This assignment will focus on development and awareness of the legal, ethical and professional issues associated with accountability in health care. The theme identified is record keeping. According to NMC, (2009), ‘record keeping is essential part of Nursing, Midwifery and Allied Health professionals’ practice and is necessary to the provision of safe and effective care. Records include anything that makes reference to the care of patient and any record can be called as evidence. NMC, (2009), states that, ‘ good record keeping helps to improve accountability and shows how decisions related to patient care were made’ and the courts of law approach to record keeping tends to be that, “if it is not recorded, it has not been done”.
(Potter & Perry, 2011, p. 2) As a professional nurse, you need to stay informed and be aware of the most current evidence or research. (Potter & Perry, 2011, p. 2) Research helps to inform our practice and helps us to improve patient outcomes. Just as it is important for nurses to be aware of current research, it is also critical that nurses have effective and adaptable communication skills. A nurses responsibility is to effectively communicate with patients and their familles, as well as the team. Effective communication allows nurses to develop important therapeutic skills.
More often a nursing assessment is based on the medical side of the patient rather than the holistic approach. In this assignment I will be discussing the importance of the nursing process, care planning, and looking at how these are used in practice. I will look at the tools used in the nursing process and show an understanding of how effective they are when used correctly. I will achieve this by describing a case study of a patient from my practice area, and discussing two specific areas that affect the patients care. Throughout this assignment I will be using a pseudonym to maintain patient confidentiality in order to conform to ‘The Nursing and Midwifery Code’ (NMC, 2008).
Each nurse demonstrated that teambuilding is important because it helps to provide better patient care by utilizing the expertise of the other disciplines and allowing collaborative efforts to resolve patient problems. Teambuilding also includes relationship building. As stated by the nurse midwife, she establishes a relationship with the labor nurses, which also enhances patient care. The particular care applied through these particular nursing practices, across the board, are direct patient-centered care with the exception of the infection control nurse. Her care is not directly with the patient, but her job effects the patient directly.
The role of the nurse in the GI lab is performing a thorough head-to-toe assessment, along with obtaining prior medical history, and making sure consent and all documentation is completed before the patient goes in for their procedure. The nurses’ role intra-procedure is documenting, assisting the physician, initiating the time-outs, and giving report to the next nurse of what occurred, post diagnosis, and any new orders to the next nurse. Post procedure, the nurses’ role is to assess the patient, perform vital sign every 10 minutes until stabilized, give discharge instructions and do patient teaching. Nursing care is different in the GI lab than on a med/surg floor because you’re with the patient for an hour before they go for their procedure, and then discharging them usually after 45 minutes post procedure. While a med/surg nurse is with their patient for 12 hours.
Implementing EBP in nursing care establishes who they are, what they do, and what effect they have on patient outcomes (Overholt, 2004). All nurses have the responsibility to delivering the best care that will deliver the best outcomes to the patient. Evidence-based practice serves as a framework of how to prevent or treat common issues seen in clinical practice. The process of implementing EBP into clinical practice is accomplished by a series of steps or
Malcovich of this patient’s presentation early on in her visit allowed him to investigate the details of her health and psychiatric history. He was also able to check laboratory and test results and have complete access to up-to-the-minute patient care notes. This allowed him to begin contemplating patient management options. St. Theresa’s, unfortunately does not offer inpatient psychiatric services. Therefore, once medically cleared, we have to rely on inpatient psychiatric facilities or group homes like the one Dr. Primrose runs to ensure that these patients remain safe while, in this case, initiating prescriptions to manage medical and psychiatric issues and gathering resources that will be necessary for this patient to regain her independence.
I believe that providing the best possible care for each patient should be the primary concern of nursing. In doing so, the environment is crucial in the meeting the needs of the patient. Central concepts of nursing are “person, environment, health, and nursing” ( Masters, 2014, p.48).Careful consideration must be given in educating the patient about the illness. In early years, the responsibility fell upon the physician. In recent years, the responsibility has been transferred to the nurse to manage the patient’s environment in order to promote the patient’s recovery.
I am responsible in making sure the care of the patient has been seen through to the end of their stay and to report any observations of the patient ,to the midwife in charge of that said shift and if anything needs reporting to act accordingly,ie frequent observations. Communication is key with regard to any issues which need addressing about the patients health and well being and contribute to the overall care that they have received. Standards of care can come from these values: • We treat people how we would like to be treaded • We do what we say we are going to do • We focus on what matters the most • We are one team and we are best when we work together • We are passionate and creative in our work. By contributing to all these values makes us all a better team and helps to create a professional work force for all to see. OUTCOME 2 To improve the quality of service provided it is essential to reflect on things that have already been done in order to see if there is a need to change so that they can be made better for future reference.
This essay offers a discussion of the importance of evidence based practice within the healthcare environment. Evidence based decision making in clinical practice takes into consideration, the patient’s wellbeing, where the procedure can take place and the clinical circumstances (####,####). #####,(####) suggest that evidence based research findings are the best type to inform health professionals with regards to decisions, actions and interactions with patients. #### & ####,(####) also found that nurse’s believe there is a need to evaluate the evidence so that clinical actions can be changed if the research shows the actions are more cost effective and the results are still in the patients best interest (#### & ####.,####). A choice of articles