Class Notes for Clinical Nursing Skills: Basic to Advanced Skills, 9th Edition

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Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
Chapter 1
Professional Nursing
TEACHING/LEARNING STRATEGIES
Lecture–Discussion
Instructor Planning. Have students access a copy of their state’s Nurse Practice Act. This
document may be available online or a copy may be obtained for each student. Draw the
students’ attention to the text information regarding the Code of Ethics, ANA’s Nursing’s
Social Policy Statement, and the National Student Nurses’ Association Code of
Academic and Clinical Conduct. . Interpret and discuss these documents. Also discuss the
Standards of Nursing Practice as outlined in the text.
Written Assignment
Instructor Planning. Obtain a patient chart or computerized record from the hospital
where the students will have clinical experience. Suggest they document the skills as they
practice them, i.e., chart vital signs, BP, I&O.
Resource Suggestions
Access the Joint Commission website at www.jointcommission.org. for information on
National Patient Safety Goals and Core Measures.
CRITICAL THINKING STRATEGIES
Exercise 1
Discuss the Nurse Practice Act by asking students to read sections of the act and then
describe in their own words the meaning of the statement. Ask the students to identify
how the practice act will affect their career.
Exercise 2
Ask the students to obtain the Standards of Practice for the nursing unit where they are
assigned for clinical practice. Compare the standards against the ANA published
Standards of Nursing Practice. Discuss the Standards of Nursing Practice with the
students. Break students into small groups and assign each group to one standard. As a
group, define how the standard is used in the clinical setting and how evaluation of that
standard is accomplished.
Exercise 3
Ask the students to think back to when they first decided to become a nurse. Ask, “How
does the image compare to the actual role you are assuming now? Identify the major
differences you are experiencing that you didn’t think or know about earlier.” Have the
students share their thoughts in a small group and identify similarities among the group.
The similarities can be shared with the entire class if time allows.
Exercise 4

Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
Assign each student to research and describe a potential clinical incident that could be
defined as gross negligence, criminal negligence, and malpractice. In a small group, ask
the students to describe the incident and ask the group to determine which type of
negligence has been described.
Exercise 5
Provide information about HIPAA (Health Insurance Portability and Accountability Act)
and ask the students to discuss the role of the nurse in carrying out the privacy mandate.
Scenario 1
As a new student you are going into the hospital to prepare for the clinical experience
tomorrow morning. There are two stages of preparation. The first stage is obtaining all
the necessary information you will need to provide safe care. The second stage is
reviewing your textbooks and lecture notes to gain an understanding of the client’s
diagnosis, medications, lab values, and diagnostic tests that will be done during his/her
hospitalization.
1. If you have only a limited time to review the client’s chart, what sections of the chart
will provide you with sufficient information to render you safe to care for the client?
2. In preparing for clinical practice, what information is essential to review in addition
to the data you have obtained from the clinical record? Where is the most appropriate
place to find this information?
3. List the priority interventions you will carry out within the first hour of the clinical
experience. Explain the rationale for your answers.
Scenario 2
As a student nurse, you have been assigned to complete an activity where you compare
and contrast legal/ethical issues related to nursing practice. You are assigned to research
the ANA standards of clinical nursing practice, the Nurse Practice Act in your state, and
the code of academic and clinical conduct from the National Student Nurses’
Association, Inc.
1. Briefly describe the primary purpose/function of each of these nursing regulations or
guidelines.
2. Select one of the above nursing regulations/guidelines and describe how the
regulation/guideline will impact your role as a professional nurse.
3. The National Student Nurses’ Association developed the code of academic and
clinical conduct. How do you plan to incorporate the code into your practice as a
student nurse? How will this practice prepare you for the registered nurse profession?
Resolution Possibilities for Scenario 1
1. Client’s medical diagnosis; medications to be given during clinical; essential lab
values for medications or tests; and whether client has any allergies.
2. Information on medications from PDR and drug reference texts; information on
medical diagnosis from textbooks; nursing skills protocols and procedures from skills
text; lab information from laboratory diagnostic text.

Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
3. Perform hand hygiene. Receive oral report from nurse; check Kardex or computer
generated care plan for new client information; introduce yourself to your client; take
vital signs; complete a focus assessment; and check that all medications are available
in cart if not using Pyxis machine. Each of these tasks is designed to provide safe
client care. Washing your hands prevents the spread of microorganisms to client.
Checking medications and new orders are essential to provide accurate care. Focus
assessment provides baseline information on client’s condition and promotes
individualized client care.
Resolution Possibilities for Scenario 2
1. The ANA standards of clinical nursing practice describes the competent level of
nursing care. The standards apply to all licensed registered nurses working in clinical
practice, regardless of clinical specialty, practice setting, or educational preparation.
The standards describe a competent level of professional performance common to all
nurses engaged in clinical practice.
The Nurse Practice Act defines professional nursing and recommends those actions
that the nurse can practice independently and those actions that require a physician’s
order before completion. The act is a series of statutes enacted by a state to regulate
the practice of nursing in that particular state. Each state has their own individual
nursing practice act.
A code of academic and clinical conduct outlines the ethical principles that guide the
student’s professional development. Included are guides that describe the advocacy
role for the rights of clients, providing for client safety, and actively promoting the
highest level of moral and ethical behavior.
2. The answer depends on the regulation or guideline selected. For the content that
needs to be addressed, refer to the chapter information.
3. Discussion of how ethical practice is critical in developing as a registered nurse is
important. These practices include promoting the highest level of moral and ethical
conduct, accepting responsibility for one’s actions, using every opportunity to
improve faculty and clinical staff, and providing safe, timely, and compassionate care
to clients. All of these behaviors are part of assuming the RN role.

Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
Chapter 2
Nursing Process and Critical Thinking
TEACHING/LEARNING STRATEGIES
Lecture–Discussion
Use a nursing diagnosis book to explain in detail how to use nursing diagnosis
appropriately. Apply categories to clients in the hospital.
Obtain a copy of Nursing Diagnosis Handbook10th ed. Judith Wilkinson (Prentice Hall
2014),Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 10th
edition. Ackley and Ladwig, C.V. Mosby 2014, Nursing Diagnoses 2015-2017:
Definitions and Clarification (NANDA), or
Nursing Diagnoses: Application to Clinical Practice, 14th ed.Lynda Carpenito
(Lippincott Williams and Wilkins 2012). After reading their description of how to use
critical thinking, determine which definitions best fit your curriculum framework. Based
on that decision, you can develop a methodology for inclusion of critical thinking into
your coursework.
Oral Assignment
Have students identify a client-based problem and then follow the four steps in the
problem-solving process related to Evidence Based Practice. Students need to research
the problem using appropriate references. You may need to give them a list of
appropriate references.
Each student, or student group, should then report their findings to the class.
Written Assignment
Provide each student with a list of current nursing diagnoses. These could be written on
index cards to carry to the clinical setting.
Resource Suggestions
Critical Thinking and Clinical Judgement: A Practical Approach to Outcome-Focused
Thinking, 6th ed., by Alfaro-LeFevre, Rosalinda (Saunders), 2017.
CRITICAL THINKING STRATEGIES
Exercise 1
One example of how to introduce both critical skills and nursing process into skills and
clinical courses is to have a discussion of how critical thinking skills are used throughout
the nursing process. Resolution Possibilities for Exercise 1
You can develop your own “thinking system,” incorporating the nursing model you use
as your theoretical framework in the program. As an example, if you use the Roy
adaptation model, you may have the students state the critical thinking skills according to
the specific terminology in the model. The Roy model would list under assessment, first-
and second-level assessment behaviors. The students then use that data and cluster
ineffective behaviors and form a nursing diagnosis. You then expect them to be able to

Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
distinguish relevant from irrelevant data, important from unimportant data. They should
also be able to provide a rationale for their answers.
You may choose to have the students determine what specific information belongs under
each step of the nursing process. They can be given characteristics of each phase in a
random order. They are to take each characteristic and place it under the correct phase of
the nursing process.
After they have placed the characteristics in the appropriate phase of the nursing process,
it is a good idea to show multiple-choice test questions that test each phase of the nursing
process. Ask the students to identify the phase being tested and provide the rationale for
their answer.
It may be helpful to administer one of the commercial instruments available on critical
thinking to the beginning students and then to the graduating students to determine if an
increase in ability to use critical thinking skills has occurred throughout the program. It is
important that the faculty look at the many tools available and choose the tool that most
represents the definition of critical thinking that is used throughout the nursing program.
Scenario 1
You have been assigned to care for Mr. Peters, a 76-year-old widower who was admitted
with the diagnosis of congestive heart failure. He has lived alone for the last two years
since his wife died. His children live about one hour away and visit him once a month.
The children ordered Meals on Wheels for him, but he refused to eat the food that was
delivered. “I can do my own cooking. I am not an invalid,” was the answer when the
nurse asked why he didn’t like the Meals on Wheels program. He had not seen the
physician for at least 2 years. At the last visit, the physician prescribed a moderately low
sodium diet, furosemide (Lasix) 40 mg. daily, verapamil (Calan), and multiple vitamins.
His admitting vital signs were BP 180/90, P 98, R 22. His weight indicated a gain of 10
pounds since the last visit. His physical assessment indicated rales in the lung bases, 3+
edema of the ankles, and difficulty breathing in a supine position.
1. How will you use the nursing process to determine an accurate data base?
2. What information is missing that might be important to the nurse to assist in planning
care for this client? What is the best approach for obtaining the information?
3. Identify at least four nursing diagnoses that are relevant for this client’s plan of care.
Write a two-part and a three-part diagnostic statement for each nursing diagnosis.
4. Using a nursing diagnosis book, identify NIC and NOC statements for the four
nursing diagnoses listed in question 3.
5. Identify the priority nursing diagnosis, and provide the rationale for your decision.
6. Develop a very brief nursing care plan using the nursing process format as outlined in
the text.
Note: Scenario 1 can be used as a critical thinking scenario for a beginning student. This
is a good scenario for role play. To encourage nurse–client communication and
questioning techniques to obtain data, have the students divide into pairs. Give one
student in each group (the client) cards with additional information regarding his

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Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
symptoms and clues on how to answer questions posed by the “nurse.” Have the “nurse”
proceed to gather additional data without the use of cards or prompts.
After the role play is completed, ask the students to complete the nursing care plan with
the information they gathered. After completing the care plan, have the students
determine if they gathered sufficient information for the care plan. If not, ask them what
data they needed.
Scenario 2
8 A.M. You are assigned to a 22-year-old male client who was in a motorcycle crash
yesterday. He sustained a compound fracture of the right fibula and tibia. He states his
pain is 9/10 and is throbbing. He is nauseated all the time. He is scheduled for surgery
later in the day. You assess his wound area and notice there is a large amount of
serosanguinous drainage of the dressing. You reinforce the dressing.
1. Based on the information provided in the scenario, identify two nursing interventions.
2. Determine priority nursing diagnoses and provide rationale for your decision.
3. Using a nursing diagnostic textbook, develop a client care plan incorporating NIC
and NOC data.
Resolution Possibilities for Scenario 1
1. Assessment phase
Gathering data
Confirming observations
Verifying data
Nursing Diagnosis
Analyze collected data
Determine cluster of clues
Identify related factors
Identify potential nursing diagnosis
2. a. Can he actually cook for himself?
b. What are his physical assessment findings related specifically to his heart and
lungs? (e.g. heart assessment, particularly the PMI.)
c. Who is responsible for his care at home? Can he actually return to his house
with/without outside help?
d. Is he taking his medications as prescribed? Does he know the action of the drugs
and what happens if he doesn’t take them?
The best approach is to ask him questions directly and have him state information about
his drugs. It may be that the children will also have to answer the questions as well to get
a complete picture of Mr. Peters and his ability to care for himself.
3. There are many potential nursing diagnoses. Four common nursing diagnoses for Mr.

