The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [45]
The formulation of nursing interventions is dependent on adequate information collection and accurate clinical judgement during patient assessment. As a result, specific patient outcomes may be derived and appropriate nursing interventions undertaken to assist the patient to achieve those outcomes (Hardwick 1998). Nursing interventions should be specific to help the patient achieve the outcome and should be evidence based. When determining what interventions may be appropriate in relation to a patient’s problem, it may be helpful to clarify the potential benefit to the patient after an intervention has been performed, as this will help to ensure its appropriateness.
It is important to continue to assess the patient on an ongoing basis whilst implementing the care planned. Assessing the patient’s current status prior to implementing care will enable the nurse to check whether the patient has developed any new problems that require immediate action. During and after providing any nursing action, the nurse should assess and reassess the patient’s response to care. The nurse will then be able to determine whether changes to the patient’s care plan should be made immediately or at a later stage. If there are any patient care needs that require immediate action, for example consultation or referral to a doctor, recording the actions taken is essential. Involving the patient and their family or friends will promote the patient’s well-being and self-care abilities. The use of clinical documentation in nurse handover will help to ensure that the care plans are up to date and relevant (Alfaro-Lefevre 2002, White 2003).
Evaluating care
Effective evaluation of care requires the nurse to critically analyse the patient’s health status to determine whether the patient’s condition is stable, has deteriorated or improved. Seeking the patient’s and family’s views in the evaluation process will facilitate decision making. By evaluating the patient’s outcomes, the nurse is able to decide whether changes need to be made to the care planned. Evaluation of care should take place in a structured manner and on a regular basis by a Registered Nurse. The frequency of evaluation depends on the clinical environment within which the individual is being cared for as well as the nature of the nursing diagnosis (problem) to which the care relates. Questions such as:
What are the patient’s self-care abilities?
Is the patient able to do what you expected?
If not, why not?
Has something changed?
Are you missing something?
Are there new care priorities?
will help to clarify the patient’s progress (Alfaro-Lefevre 2002, White 2003). It is helpful to consider what is observed and measurable to indicate that the patient has achieved the outcome.
Documenting
Nurses have a professional responsibility to ensure that healthcare records provide an accurate account of treatment, care planning and delivery, and are viewed as a tool of communication within the team. There should be ‘clear evidence of the care planned, the decisions made, the care delivered and the information shared’ (NMC 2009, p.8) (Box 2.12). The content and quality of record keeping are a measure of standards of practice relating to the skills and judgement of the nurse (NMC 2009).
Box 2.12 The Royal Marsden Hospital guidelines for nursing documentation
General principles
1 Records should be written legibly in black ink in such a way that they cannot be erased and are readable when photocopied.
2 Entries should be factual, consistent, accurate and not contain jargon, abbreviations or meaningless phrases (e.g. ‘observations fine’).
3 Each entry must include the date and time (using the 24-hour clock).
4 Each entry must be followed by a signature and the name printed as well as:
the job role (e.g. staff nurse or clinical nurse specialist)
if a nurse is a temporary