...admission of a patient. Physical examinations may be used from the previous hospitalization if the examination was within 30 days. A physical examination may be accepted from a physician’s office if the examination was within 30 days and meets the standards as defined by hospital policy and procedure. If the patient was transferred from another hospital, the physical examination may be accepted if the examination was done within 30 days, provided they are updated within 24 hours of admission or registration by the attending physician. In the above three cases, the attending physician must validate the examination in the medical record (on the physical exam) by noting that there are no significant findings or changes and signs and dates the report. Guidelines for contents of a complete History & Physical include: a. The Emergency Room documentation form may not be used as a History and Physical. b. A complete history and physical examination shall be recorded before the time stated for operation or the operation shall be canceled unless the attending surgeon indicates it is an emergency procedure. c. If the complete history and physical was dictated shortly before the operation, but not yet transcribed, the surgeon/physician will document that the history and physical has been dictated. A short History & Physical can be used for procedures using procedure/moderate sedation. No History & Physical is required for procedures using local sedation. d. The...
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...Description: Register Nurse Alexia Hogle, Courtney Nessel, Tristin Gibson, Kyle Armstrong Registered Nurse Job Purpose: Registered nurses (RNs) provide and coordinate patient care, educate patients and the public about various health conditions, and provide advice and emotional support to patients and their family members. Registered Nurse Duties: • Record patients' medical histories and symptoms • Give patients medicines and treatments • Set up plans for patients’ care or contribute to existing plans • Observe patients and record the observations • Consult with doctors and other healthcare professionals • Operate and monitor medical equipment • Help perform diagnostic tests and analyze results • Teach patients and their families how to manage their illnesses or injuries • Explain what to do at home after treatment Education: In all nursing education programs, students take courses in nursing, anatomy, physiology, microbiology, chemistry, nutrition, psychology and other social and behavioral sciences, as well as in liberal arts. BSN programs typically take four years to complete; ADN and diploma programs usually take two to three years to complete. All programs also include supervised clinical experience in hospital departments such as pediatrics, psychiatry, maternity, and surgery. A number of programs include clinical experience in extended and long-term care facilities, public health departments, home health agencies, or ambulatory (walk-in) clinics. Bachelor's...
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...Kolotylo, C. (2010). A questionnaire for assessing community health nurses' learning needs. Western Journal of Nursing Research, 32(8), 1055-1072. This journal covers the important stages of the Learning needs assessment and how it impacts every educational process that is aimed to inform changes in practice and policy for continuing professional development. Professional opportunities have been widely used as a basis for the development of learning needs assessment. This article reports on the development of a learning needs assessment questionnaire for Community Health Nurses (CHNs). Exploratory and confirmatory factor analyses were conducted to examine the consistency of factors underpinning the Canadian Community Health Nursing (CCHN) Standards. Also, validity and reliability of the questionnaire were evaluated using appropriate techniques. This process resulted in a valid and reliable CHN learning needs assessment questionnaire to measure learning needs of large groups of practitioners, where other forms of measurement cannot be feasibly conducted. Aydin, A.K., & Karadaq, A. (September-October 2010). Assessment of nurses knowledge and practice in prevention and management of deep tissue injury and stage 1 pressure ulcer. Journal of Wound, Ostomy, and Continence Nursing, 37(5), 487-494. This is a good overview from a well-known nursing journal that focuses on a descriptive study on how to determine a nurses knowledge and usual practice and prevention of deep tissue injuries...
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...Title: Evidence Based Practice in Nursing Name Course Tutor April 20th, 2013 Introduction The paper herein provides a critical discussion of evidence based practice (EBP) in nursing. It clearly elaborates on the meaning and definition of EBP as used by nurses as well as the importance of evidence based decision making as it relates to nursing care. It broadly examines the concept of EBP in nursing care and its relevance to nursing practice and to the delivery of quality patient care. Subsequently, the essay will also expound on the broad research methods that are used in evidence based nursing and conclusively show how this evidence can be applied in day to day health care practice. The Definition and Importance of EBP Evidence based practice in nursing has wide and varied definitions among the nurses in practice and in academic centres. However, the most generally accepted definition is the integration of the best research evidence with clinical expertise and patient values (Sacket et al., 2000). Van, Schoonhoven & Grol (2008 at p. 382) while citing Sacket et al., (2000), define evidence based nursing as the conscientious, explicit and judicious use of current best evidence available in making decisions that are pertinent to the care of individual patients. It is the optimal use of the available research evidence in nursing (Van, Schoonhoven & Grol, 2008). In other literature, evidence based practice (EBP), in nursing has been defined to mean the...
