Write in dark ink preferably black ink , never in pencil, and keep records out of direct sunlight. This will help to ensure they do not fade and cannot be erased. On admission, record the patient's visual acuity, blood pressure, pulse, temperature, and respiration, as well as the results of any tests. State the diagnosis clearly, as well as any other problem the patient is currently experiencing. Record all relevant observations in the patient's nursing record, as well as on any charts, e. File the charts in the medical notes when the patient is discharged.
Ensure that the consent form for surgery, signed clearly by the patient, is included in the patient's records. Include a nursing checklist to ensure the patient is prepared for any scheduled surgery. Note all plans made for the patient's discharge, e. Patients' records must provide an accurate account of their hospital stay. Ensure the statements are factual and recorded in consecutive order, as they happen.
Only record what you, as the nurse, see, hear, or do. Do not use jargon, meaningless phrases, or personal opinions e. If you want to make a comment about changes in the patient's vision, check the visual acuity and record it. Do not use an abbreviation unless you are sure that it is commonly understood and in general use.
For example, BP and VA are in general use and would be safe to use on records when commenting on blood pressure and visual acuity, respectively. Do not speculate, make offensive statements, or use humour about the patient. Patients have the right to see their records! If you make an error, cross it out with one clear line through it, and sign.
Do not use sticky labels or correction fluid. Remember, some information you have been given by the patient may be confidential. Think carefully and decide whether it is necessary to record it in writing where anyone may be able to read it; all members of the eye care team, and also the patient and relatives, have a right to access nursing records.
Keep the nursing records in a place where they can be accessed easily; preferably near to where the nursing team meet at shift change times. This will ensure that records are available for handover sessions and also that they are easily accessible to the rest of the eye care team. The handover may take place with the patient present, if appropriate. Indeed, nursing records can only be accurate if patients have been involved in decision making related to their care.
Anatomy of Writing for Publication for Nurses, Third Edition , has been fully updated to include even more useful information to help prospective authors turn their early drafts into published manuscripts. Lead author Cynthia Saver, joined by 25 expert writers and editors, shares important advice and insight to demystify the writing and publishing process.
Learn techniques to write more effectively, collaborate with other healthcare professionals, turn your dissertation or capstone into a published article, and manage contributing authors. Clinical reasoning is a skill vital to nursing practice and split-second decisions. OPT emphasizes reflection, outcome specification, testing, and the development of clinical judgment given the context of a client's or patient's story, all of which contribute to successful clinical reasoning and positive patient outcomes.
In this comprehensive new guide, author Cynthia Clark explores the problem of incivility and provides practical solutions that range from ready-to-use teaching tools to principles for broad-based institutional change. While written primarily for nurse educators and students, practicing nurses will find helpful perspectives on managing incivility in a clinical setting.
In nursing school, you likely envisioned a career focusing exclusively on patient care, until you were thrust into the reality of numerous additional responsibilities. Whether staffing and productivity are part of your current role or next career move, The Nurse Manager's Guide to Innovative Staffing, Second Edition, is for you. In this new edition, you'll find detailed examples of staffing plans, policies, and delivery models for different care settings, real-world staffing experiences, calculation formulas and worksheets, and so much more. This new STTI book takes readers on a journey from accountability to ownership, providing a proven model, strategies, and practical solutions to help improve organizational culture in a healthcare setting.
Learn how investing in your organization and your people can enable a significant successful change in productivity; employee engagement; nurse satisfaction, recruitment and retention; quality of care; patient satisfaction; and financial outcomes. This new book presents the Caritas Coach Education Program, based on the moral, ethical, philosophical, and practice principles of Caring Science. Caritas Coaching provides nurses and other caregivers a deep, intimate look at how to infuse their practice with Caring Science, a scientific and philosophical context to explore, describe, and research human healing.
This new book focuses exclusively on 60 non-hospital nursing careers in areas where job growth is expected to remain strong. Each position includes a basic description, the required education or skills, typical work hours and settings, availability of specialty certifications, related professional organizations, and additional online resources for that specialty.
Did you know that a greater proportion of the world's population is reaching 60 years of age or more? Keeping older adults healthier longer includes keeping them in their homes, creating a growing demand for nurses to deliver home-based care. In this practical and comprehensive guidebook, one of the top names in home care nursing, Tina M.
The result is a definitive resource for understanding the challenges and complexities of healthcare at home.
Medical errors now rank as the third leading cause of death in the United States, according to a recent study by Johns Hopkins Medicine. Anatomy of Medical Errors: The Patient in Room 2 is one nurse's personal story of survival and fact-finding as a victim of preventable medical errors. As this mesmerizing story recounts the author's struggles, it teaches nurses and other healthcare providers how to avoid potentially dangerous situations, recognize warning signs, and work collaboratively to provide transparent patient care.
