Examples Of Observation In Nursing

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Examples Of Observation In Nursing

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Observations OSCE

The ability and opportunity to help other people who are in need of medical attention and are not able to care for themselves is a huge motivation. Being compassionate towards other people is one of the values CNAs need to have. Documentation is critical so that other healthcare employees can do their job effectively. In addition, it is the job of the prescribing doctor to enter the prescription information into the health management system correctly so the pharmacist can get the prescribed medication to the client.

The pharmacist must also make sure all data is entered correctly to ensure all labels are accurate so the nurses can do their job. My intended profession is an RN registered nurse. An RNs work environment usually clean and busy, health care facilities and offices. RNs can also travel outside of their usual work environment. Nurses are trained to take care of the sick or infirm and give medical attention to patients especially in a hospital. Becoming a Nurse interest me because I love helping people and caring for your patient. My most important reasoning was to take care of my loves. Like when my father had a massive heart attack and I watched how the nurses took care of him.

That motivated me to want to pursue a this career. As a registered nurse, I had admitted countless of patient in the hospital I work at. The abilities to delegate, and supervise other healthcare workers is not an easy job. Delegation is one of the most complex nursing skill. It takes clinical judgment and practice. RNs are required to assess and evaluate the needs of the patient and then utilize the appropriate caregivers in order to achieve desired patient outcomes. Bedside shift reporting is used in many health care facilities to promote a beneficial handoff for both patients and nurses.

Nursing assessment is one of the best skills that any nurse should possess. This simple skill can help you run your operations much smoother and also help you eliminate any preventable surprises in your day. This is usually the first step in the nursing process. For instance, if a patient is hospitalized, the nurse will conduct their first assessment of the patient, including their manifestation of pain and their response to other basic elements to help them determine the best way to handle the patient. This is also referred to as triage.

It helps in determining the nature of the problem and helps prepare the patient for other assessment stages. The initial assessment is usually thorough compared to other assessments and may include putting the patient through a physical exam and assessing their mental health. During this assessment, vital signs are continuously monitored and depending on the initial treatment for pain that the patient is under. The root cause is continuously monitored, and the necessary treatment is done. Once the root cause of the pain has been identified and treated, a time-lapsed assessment is then conducted to ensure that the patient is recovering and their condition is stabilizing. Start by preparing a systematic approach to how you are going to assess the patient.

You can use the head-to-toe approach, starting with the head and next and slowly progressing down to the body and examining the feet last. After preparing the assessment approach that you are going to use to assess the patient, prepare yourself, the environment, and the patient. When preparing yourself, make sure that all the examination equipment is ready and that you have mastered the examination techniques. Some of the equipment to include in your checklist include:. NOTE: all the equipment needed for the assessment should be clean, in good working condition, and readily accessible. Basically, there are five steps of the nursing process. The processes are in place to ensure that patient care is comprehensive and well organized.

Although all the steps have a unique purpose, they are all interdependent, and they all require information from the other to develop a comprehensive plan of care for the patient. The nursing process involves:. These are also discussed in the following paragraphs. Observation is the method used most frequently in clinical performance evaluation. Student performance is compared to clinical competency expectations as designated in course objectives. Faculty observe and analyze the performance, provide feedback on the observation, and determine whether further instruction is needed.

Authors noted that continuing issues in clinical evaluation include wide variability in clinical environments, increasingly complex patients, and more diverse students. Real-time observation and delayed video observation are both considered in this discussion. Technology or online cases also provide unique opportunities for enhancing evaluation opportunities and standardization of evaluations. Newer approaches to use of videos in evaluation include online tools such as the National Institutes of Health Stroke Scale training. In this example, video cases were developed based on needed competencies for appropriate use of the Stroke Scale. Students complete testing specific to these competencies as they refer to the online video cases NIH Stroke Scale, n.

This provides a standardized testing approach. Advantages of observation include the potential for direct visualization and confirmation of student performance, but observation can also be challenging. Faculty should seek tools and strategies that support a fair and reasonable evaluation. The more structured observational tools are typically easy to complete and useful in focusing on specified behavior. Although structured observation tools can help increase objectivity, faculty judgment is still required in interpretation of the listed behaviors.

Problems with reliability are introduced when item descriptors are given different meanings by different evaluators. Faculty training can help minimize this problem. An abundance of information must be tracked in clinical observation. Faculty can benefit from systems to help document and organize this information. Faculty can carry copies of evaluation tools and anecdotal records or can consider the use of a PDA to help facilitate retrieval and use of clinical evaluation records. Privacy in PDA records is also needed. Common methods for documenting observed behaviors during clinical practice vary in the amount of structure.

Examples include anecdotal notes, checklists, rating scales and rubrics, and videotapes. Anecdotal or progress notes are objective written descriptions of observed student performance or behaviors. These written notes initially serve as part of formative evaluation. As student performance records are documented over time, a pattern is established.

Liberto, Roncher, and Shellenbarger noted the importance of determining which clinical incidents to assess and the need to identify both positive and negative student behaviors. Checklists are lists of items or performance indicators requiring dichotomous responses such as satisfactory—unsatisfactory or pass—fail Table These short, easy-to-complete tools are frequently used for evaluating clinical performance. Checklists, such as nursing skills check-off lists, are useful for evaluation of specific well-defined behaviors and are commonly used in the clinical simulated laboratory setting. A list of clinical behaviors or competencies is rated on a numerical scale such as a 5-point or 7-point scale with descriptors. These descriptors take the form of abstract labels such as A, B, C, D, and E or 5, 4, 3, 2, and 1 , frequency labels e.

A rating scale provides the instructor with a convenient form on which to record judgments indicating the degree of student performance. Mahara noted the benefit of more standardized assessments such as checklists and rating scales but faults these objective scales for failing to capture the complex clinical practice environment and clinical learning. Oermann emphasized the benefit of asking appropriate patient care questions along with clinical observations to gauge student critical thinking abilities. On a scale of 1 to 5, rate each of the following student behaviors:.

Rubrics, a type of rating scale, help convey clinically related assignment expectations to students. They provide clear direction for graders and promote reliability among multiple graders. The detail provided in a rubric grid allows faculty to provide rapid and extensive feedback to students without extensive writing Walvoord et al. Rubric examples exist for providing detailed feedback for clinical related assignments such as written clinical plans and conference participation.

A web search by topic can provide samples for review. Rubrics or checklists are beneficial in facilitating both the lab experience and the clinical grading for faculty and students. They promote clear communication as to expectations of best practice in completing skills. Providing skills checklists for students provides direction in their skill learning and practice. Students can use these tools for self-assessments and participate in peer assessments to promote learning. Rubrics can be used within learning management systems as well. Videos, often completed in a simulated setting, can be used to record and evaluate specific performance behaviors relevant to diverse clinical settings.

Advantages associated with videos include their valuable start, stop, and replay capabilities, which allow an observation to be reviewed numerous times. Videos can promote self-evaluation, allowing students to see themselves and evaluate their performance more objectively. Videos also give teachers and students the opportunity to review the performance and provide feedback in determining whether further practice is indicated. Videos are particularly popular for evaluation in distance learning situations. Videos can also be used with rating scales, checklists, or anecdotal records to organize and report behaviors observed on the videos.

Additionally, writing can reinforce new knowledge and expand thinking on a topic.

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