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Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
Peters might include:
Excess fluid volume
Ineffective role performance
Ineffective self-health management
Deficient knowledge related to drug therapy
Two-part statement (Example)
Excess fluid volume related to decreased cardiac output secondary to congestive heart
failure
Three-part statement (Example)
Excess fluid volume related to decreased cardiac output secondary to heart failure as
evidenced by peripheral edema, shortness of breath, and weight gain
The two statements will be reflective of your identified nursing diagnosis.
4. Information for this answer is dependent on the chosen nursing diagnosis.
Example for the excess fluid volume:
Electrolyte and Acid-Base Balance:
Balance of electrolytes and nonelectrolytes in the intra- and extracellular
compartments of the body.
Fluid Balance: Balance of water in the intra- and extracellular compartments of
the body.
Hydration: Amount of water in the intra-

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Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
f. Disturbed body image.
2. Determine the two highest priority nursing diagnoses: a and b are probably the
highest priority. After you have identified the diagnoses and their interventions, refer
to a nursing diagnosis textbook to check interventions related to the diagnosis and
evaluate the rationale for your selection.
3. The nursing diagnoses most likely considered last would be e and f.

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Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
Chapter 3
Managing Client Care: Documentation and Delegation
TEACHING/LEARNING STRATEGIES
Lecture–Discussion
Instructor Planning: Obtain examples of different standard care plans from the
hospital/computer and review the procedure for using the plans. Include how they are
initiated, updated, and discontinued.
Obtain several copies of clinical or critical pathways and describe how they are used in
managed care health systems.
Demonstrate the hospital documentation format used in the clinical facility.
Discuss various charting formats and the rules for documenting client care. Simulated
situations can be printed on 5  9 cards. Ask the students to document their findings on a
form.
Written Assignment
Use a nursing care planning book and have students identify a standard care plan for one
client they have cared for in a recent clinical experience. Instruct students to state how
and why this standard plan fits their client.
Demonstrate and then assign students to write a nursing care plan after they are familiar
with the care planning and have sufficient knowledge.
Suggest they start by writing only the client needs that are actual problems. (When needs
are placed in priority order, this action assists students with critical thinking and decision
making.)
An excellent critical thinking exercise can be included in the written assignment. Have
students provide a brief scientific rationale for the priority nursing intervention, which is
determined for the priority client problem. Ask them to state the rationale in their own
words.
Have students identify if the stated goals on their client’s care plan, either short- or long-
term, are measurable and appropriate for the client’s situation. If not, have them identify
a more appropriately stated goal.
Laboratory Experience
Provide a taped or verbal shift report/handoff and have students practice writing
information on a worksheet.
Have students complete a prep sheet based on a simulated situation.
Prepare a work sheet for students or have them bring a work sheet from the clinical area.
Ask them to give a verbal shift report to a group of peers. Have students demonstrate
electronic charting on a recent client.
Clinical Experience

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Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
Have students attend a care conference on their assigned client and write a summary of
how the conference was organized, which health team members participated in the
conference, and their role in delivery of health care to clients.
Have them identify the leader of the conference. Include a brief summary of the final
results from the conference.
Students should begin updating, activating, and deactivating care plans or clinical
pathways with instructor guidance early in their first clinical experience if this is
permitted by the facility. If not, guide students through the process outside of the clinical
site.This helps them identify the need for accurate care plans and pathways.
Have students critique a shift report/handoff, including pointing out any information that
was not relevant to the situation and any essential information that was omitted.
Resource Suggestions
Use standard care plans developed by hospitals.
1. Obtain several critical pathways for clients that students have been assigned to in the
clinical setting.
2. Break students into small groups, each with a different pathway. Have the students
prioritize the aspect of care for the first day. Have them state the rationale for their
decisions. Asking the students to identify the priority nursing diagnosis can be added
to the task if time permits. Assign a time frame for this activity that will allow the
groups to present their findings at the end of class.
3. You may need to write a clinical client scenario for a particular pathway if the
students have not had an assignment supporting the pathway you have chosen for the
activity.
4. Select one spokesperson from each group to present the findings from the group.
Allow time for group discussion by the entire student group. Encourage all students
to participate, challenge the prioritization, nursing diagnosis, or rationale. If they have

