The patient should be given time to express their thoughts. The family should be informed about the condition. Their participation is essential in making sure the patient is being taken care of. “To meet the needs of the older adult, individualize nursing care to enhance quality of life and maximize functional performance by improving condition, mood and behavior” (Potter & Perry, 2012). Information Management Interventions Since there is no cure for dementia the nurse should be mindful of the pharmacologic and nonpharmacologic interventions used to treat the condition.
One such example would be, nurses have to frequently assess any change on patient’s condition and notify doctor immediately if there are changes. Delaying may increase the complication and makes it harder to treat. Other than that, nurses must document down all the information in accordance to approved standards of practice which includes evaluation of how treatments work, assessment, compliance, reaction of patient and communication. Evidence by charting can help to prevent liability in a malpractice suit. 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.
Factors contributing to missed nursing care ranged from nurses’ values, perceptions, and socioeconomic factors (nurses’ accountability) to facilities scarce resources, staffing, and increased work demands (wards’ accountability). Additionally, this research article included the researchers own findings from a primary cross sectional study involving RNs from different wards in eight general hospitals aiming to test the effects of personal and ward accountability. The study included articles of established research from other related disciplines such as psychology, organizational controls and safety, hierarchical models, multilevel theory research, and other cross sectional studies. •Does the review rely on appropriate material (mainly primary source articles)? The review relied on appropriate material and used a majority of primary source articles.
( Urquhart et al, 2009). Nursing documentation encourage many aspects of nursing care. Voutilainen et al, 2004 believes that quality nursing documentation promotes structured, dependable and effective communication between caregivers and will facilitate continuity and individuality of care and safety towards patients. One believes documentation is a useful tool in addressing what happens in the nursing process and what decision making is based on presenting information from admission, nursing diagnosis, interventions and the evaluation process resulting in the outcome. Delaney et al, 1992 firmly believes that exact nursing documentation allows nurses to evaluate nursing outcomes as a logic result of nursing diagnosis and
In healthcare, the dilemma becomes even more complicated because patients are at a vulnerable position (Mansbach et al, 2014). Nurses can choose not to report their colleague or management’s wrongful behaviour but by doing so, they may be violating their basic professional commitment as patient’s advocate to protect their well-being (Mansbach et al, 2014). This is especially complicated when the nursing profession has a contractual or legal duty to report (Lewis, 2007). Nurses worry that if they report, they may be victimised and if they do not, they may be punished for breaching of contract. The belief that the management or relevant authorities will not take necessary action to prevent further harm is one of the main reason why nurses do not report wrongdoings (Lewis, 2007).
Warren and Creech-Tart (2008) discussed that fatigue experienced by health care provider is one of the contributor factors to deficiencies in documentation. Since some health care providers work long hours and have demanding client assignments, they may not have clear thinking processes required during the process of documentation. Illegible writing is one of the most common complaints in written documentation as a result of messy handwriting (Rodríguez-Vera, Marín, Sánchez, Borrachero, & Pujol, 2002). A messy handwriting may occur if the nurses write the notes too quickly in order to save time or too many workloads on the same time. Messy handwriting can lead to misinterpretation of information and cause poor nursing care.
She believes that nursing interventions are key to nursing care. Watson’s nursing theories express that the mind, body and spirit of the patient should be taken into consideration. I agree with Watsons that while providing care the nurse should consider care base on the patient as a whole and not just focus on the disorder. I was taught to use Maslow’s hierarchy of need while planning and providing care for my patients. Maslow’s hierarchy is use to prioritize a patient need from life treating issues to love and belong.
There are consequences of inappropriate or inadequate documentation. A care provider could face loss of employment or suspension from his or her workplace. No doubt, there would be personal stress, possible loss of income and perhaps legal expenses. Since nurses are team of health care provider, one of the most serious situations could involve a severe injury or death of a client due to inadequate or inaccurate documentation. The use of uncommon abbreviation can also lead to undesirable impression and interpretations.
A person is in need of nursing care when they experience any deficiency of health, in the internal or external environment. Nursing is actively caring for the physical, mental, emotional, and social state of a person, and their perception of their external environment. Personal Philosophy Nursing is the art of holistically caring for a human being. Humans want to be cared for in order to maintain healthiness, but interaction with the environment can change their health status due to many different variables. The act of nursing helps people to achieve this goal comfortably and appropriately.
First, SN Jo admitted to have falsely recorded the respiration rate of the patient. Recording a false assessment is a serious documentation error and is unethical. The ethical value of veracity which is the practice of telling the truth, is breached which is an absolute no to the nursing goals. Truth telling is an important function of the nurse and the act of falsifying document is dishonesty which is a lack of respect to the patient and to the profession, According to Jameton (1984), deceiving others constitute unnecessary assumption of responsibility so when unfortunate events occur the one responsible for the deception which in the case here is false documentation will be liable for the consequences. Though in the scenario it was not mentioned what the effects were of the false documentation in relation to patients’ condition the nurse must actually carry out the assessment and monitoring and in the event harms come to the patient as a result of the failure to do proper documentation of assessment the nurse will be held liable.