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... although it is recognised that the fundamental theories explored may be applied to any setting where the teaching, training and mentoring of adults occur. The essay will explore the writer’s understanding regarding the role of a mentor within the workplace and the theoretical ties surrounding mentorship and how these are linked into the writer’s role of a mentor. Any names or areas of work mentioned in the essay have been changed in order to maintain confidentiality, clause five of the Nursing and Midwifery Council (NMC) Code of Professional Conduct: Standards for Conduct, Performance and Ethics (NMC 2004). The term ‘mentor’ is defined by the English National Board (ENB) and the Department of Health (DOH) to “denote the role of the nurse, midwife or health visitor who facilitates learning and supervises and assesses students in their practice setting” (ENB & DOH 2001a P6). Nicklin and Kenworthy (2000) define a mentor as someone who by example and facilitation guides, assists, and supports the student in learning new skills, adopting new behaviour and acquiring new skills. Quinn (2000 P.427) furthers this definition by pointing out the fact that a mentor is someone who “enters into a formal arrangement to provide education and personal support to a student throughout the period of the placement.” This denotes the level of responsibility and commitment required by the mentor, as an agreement is established. Within that agreement a contract of...
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...Immediate Post Operative Care 2 The following essay will use a systematic approach to critically evaluate the care and treatment delivered to a non-elective paediatric orthopaedic patient within the Post Anaesthetic Care Unit (PACU) by a student Operating Department Practitioner at a local trust hospital. The assessment and management of the patients care will be examined and rationale provided for strategies employed during delivery of individualised patient care. In accordance with Health and Care Professional Council’s standards of conduct, performance and ethics (HCPC, 2012) the confidentiality of the service user will be up held at all times. The service user shall be referred to as “Daisy” to protect her confidentiality. Daisy was received to the PACU after surgical stabilisation of her left fibula and tibia with flexible intramedullary nails following a fall. A specified paediatric bay was utilised enabling the patient to be cared for separately from the adults in the PACU (RCOA, 2013). Anaesthetic and surgical handover was received (RCOA, 2013) which detailed that she was 14 years old with no known allergies. She had no significant medical history. She had a general anaesthetic with 140mfg of Propofol used on induction followed by Sevoflurane as a maintenance agent. 30mg of Atricurium, 4mg Dexamethasone, 4mg Ondansatron, 10mg Morphine and 1g Paracetemol had been administered intraoperatively. 1 litre of Hartmanns solution had been administered during surgery and...
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...encompasses implementing the best-known practices into the clinical setting using a scientific approach. It evolved from evidence-based medicine, which was developed in Canada to teach medical students. “Evidence-based medicine has been defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”3, p. 3 The National Quality Forum’s report A National Framework and Preferred Practices for Palliative and Hospice Care Quality is a consensus report that is a first step toward introducing evidence-based measures into palliative practice on a formal, national level.4 The Agency for Healthcare Research and Quality (AHRQ) supports organizations in their efforts to improve the quality and efficiency of healthcare by facilitating the use of evidence-based research findings in clinical practice.5 The nursing discipline has also embraced evidence-based practice over the past 25 years, initially through its support of “research utilization,” the integration of research into nursing curricula, and the education of nurse scientists. Sigma Theta Tau International, the Honor Society of Nursing, considers evidence-based nursing “as an integration of the best evidence available, nursing expertise and the values and preferences of the individuals, families, and communities who are served.”6...
