N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide the task should not be delegated until the person has the appropriate training. o The response of the patient to the intervention and the documentation of that response is a nursing responsibility. The person to whom the task is delegated must have a clear understanding of what to watch for during the intervention and what must be reported to the nurse. • Documentation of the activities of care: It is the nurse’s responsibility to record the patient’s status before, during, and after any intervention. This documentation should include information about the patient’s condition before the intervention, what intervention was performed, how the patient responded to the intervention, and the final outcome of the intervention. Any documentation in the patient record should be objective, descriptive, and complete, conveying an accurate picture of the patient’s status and progress toward goals. This documentation provides the following: • A legal record of what was done, by whom, and how the patient responded • A formal means of communication between team members to ensure continuity of care • A record of services that allows for reimbursement of care • A baseline for evaluation of progress toward expected outcomes In addition to the written documentation of progress in the nurses’ notes, the astute nurse will ensure continuity of care by providing succinct and accurate hand-off reports to other team members who assume care for the patient. This hand-off mechanism will vary depending on the practice setting. In some settings, the nurses may have a tape-recorded report fromone shift to the next; in other settings, the hand-off may be a face-to-face report. In any setting, the hand-off should include information that will allow the on-coming nurses to know what interventions have been attempted and how the patient responded to each. During the implementation of the plan, the nurse will also be involved in the evaluation of the plan of care. 1.5 Evaluation The final stage of the nursing process is the evaluation phase. In this phase, the patient, nurse, and healthcare team work together to determine whether the patient goals have been met, partially met, or not met. In order to do this evaluation: • The nurse collects the measurable data to compare with the desired outcomes. The nurse analyzes the data obtained during the implementation phase to determine what variables affected the outcomes. • The nurse, patient, and other healthcare team members collaborate to determine if progress or lack of progress is related to the interventions performed. If goals have not been met, the nurse will try to determine why goals were not fully met. Some of the reasons goals are not met include: o The initial assessment may have been o The diagnoses may not have been appropriate for thepatient.

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