Nursing 4400A/B Lecture Notes - Lecture 1: Nursing Diagnosis, Uptodate, Chest Tube
2 Jan 2017
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Document Summary
Providing high quality nursing car is not simply a matter of the nurse having up-to-date knowledge and skills. Being mindfully aware of the relational complexities that are at play in a situation and intentionally and skillfully working in response to those relational complexities. Clinical judgments are more influenced by what a nurse can bring to the situation, rather then objective data about situation. Sound clinical judgment rests to some degree on knowing pt and their typical response, and engagement. Documentation of a client"s condition is important in order to: Communicate relevant information about client needs to all members of the health care team. Factual avoid opinions (seems, appears, progressing well), vague working (good, normal) Accurate precise, detailed, proper terminology, own assessment and not from others on your shift, reasonable time. Concise one issue per note, relevant info, point form preferred and acceptable. Complete date and time, title, enough info, lab values, signed and profess designation.
