Posted: August 4th, 2016
An important legal requirement of nursing practice is to effectively and succinctly communicate relevant information, actions and outcomes related to patient care and provide an accurate reflection of the health status of the patient, their responses to care and the patient’s perspective.
It is now Day 5 post-operation and the Orthopaedic Team have decided that Gill is ready to be transferred to a rehabilitation facility for ongoing treatment and therapy to assist her to reach optimum function and mobility.
Using the ISBAR format, the handover you initially received and the additional information below:
• Write a handover for the rehabilitation service that clearly and succinctly outlines the important information other health professionals, including other nurses, need to know about Gill
Additional information you need to know for Task 5 is as follows
During the past 5 days
• Gill recovered well from surgery with no complications
• With physiotherapy assistance Gill has been mobilising since post-operative Day 2
• Gill is not yet weight bearing on left leg
• Observations stable and within normal parameters
• Wound healing well, dressed daily with a non-adherent dressing and sutures to remain until day 14 post-operation
• Medications continue as prescribed
• Indwelling catheter removed Day 3 post operation
During your shift today the following has occurred:
• Gill has declined the prescribed subcutaneous enoxaprin due to extensive bruising on her abdomen
• You have assisted her to transfer onto a commode chair to shower and to sit out of bed
• Gill has been reviewed by the physiotherapist and assisted to mobilise with a forearm support frame.
• Gill regularly complains of pain but is declining oxycodone. She states it is making her drowsy and nauseated
• Towards the end of your shift Gill reports moderate pain and some swelling in her left lower leg
• Gill’s heart rate and blood pressure are elevated above her normal values
Your handover must:
• Demonstrate person-centred care
• Address the physical, functional and psychosocial aspects of care and reflect any changes
you have made to Gill’s care plan
• Adhere to the legal and professional standards for documentation
• Be in appropriate professional language
• NO abbreviations or nursing jargon
Place an order in 3 easy steps. Takes less than 5 mins.