Today's nurses are at the forefront of leading change and promoting social justice in healthcare. The newest edition of this popular book provides everything current and future nurses need to create a public health strategy in the communities where they practice. This third edition includes practical material to help nurses assess Joint Commission preparedness and apply concepts that lead to health equity and a healthier future for their communities.
High reliability is quickly becoming a primary focus for health providers as patient safety and quality standards are increasingly scrutinized. But what are high reliability organizations HRO and what do they look like in the healthcare field?pemiwhislra.ga
This new book addresses the gap between understanding HRO and applying their principles to clinical practice. Authors Oster and Braaten provide tools and best practices that will improve and enhance patient safety and quality outcomes. Emergency Nursing provides students, new nurses, and existing emergency nurses the tools and information they need to pursue and sustain a successful career in emergency healthcare. Filled with facts, notes, and practical advice, this book is a fantastic resource for a student or nurse eager to learn more about emergency care.
While nursing is a rewarding profession, the long hours, physical and mental exhaustion, heavy workloads, and organizational change are stressors that often lead to burnout. Adopting healthy coping behaviors are key for a successful career and overall life satisfaction! In this book, author Suzanne Waddill-Goad provides practical solutions and strategies for fresh thinking, including ways to prevent burnout in the first place, harness and manage overwhelming stress, and set new priorities to care for yourself.
Authors Malloch and Porter-O'Grady share their own experiences to help present and future healthcare and nurse leaders with proactively preserving and sharing their valuable knowledge and experience across generations. Using an approach that emphasizes mentoring and sustainability of expertise, this book aims to facilitate smooth transitions and sustain the continued viability of healthcare organizations. Written for student nurses, new nurses, and those returning to the field, this straight forward how-to guide will prepare you to confidently enter professional practice.
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From ethical issues to continuing education to coping with stress, the authors provide practical strategies and tools to help you reach your greatest nursing potential. Only a small fraction of healthcare board positions are held by nurses in the U. Nurse on Board provides all the tools needed to attain and succeed in your first board role—or advance into ever-greater board responsibilities.
Higher acuity and more chronic patients, increasingly complex technology, and the rapid generation of knowledge all mean nurses must grow and adapt to continue providing high quality care for patients. This book provides nurse educators with the training tools they need to create a successful professional development program for nurses. Mastering Patient and Family Education presents a model that makes teaching patients and their families a central part of the healthcare system.
This model provides nurses and healthcare professionals the tools they need to inform and educate patients so they can actively participate in their own treatment, improve outcomes, help identify errors before they occur, and reduce length of stay.
Pagana provides you with the tools you need to become a polished and confident professional. It challenges them to explore culture as it affects their professional roles, enabling more culturally aware and sensitive healthcare encounters. Fostering a Research Intensive Organization details the ways a strong nursing research agenda can positively impact patient care and influence the redesign of services necessary to nimbly respond in an ever-changing healthcare environment.
Jones provide a comprehensive review to support the practice environment as an important place to advance nursing science through research. The evolving world of healthcare requires educators and practitioners to be nimble, flexible, and responsive to change. This highly anticipated book helps ensure that nursing students are as prepared as possible to respond to disasters, whether in their own neighborhoods or around the world, by giving nurse educators strategies and solutions for incorporating disaster preparedness into their curriculum.
In Fostering Clinical Success , Massachusetts General Hospital nurse leaders share their model for creating, embedding, and fostering a narrative culture.
Thinking of living and working in the UK?
This text provides nursing professionals with a foundational knowledge of human genetics and genomics that can be applied in optimizing drug therapy and patient care delivery. This unique resource provides a road map to managing responsibilities, fostering productive environments, managing finance and regulations, and more. Starting with a multidisciplinary approach to health care research administration, the authors share their tools, techniques, and tactics to create an effective research infrastructure. This book sheds light on why nurses are where they are and, more importantly, how nurses can approach the future in a different way.
It asks the hard questions the nursing profession must answer in order to move past its recurring challenges and progress into the future. This fully revised, expanded, and updated second edition offers even more practical tips, tools, and tricks for rebalancing your life. Learn how to set a course of action to build the life and career you want, need, and deserve.
HCAs, APs and TNAs: Subject Guide | Library | Royal College of Nursing
This award-winning handbook for nurses details how to care for patients at the end of life. Fully revised and updated, this is a practical guide to understanding the needs of both patients and families and the important roles nurses play in addressing those needs. Using a case-based, controversial format, authors Mathes and Reifsnyder present and illustrate the legal context for nursing practice and provide answers for dealing with legal issues as they arise.