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Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
To increase students’ observation skills, an activity can be used for students to determine
their ability to observe and recall details that are a part of data collection. During a
discussion of the various types of documentation and the importance of accurate
observation skills, ask a faculty member or a student to pass through the front of the room
and exit. It would be helpful if the person looked embarrassed, carried something in his
or her hands, and had on nondescript clothing. The best time would be about five minutes
into the class on documentation. After the person has exited, ask the students to describe
what they observed. Leave the observation very open to the students’ recall of the person.
Do not ask specifically for clothing, appearance, etc. Allow the students five minutes to
recall the information. Ask the person to return to the room. Have the students verify
their observations. Identify errors in recall and what observations were missing. After this
exercise, discuss the importance of accurate and complete observational skills.
Exercise 3
Ask several of the students or the faculty to participate in a role-play situation. The intent
of the role play is to depict a potential litigation issue. Examples for the role play include:
a client falling out of bed and fracturing a hip when the side rails are down; an antibiotic
given to the wrong client who is allergic to the drug; an IV with a toxic drug infiltrated
into the subcutaneous tissue, causing a sloughing of the tissue. During the role, the
“nurse” should describe what she or he observed to a “physician” and to the “nurse
manager.” Cue cards may need to be given to the players, describing what they probably
observed. It depends on the level of the student or if a faculty member is acting the part
of “nurse” or “physician.” The “client” should be given cue cards directing him or her on
what to communicate, how to react to the incident, such as grimacing with pain, feeling
nauseated, etc.
Ask the students to chart the incident and fill out an Unusual Occurrence Report. A
discussion related to the content of the documentation should follow the charting and
completion of the report. Ensure that the critical information needed for the Unusual
Occurrence Report is included and stated in the correct manner. Information related to
how the Unusual Occurrence Report is used within the hospital facility should be
included in the discussion.
Scenario 1
Determine appropriate delegation of client activities for a staff team on a unit. This
scenario does not take into consideration the acuity of the client, only the nursing tasks
needed for the day shift. Each facility and state have differing policies regarding
personnel; therefore, these policies need to be reviewed before this activity is completed.

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Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
Vital signs every 4 hrs., low sodium diet, restricted fluids to 1500 mL.
IV #2 1000 mL D5/0.2NS with 20mEq KCL at 50 mL/hr. 800 mL remaining
IV medications: furosemide 40 mg BID
Oral medications: digoxin 0.25 mg daily, vitamin supplement
RM 601B Mr. Jamisen, 69, admitted this A.M.
Diagnosis: coronary artery disease
Surgery at 10 A.M.: triple bypass-- will go to ICU following surgery
Pre-op checklist and client teaching has been completed
Pre-op meds on call to OR.
IV medications
IV #1 1000 mL D5/0.2NS at 75 mL/hr.
RM 602A Mr

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Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
Nasotracheal suction PRN.
IV #5 1000 mL D5W at 50 mL/hr.
PCA pump for pain medication
Chemotherapy IV daily
RM 604A Mr. Scott, 64, admitted this A.M.
Diagnosis: benign prostatic hypertrophy
Surgery: TURP scheduled for 1 P.M. to return to the nursing unit
Needs pre-op teaching and a surgical checklist completed
RM 604B Mr. Jackson, 37, admitted last night
Diagnosis: torn ACL
Surgery this A.M. at 7:30--will return to unit by 10:30 A.M.

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Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez
Chapter 4
Communication and Nurse–Client Relationship
TEACHING/LEARNING STRATEGIES
Lecture–Discussion
Write examples of therapeutic communication and blocks to communication on blank
transparencies, smart board, or on the chalkboard before class begins.
Discuss the importance of communication as the primary link between client and nurse
and as the foundation for all nurse–client interactions.
Review basic guidelines to communications.
Laboratory Experience
Ask the class to identify and discuss how specific communication techniques facilitate or
block communication with their clients.
Pair off students and assign them to role play a situation in which the nurse is assisting
the client to
• Describe an experience
• Talk about feelings
• Express needs
Role play initiating a relationship with a client as a demonstration, then have students
practice in pairs.
Written Assignment
Assign students in pairs to write actual examples of blocks to communication from a
nurse–client interaction. Then have another student critique or correct it so that the
nursing responses are more therapeutic.

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