assist with nursing care

• When assisting the Nursing team in an acute care environment there are many factors the health care worker must consider
• Factors to consider when assisting in nursing care


  • Holistic needs of the client and their personal care
  • Working within a plan of care
  • Use of appropriate equipment
  • Communication to appropriate health care provider
  • Infection control and work health & safety (WHS) principles
  • Organisation's policy and procedures
  • Working under direction of the registered nurse
  • Liaising and reporting appropriately to health professional
  • Be responsible for the care that you delivered
  • Adhere to your scope of practice
• Nursing care plans


  Provide continuous and standardised care to clients whilst identifying the individualised care a client will need

  
• Relevant policies and procedures to comply with


  • Work health and safety
  • Access and Equity
  • Antidiscrimination
  • Child protection
  • Infection control and personal hygiene
  • Manual Handling
  • Communication
  • Privacy and confidentiality
  • Code of conduct
• Communication in the acute care environment


  • Good communication skills are essential
  • Communication is a complex blend of verbal and nonverbal behaviours integrated for the purpose of sharing information
  • Everyone involved in communication comes to the process from a different standpoint
  • Confidentiality and privacy of clients' personal and medical details and circumstances must be maintained at all times
  • Techniques to assess whether messages are being understood: Ask and clarify, Ask the client to do something, Summarise major points, Be receptive to non-verbal communication
• Conflict and interpersonal differences in the workplace


  • Conflict can occur because workplace differences exist in attitudes, needs, experience and understanding
  • How these differences are worked through is important
• If it is a matter you can resolve yourself, then try resolving it
• Occasionally there will be disagreement about some aspect of the work. To work effectively, care needs to be taken when disagreement exists and conflict occurs.
• Conflict


  • Can occur because workplace differences exist in attitudes, needs, experience and understanding
  • These differences are unavoidable, however how these differences are worked through is important
• Resolving conflict


  1. Be clear about what has happened or what the problem is and say how you feel

  2. Listen to the other person

  3. Try to understand how the other person sees the issue

  4. Try to find an option that works for all (usually involves a compromise)
• If you are still concerned about a conflict in the workplace speak to your supervisor or manager.
• Health care records contain health information which is protected under legislation, with all information in a client's health care record is confidential and subject to privacy laws and policies.
• Health care personnel should only access a health care record and use or disclose information contained in the record when it is directly related to their duties and is essential for the fulfilment of those duties.
• To access client notes for other purposes breaches the NSW Health Code of Conduct and may breach client privacy and confidentiality.
• Entries in the client health care record should reflect in a timely way the level of assessment and intervention. The results of significant diagnostic investigations and significant changes to the client's condition and/or treatment should be documented as these occur (contemporaneous).

  
• General rules for documentation in client's notes


  • The nurse allocated to a client must read the client's clinical record on their shift
  • A progressive nursing report must be written for every client on EACH SHIFT
  • Reports must be sequential and written as the client's condition and/or treatment changes
  • Student AIN entries should be co-signed by their supervisor

  
• At all times the assistant in nursing remains responsible for their own professional actions and remain responsible to the registered nurse for delegated actions.
• All nurses who provide care, assessment, management and/or professional advice are responsible for legibly documenting and dating this activity in the client care report / electronic medical record (eMR)

  
• Contemporaneous documentation is required. Entries should be made in the health care record when the observation is made, or the care given.

  
• Standards for documentation - Every page of the health care record or on each screen of eMR must contain


  • Client identification (MRN, family name, given name, DOB, sex)
  • Medical record number
  • Any known allergies or 'NKA'

  
• Standards for documentation - Each occasion of documentation in the health care record must contain


  • Time of entry (24-hour clock)
  • Date of entry (ddmmyy or ddmmyyyy)
  • Signature of the author including printed name and designation
• Documentation in health care records must comply with


  • Be clear and accurate
  • Be legible and written in English
  • Use approved abbreviations and symbols
  • Paper based records must be written in dark ink that photocopies well, legible, and difficult to erase and write over
  • Made at the time of an event or as soon as possible afterwards
  • No gaps are to be left between entries
  • Be relevant to that client
  • Only include personal information about other people when relevant and necessary
  • Objective information only is to be documented (avoid subjective or demeaning language)
  • All errors must be appropriately corrected using established processes
• Documentation by nurses must include


  • Care/treatment plan, including risk assessments with associated interventions
  • Completed client care forms
  • Any significant change in the client's status with the onset of new signs and symptoms recorded
  • If a change in the client's status has been reported to the responsible medical practitioner, documentation of the name of the medical practitioner, date and time

  
• Each nursing entry is to commence with 'Nursing'.
• Managing incorrect entries in client documentation


  1. Draw a line through the incorrect entry or 'strikethrough' text in electronic records

  2. Document "written in error", followed by the author's printed name, signature, designation and date / time of correction

  3. The original incorrect entry must remain readable, therefore, do not overwrite incorrect entries and do not use correction fluid

  4. No alteration and correction of records is to make the previous entry in the records illegible or unreadable

  5. eMR history is kept and the replacement information and original entry are linked and flagged as "written in error"
• Adding information to an existing document


  Write 'Addendum' and document the date and time of the omitted event, date of the omitted event, and time of the addendum
• Issues that require particular attention or pose a threat to the client, staff or others that must be flagged


  • Allergies/sensitivities or adverse reactions, and the known consequence
  • Infection prevention and control risks
  • Behaviour issues that may pose a risk to themselves or others
  • Where clients have similar names and other demographic details
• Assistants in nursing are responsible for measuring and recording vital signs for clients in their care.
• Measurements are always taken when a client is first admitted to the ward/department or when there has been a change in their condition.
• The ongoing frequency of measuring vital signs should be assessed on each client's needs rather than on specific time intervals or when instructed to do so by the registered nurse or team leader.
• As a minimum, client's should have their vital signs taken and recorded at least once per shift (or accordingly to hospital policy)
• Regular clinical observations (such as blood pressure, pulse and temperature) are recorded as part of a client's clinical status and regular assessment and to observe trends to support clinical decision making.

  
• NSW Health has a standard observation chart (known a SAGO chart) that is a "track-and-trigger" colour-coded tool that enables vital signs to be graphically recorded with trigger zones clearly identified.

  
• The five major vital signs used to assess the general physical health of a client


  • Blood pressure
  • Heart rate (pulse)
  • Respiratory rate
  • Body temperature
  • Neurological

  
• Pulse


  The measurement of the heart rate or the number of times the heart beats per minute and measures the rhythmic expansion and contraction of an artery produced by pressure of blood moving though the artery
• Normal pulse parameters are 60 - 100 bpm, less than 60 bpm is bradycardia, and greater than 100 bpm is tachycardia.
• Preparing and performing pulse rate procedure


  1. Stand (or sit) facing the client

  2. Grasp the client's wrist with your free hand

  3. Compress the radial artery with your index and middle fingers

  4. Count the pulse for one full minute

  5. Record the rate and note any rhythm observations

  6. Note whether the pulse is regular or irregular

  7. Report any abnormalities to the Registered Nurse

  
• Blood pressure


  The force of the blood pushing against the artery walls, and will vary from person to person
• Blood pressure can be measured in three positions: supine (lying), seated and standing

  
• Systolic blood pressure


  Occurs during heart muscle (ventricular) contraction. Average is 120 mmHg