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...Code of Professional Conduct for Nurses in Australia Introduction Professional conduct refers to the manner in which a person behaves while acting in a professional capacity. It is generally accepted that when performing their duties and conducting their affairs professionals will uphold exemplary standards of conduct, commonly taken to mean standards not generally expected of lay people or the 1 ‘ordinary person in the street’. The Code of Professional Conduct for Nurses in Australia is supported by the Code of Ethics for Nurses in Australia. This Code of Professional Conduct for Nurses sets the minimum standards for practice a professional person is expected to uphold both within and outside of professional domains in order to ensure the ‘good standing’ of the nursing profession. These two companion Codes, together with other published practice standards (e.g. competency standards, decisionmaking frameworks, guidelines and position statements), provide a framework for legally and professionally accountable and responsible nursing practice in all clinical, 2 management, education and research domains. The support and assistance of Royal College of Nursing (unified with The College of Nursing on 1 July 2012 to become Australian College of Nursing) and the Australian Nursing Federation in developing this edition of the Code of Professional Conduct for Nurses in Australia is acknowledged. In considering this Code and the Code of Ethics for Nurses in Australia, it should be borne...
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...always ranges from 140 to 150. During the primary assessment, it is noted that she is not in danger and she opens her eyes when her name is called. She is able to talk and her airway is patent. Her accessory muscle use is increases; her RR is at 22 and SP02 is at 95% on room air. She is also pale and diaphoretic. Her pulses are weak and thread y with the heart rate of 120 and blood pressure of 95/50, GCS at 13/15, temp at 38.5, BGL at 13.2mmol/L and pain in the lower abdomen. Nurses role in recognizing and responding to clinical deterioration The nurses also have a role of ensuring that the medication that a specific patient is getting provides the best possible results. Any specific medication taken by a patient has the capability of working effectively if the nurse involved is able to efficiently observe and identify any worsening conditions a patient might be having, in order to take the necessary actions to manage the said conditions (Adam, Odell, & Welch, 2010). If a specific nurse fails to take note...
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... |First publication date and importance: | |Nursing Research |First published: 1952 | | |Importance: Research activities of the 1940 are led to the need to | | |publish this journal. The first journal published that was devoted | | |entirely to nursing research (Burns & Grove, 2012, p. 12). The goal | | |of the journal is to provide the highest quality research and report| | |its findings and the impact of therapeutic actions and nursing | | |systems (Lippincott, Williams & Wilkins, 2012). | |Sigma Theta Tau Journal published by this organization is |First published: 1967 | |now called Image—The Journal of Nursing Scholarship |Importance: This journal published research articles and included | | |research conducted on various topics by some of the top nursing | | |researchers. It helped...
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...Abdelhak Exercise 1. Identify all the users of the health record AND explain how each uses the record. (Complete for all that are listed in Abdelhak under the “health data users and uses” section. - Patient: uses their medical data to understand their health care and to become more active partners in maintain or improving their health. - Health care practitioners: uses it as a primary means of communications among themselves. - Health Care providers and Administrators: uses the data to evaluate care, monitor the use of resources, and receive payment for services rendered. Administrators analyze financial and patient case mix information for business planning and marketing activities - Third party payers: the data become the basis for determining the appropriate payment to be made. - Utilization and case managers: uses it to coordinate care so that the patient is cared for in the most clinically cost-effective manner. - Quality of care committees: use the information as a basis for analysis, study, and evaluation of the quality of care given to the patient. - Accrediting, licensing, and certifying agencies: use the record to provide public assurance that quality health care is being provided. - Governmental agencies and public health: to determine the appropriate use of the governmental financial resources for health care facilities and educational and correctional institutions - Health information exchanges: provides...
