thanks so much, and happy studying! I invite you to subscribe to our channel and share a link with your classmates and friends in nursing school. If you found value in this video, be sure to hit the like button and leave a comment, letting us know what you found particularly helpful.