Lack of documentation can alter the nursing intervention, such as in the scenario which stated medication was not discontinued when the resident was at high risk for bleeding. This can put a patient to danger and at risk for injury. Hence, they must make sure to record down all the patient’s evaluation findings, information and findings. Other than that, nurses should also be discreet, stay educated and follow proper procedure and
Nurses interpret and evaluate diagnostic examinations to determine an individual’s condition, as well as making the necessary adjustments in patient treatment plans on their health progress. In collaboration with other medical personnel, nurses engage in the development and enactment of patient care plans. Furthermore, they provide education to families and groups on various health issues such as disease prevention, among others. Scope of Practice The nursing scope of practice gives a precise definition of the strict duties of a registered nurse practitioner. It is obligatory for these professionals not to engage in medical activities that go beyond their scope of practice.
Next, the undocumented verbal order is also another area of concern in relation to documentation (Williams & Wilkins, 2007). A verbal order is medical orders from the physician when the physician is communicating verbally by telephone about the patient’s management especially with the nurses in charge. This might happen for example when the doctors are not available in the ward to submit written orders but the continuity of care is urgently needed. When the nurse encounter this kind of situation, the nurse who is taking verbal order should document the order, physician’s name, as well as the date and time the order was taken. In a hospital setting, the nurse needs to ensure that verbal order should be signed by the physician within 24 hours.
There is a lot of technical and clinical information that the one will need as a nurse: critical thinking and communication skills, patient assessment skills, understanding disease management protocols and development of care plans (just to name a few), most of which is only obtainable through college or technical school and on the job experience. Respect for the patient, the patient’s support system, as well as, respect for yourself is another essential trait necessary to be a successful registered nurse. If patients are sick or worrying about what might be wrong with them, they are going to understandably be anxious or upset (and probably both). Part of practicing compassion as a nurse is recognizing situations like this – and so many more – and striving to help patients maintain their dignity through it all. This requires honest and straightforward communication.
The meaning of professionalism in nursing profession is different meaning to different people. In order to encompass a high-quality working environment, professionalism is very important. Professionalism is a characteristic of productive workplace. In the profession of nursing, each nurse has to display a certain degree of respect and responsibilities to meet the standard values of caring. Professionalism is critical in health care.
When it comes to wounds, nurses differ in their opinions as to what appropriate treatment and dressing needs to be used. In the wound assessment guideline, it only states that we need to follow the facility’s wound treatment protocol, which I have not found when I searched for it. I believe that this leads to confusion amongst the nurses. They tend to treat wounds the way they were practiced before. Aside
Introduction Nurses are located across the healthcare spectrum in various care settings carrying out specific scopes and practices. Regardless of the different nursing job scopes and practices that each nurse has to carry out, nursing is a profession and there are practice standards that each nurse must uphold and maintain. Major institutions like hospitals and governmental bodies will have policies and protocols in place for nurses to abide to maintain the level of quality in the profession. For example, nursing care plans and pathways for ward nurses, and assessment grading guidelines and criterias for nursing lecturers. As for nurses who are employed by doctors in private clinic setups, standards of practice are generally left up to the employer and the clinic nurse to uphold.
Nurses play an essential role in the healthcare industry. The nurse workforce is made up of licensed nurses: registered nurses (RNs), licensed vocational nurses (LVNs) and licensed practical nurses (LPNs), along with nurse aides. Registered nurses are responsible for assessments of patients’ needs, development of care plans, medication administration, and treatments, while licensed vocational nurses perform specific care under the delegation of the registered nurses and supervisions. Nursing aides perform activities of daily living (unskilled attention) to the patient. Adequate nursing staffing is essential to both patient care and outcomes, also to the retention of nurses while inadequate staffing creates problems for both the patients and
In healthcare institutions, nurses are the backbone of every healthcare and always the first contact patients meet on the arrival into the hospital. The nurses’ ability to communicate effectively with patients influence patients’ care and their belief about care. Through effective communication, nurses help patients to know and understand their health problems and give them guide on how to care for themselves. Effective nurse-patient communication requires listening and honesty. This will enable patients to talk about health issues including emotional, social, mental problems that disturb them.
ROLE OF RECORD KEEPING IN NURSING PRACTICE Introduction Clinical record keeping is an essential fragment of high class treatment and care and all nursing professionals have an obligation to record precise information about the care they are giving. According to Beach and Oates (2014) the relationship between the nurse and patient is changing rapidly and this will result in the way nursing staff record everything. The main reasons for keeping the records are to create a complete record of the patient in the services and to enable the continuity of care for that patient. The purpose of this essay is to explain the importance of good record keeping in nursing practice.