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...Council’) under the Health Practitioners Competence Assurance Act 2003 (‘the Act’) is the responsible authority that governs the practice of nurses. The principle purpose of the Act is to protect the health and safety of members of the public by providing mechanisms to ensure health practitioners are competent and fit to practise their professions. The Council sets and monitors standards in the interests of the public and the profession. The Council’s primary concern is public safety. This Code outlines the standards of ethical conduct set by the Council under section 118(i) of the Act. This Code complements the legal obligations that nurses have under the Act, the Health and Disability Commissioner (Code of Health and Disability Services Nursing Council of New Zealand, PO Box 9644, Wellington 6011 www.nursingcouncil.org.nz Published June 2012 The Code of Conduct for nurses has been revised and rewritten. This document replaces the previous Code of Conduct for nurses published by the Nursing Council of New Zealand between 1995 and 2011. © Consumers’ Rights) Regulations 1996 and the Health Information Privacy Code 1994. The Act and Code of Rights can be found at http://www.legislation.govt.nz The Code of Conduct for nurses is a set of standards defined by the Council describing the behaviour or conduct that nurses are expected to uphold. The Code of Conduct provides guidance on appropriate behaviour for all nurses and can be used by health consumers, nurses, employers, the Nursing...
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...admission assessment experienced during placement. It is not a care study. There will be an overview of the nurse-managers responsibilities during the admission assessment and attention drawn to local and government policy. Particular consideration is given to risk assessment, Essence of Care (DoH 2001) in respect of the Waterlow Pressure Damage Assessment (1985), pressure sores, nutritional screening and delegation. Other issues considered will be communication, partnership working, the therapeutic relationship, and the nurse as an agent of change. Findings will be supported by literature. Identifying factors have been changed to respect patient confidentiality. Mary had no previous psychiatric history. She was eighty-four and lived in residential accommodation. She had two adult daughters who were unable to attend Mary’s admission. Prior to admission Mary’s behaviour had changed over several weeks and she had been refusing to get out of bed during the day. During admission she showed occasional signs of confusion but was able to give consent. Physically, Mary was in a wheelchair, had a history of falls, pressure damage, skin flaps. and needed full assistance with mobility. My mentor facilitated her admission assessment. I observed this in preparation of undertaking future ones myself whilst under supervision. From a management perspective my mentor who was the senior nurse needed to consider who would be left on the ward whilst he and I did the admission. He needed to consider...
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...and lack of clinical sites are just a few concerns of nursing programs. Nurse educators seek teaching strategies that promote students that are highly skilled practitioners. Students must learn how to transfer their knowledge and learned skills into their clinical practice. It is the nurse educator’s goal to “produce safe and competent registered nurse” (Reid Searl, Eaton, Vieth, & Happell, 2011, p. 2758). Sufficient clinical experience is challenged as there is an increased demand for nursing schools to produce nurses that are competent, with the increasingly “ill population, coupled with the shortage of faculty” (Sportsman et al., 2009, p. 67). High Fidelity Simulation (HFS) is a method of providing students with clinical experience that is essential in developing the skills and knowledge. Many nursing programs are now using HFS in their curriculum. These simulators “allow students to experience high-risk, low volume patient problems in a realistic setting” (Tuoriniemi & Schott Baer, 2008, p. 105). The HFS are full size mannequins that can respond verbally and physiologically to the students interventions as well as omissions of care (Leigh & Hurst, 2008). The HFS offers students many advantages. This method of clinical training allows students to experience real life like patient encounters that they may not have the opportunity to experience during their clinical training. Nurse educators can correlate HFS with the current topics. Often, there are...
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...A. The sentinel event was related to respiratory arrest secondary to conscious sedation procedure. There were several factors that played a role which included high patient census, poor staffing, alarms dismissed by staff members, patient was left unmonitored, and no supplemental oxygen initated prior to the procedure. When the patient was pulseless no CPR was initiated until the code team arrived and critical interventions were delayed by the emergency room staff. The patients medication reconciliation or history weren’t reviewed by the emergency room physician. Tripple doses of intravenous valium and dilaudid were given without a lapse in time. The patient was elderly and on chronic oral opioid medications. “Normally these types of medications are administered with low doses and titrated per patient’s sedation level. Patient, monitoring or sedation level weren’t assessed between doses. This event is known as a sentinel event. In any situation that causes injury, or death a root cause analysis must be completed and reported to the Joint Commission. B. To implement a change in the conscious sedation procedure a team or committee needs to be established. All staff in the emergency room can become active participants by joining a committee or subcommittee. These main categories may include patient characteristics, task factors, individual staff members, team factors, work environment, and organizational management (IHI, 2014)...
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