NNS5806: Importance of Documentation in Nursing – Essay Writing Nursing Assignment Help

Assignment Task:

Description
During my bachelor’s degree,I was posted in the medical ICU for my clinical posting. One day, an obese bed bound patient was assigned to me. While performing back care, I noticed skin peeling in the sacral area. I dressed the area and documented the same. The wound went unnoticed for 2 days and it worsened into a second-degree pressure ulcer.

Feelings
At first, I did not realise I was at fault as I only had this patient assigned to me once and I documented the skin condition in my progress notes. When I realised it was my duty to mention it to the staff during handover, I felt equally responsible.

Evaluation
Even though the incident was well documented in my notes, harm had occurred to the patient. Hospital acquired pressure ulcer highlights the inability to uphold the duty of care. The length of stay in the hospital got increased.

Analysis
This shows that an effective documentation and nursing handover tool should be adopted which is evidence based. It cannot be achieved only by individual staff training. It demands multiple approaches to combat the challenges faced with poor documentation.

Conclusion
Standardised nursing handover tools should be followed by the team leaders while taking shift rounds. The nurses should be committed to lifelong learning and be across newly published research to become competent. Leaders should support and supervise the staff in an effective and regular manner.

Action Plan
Considering the aforementioned scenario, I strongly believe this situation could be completely avoided by ensuring the Unit Managers run the new staff or staff members in training through the importance of proper documentation during the handover.