Mr Symes Case Study

Major studies in the last three decades have confirmed an association between the registered nurse to patient ratio and adverse patient outcomes such as mortality, morbidity, length of stay, failure to rescue (Hunt 19). For example, bed sores or patient falls, are considered an adverse outcome because it is a complication that occurred after the patient was admitted to a healthcare facility, Nonetheless, the key to

(Geyer, 2015) distinguished ‘The prevalence of poor nursing care reported is notable, with 410 cases of a total of 899 professional conduct cases, involving poor nursing care being reported. This represents 46% of the cases. Total patient care constitutes both the hands-on physical care provided, as well as the recording thereof, followed by monitoring of the response and condition of the patient. Poor record keeping plays a role in all of these cases’. ‘Complaints to the NHS frequently and persistently focus on issues of poor communication, deficiencies in nursing care documentation and poor record-keeping’ (Law, Akroyd, and Burke, 2010, Pp.1227). There are issues which tend to occur during or after patient hand overs. Recent reviews, have been made on these issues surrounding recording patient care (World Health Organisation, 2007).My understanding and learning about non-verbal communication (written communication), has clearly shown that clinical record keeping, is crucial in all aspects of their patient’s care and wellbeing. The role of a nurse extends further than just facilitating interprofessional communication, it includes all of the six C’s which is essential to

As nurses in the health care system, we are the one that is been looked upon with high expectation to provide safety and quality care. Even more the nurses that are present and future in the field of evidence base practice and nursing informatics. With this development knowledge, nursing are expected to perform at a certain level when it comes to engaging in electronic health record and patient care. Gone are the days where paper records was used because it doesn’t sufficiently meet the needs of the health care delivery system today.

Record-keeping and documentation are a hugely important part of nursing practice that unfortunately is often overlooked. Good record-keeping is in fact an essential element of being a good nurse. This assignment will discuss the importance of record-keeping in the healthcare setting. Record-keeping is vital for three main functions of nursing. It facilitates communication, promotes safe and appropriate nursing care and meets professional and legal standards (CRNBC 2008). These purposes and other important functions of record-keeping will be described in this assignment. The professional and legal implications of poor record-keeping will also be outlined. The topics will only be briefly and broadly discussed due to word count

The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk

Keeping data on specific nursing sensitive indicators and making that information available to staff, would help raise awareness of the issues that need to be addressed. With the documented information provided it could empower the staff in patient safety and quality improvement efforts, something they have a direct impact on. By educating staff to be aware of potential issues it would help advance quality patient care. In this current case, pressure ulcers, the use of restraints and patient/family satisfaction could have been handled in a better way to improve patient satisfaction and outcomes. It’s possible that restraints might have not been necessary, the pressure ulcer may have been prevented and the patient and family would have felt that their needs were being met, and not neglected.

This essay sets out to discuss the importance of comprehensive and accurate assessment on a registered nurses’ ability to make excellent clinical decisions. It will examine what factors can change a nurses’ capability to be aware of, and act on abnormal assessment findings. As well as assessment being part of the nursing process that is used in every day nursing, it is also a critical part of patient safety (Higgins, 2008). Assessment findings are used to determine what needs to be done for the patient next. Early warning scoring systems currently exist to aid in the early detection of patient deterioration (Goldhill, 2005). The rationale for the use of these systems is that early recognition of deterioration in the vital signs of a

In this assignment we will discuss the holistic assessment process on admission to the clinical area and the duties that the nurse has throughout this process. We will also consider the medical conditions Mr C is presenting with and the appropriate care the nurse should provide relating to specific conditions. We will also discuss the pathophysiology of each of his conditions. Within the assignment we will discuss the post-operative care Mr C will be given by the nurse and the reasoning for this care. Including airway and breathing, circulation, pain management and psychological care. Whilst still in the clinical area we will explore the process of discharge planning and the role of the nurse throughout this process. Lastly we will

Care within the hospital has become very complex and challenging as nurses are being faced with taking critical decisions associated with care of seriously

Introduction The Guide to Patient The and Family and Engagement in Hospital Quality in Hospital Quality and safety is a resource to help hospital develop effective partnerships with patients and family members with the goal of improving multiple aspects of hospital quality and safety. Nurse shift changes require the successful transfer of information Between Nurses Between. To prevent adverse event’s e and medical errors Patient and Family can play a role to make sure these can play a role to make sure this transition in care safe and effective?

A surgical nurse is responsible for monitoring and ensuring quality healthcare for a patient following surgery. Assessment, diagnosis, planning, intervention, and outcome evaluation are inherent in the post operative nurse’s role with the aim of a successful recovery for the patient. The appropriate provision of care is integral for prevention of complications that can arise from the anaesthesia or the surgical procedure. Whilst complications are common at least half of all complications are preventable (Haynes et al., 2009). The foundations of Mrs Hilton’s nursing plan are to ensure that any post surgery complications are circumvented. My role as Mrs Hilton’s surgical nurse will involve coupling my knowledge and the professional

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.

This then helps to emphasise the importance of vital signs in contemporary nursing practice as ‘better monitoring of patients implies better care’ for this reason it is the nurses responsibility to ensure accuracy of the data, interpret the vital signs findings and to report any abnormalities (Lynn, 2008 ; Kyriacos et al, 2011 p.3225). This also builds the nurses core skill set and offers the earliest information of a patient at risk of deterioration, which helps to prevent deaths or further health complications (Boulanger, 2009).

Urgency of acute care varies depending on the situation but can range to anything from emergency surgeries, to injuries, chronic illnesses, and also for the recovery of those procedures. Majority of the patients in acute care settings are critically ill. Nursing responsibilities in acute care settings are vital to patient’s recovery due to the front line position nurses play as well as the wide variety of tasks carried out. Assessments are made during every encounter the nurse has with the patient along with monitoring the patient’s progress. Nurses are responsible for recognizing symptoms the patient may be experiencing due to illness or injury and whether they fall in the spectrum of normal reactions. Vital signs are measured routinely and can be indicators of the patient’s current status. When vitals are questioned diagnostic tests can be arranged to further assess possible comorbidities the patient may have. Care plans are made to plan interventions the health care team can take to help patients through challenges they face, both physical and mental. Nurses administer medications as well as first aid as needed. They are responsible for maintaining special equipment patients may require including monitors and ventilators are well.