Information Needed in Knowing the Patient

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Information Needed in Knowing the Patient

Information Needed in Knowing the Patient

The practice of nursing relies heavily on communication among nurses and other health providers. For quality care delivery and handing-over at the end of shifts, the primary nurse should communicate and document vital information about the patient to ensure continuity of care (Kelley, Docherty, & Brandon, 2013). Therefore, this paper discusses the continuity of care of an in-patient client admitted at a critical care ward with left ventricular cardiac failure.Information Needed in Knowing the Patient

Question 1

The nurse has to collect critical information about the patient for continuity of care. Nurses collect two sets of information to manage the patient; personal and clinical information (Kelley, 2014; Kelley Docherty, & Brandon, 2013). The latter includes prior medical history, chief complain, and current diagnosis .Physiological assessment includes urine output, hydration, hemodynamic, and changes in the trends of the vital signs (Kelley, Docherty, & Brandon, 2013). Personal information includes details about the family history and dynamics and functional health patterns (Kelley, Docherty, & Brandon, 2013). Additional patient details include personal preferences at home, behavior, temperaments, and demographic data.

Question 2

Patient’s personal and clinical information is obtained from two sources; the paper-based and the electronic sources. They are the key primary sources of information in the hospital. However, whichever the source of information, what is crucial is the continuity of nursing care, effective communication and delivery of quality nursing care (Kelley, 2014). Verbal interaction between the patient, family and the nurse is another prime source of information when the patient can speak (Kelley, Docherty, & Brandon, 2013).  Nurses’ paper-based documentation in the form of handwritten, typed, and transcription notes are other sources of information. For example, the patient has left ventricular cardiac failure hence the nurse’s narratives, assessments, and flow charts detailing the fluid intake, urine output, vital signs, hydration, and hemodynamics are used to monitor the patient’s care (Kelley, Docherty, & Brandon, 2013).

Nurses that interact extensively with the collaborative patient care team are involved in both long term and short term management. Members of this collaborative team include medical specialists, nurses, social workers, and physiotherapists. The collaborative care team members provide information that helps the nursing provider to offer individualized care to the patient in the critical care unit. Another significant source of information is the shift report, in which the nurse documents information during handing over the care of the patient to another nurse. This report helps the nurse to have an insight of the patient. Nursing narrative report and flow charts are essential information stored in electronic sources.

Question 3

Patients’ information is an integral part of nursing care. It is important since it helps the nurse understand the patients beyond their clinical diagnosis, which is fundamental in the provision of holistic care (Kelley, Docherty, & Brandon, 2013). Furthermore, personal information helps the primary nurse to tailor nursing services to meet individual patient’s needs. Secondly, during a handover session during the change of shift, the nurse on shift needs the information to create a nursing care plan that details individualized nursing care and interventions (Kelley, Docherty, & Brandon, 2013). Thirdly, the nurse needs such information to make a cognitive assessment of the patient, which is essential in tailoring nursing care. Furthermore, such data is also disseminated to other health providers during patient rounds to facilitate collaborative patient care. It is also crucial in updating electronic medical records for easy retrieval and storage. Lastly, the information is needed for discharging the patient from the hospital and planning discharge plan.Information Needed in Knowing the Patient

Question 4

Several strategies can be used to obtain the patient’s information. The first is verbal interaction between the patient, family, care providers, and nurses within the collaborative management team (Kelley, Docherty, & Brandon, 2013). The second is nursing documentation in paper-based report sheets for instance in shift reports and patient medical records. Lastly, the nurses can retrieve electronic information from electronic nursing records, and these include transcribed notes.