Evaluation: Implementation of Nursing Scopes and Standards of Practice within Sentara

Standard 1: Assessment

The registered nurse collects comprehensive data pertinent to the healthcare consumer’s health and/or the situation (ANA, 2010a, p.32).

Description and Comparison

The nurse performs the head to toe assessment technique, as well as focused assessments in emergent situations. The RN systematically assesses a patient’s needs, readiness to learn, barriers (communication, educational level, emotional, and physical limitations) that affect learning, religious/cultural beliefs, medication and health history, and risk for falls. The assessment tools include the Braden Scale for pressure ulcer prevention, the Faces Pain Rating Scale, and the Johns Hopkins Fall Risk Assessment tool (JHFRAT).

We measure vital signs using equipment provided on the unit, draw blood to send to the lab, and review the patient’s chart for pending results from prior diagnostic tests. The nurse records the assessment data into the patient’s electronic medical record (EMR) using Sentara’s eCare system. The Sentara eCare Health Network system provides innovative technology for gathering, documenting, and storing patient information.

Critique and Analysis

To ensure a fall prevention plan remains effective, this requires collaboration within the interdisciplinary team. Working together as a team to check bed alarm systems for activation, to ensure patients wear socks and/or slippers with rubber non-slip soles, to keep lighting in the room appropriate for patient activities. There is the need to educate the family and patients regarding use of the call bell system for assistance and review their medication list for any high- risk medications.

Sentara’s leadership say the number one cause of patient falls is the need to use the res...

... middle of paper ...

...level of pain for patient is difficult at times because this is a subjective measurement and people have diverse perception. Some patient’s pain is easier to control, while others have no real relief. Sentara’s staff upholds this standard by paging the physician when needed and documenting appropriately within the EMR.

White boards aid with collaboration among staff and continuity of care for patients. This implementation is mostly effective; however, on some occasions I observe incorrect information or items not up to date. This happens because the staff may forget to write on the board or it is not important to them. Incorporating white board documentation as a routine during shift report makes it harder to miss. To ensure the white boards reflect the correct information, the team leader selects a staff member to perform patient rounds throughout the unit.