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4 Tips for Delivering Evidence-Based Treatment at Point of Care

Every day, nursing professionals assess and document patient conditions, perform nursing interventions, and assist primary care providers in developing treatment plans. They also educate family members, manage medications, consult with peers, and manage patient movement. These heavy workloads often leave nurses feeling overworked. However, caregivers avoid this outcome by following evidence-based nursing practices rather than relying on instinct and experience alone.

The following four sections highlight evidence-based practices for nurses as recommended by Lippincott Nursing Center.

Professionalism Tips

Assess, Diagnose, Plan, Implement, and Evaluate (ADPIE), is the everyday process for nurses treating patients. For a 24-hour job requiring team collaboration, prioritizing tasks based on deadlines is key. For example, tasks that must be completed within 30 minutes, are generally labeled as a “must do” item, while tasks with four-hour deadlines are labeled as “could do” items but must be completed before the end of the shift.

When nurses feel overwhelmed with tasks, they take a moment to regroup and formulate a viable action plan. It also may help to delegate responsibilities while ensuring that tasks are assigned to the right personnel, under the right circumstance, at the right time, and with adequate oversight.

Experienced nurses take the initiative to inspire team collaboration and assist other less knowledgeable practitioners. This show of leadership may inspire other veteran nurses to do the same.

To keep their work manageable, it’s important that nurses choose reasonable goals and work toward them. Finally, when caring for traumatized patients, they follow a standard framework: build rapport, treat critical injuries, document patient information accurately, and issue a proper referral.

Assessment Tips

Effective assessments start with thinking about how the result will fit into the patient’s overall treatment plan. [1] When conducting abdomen assessments, for example, nurses inspect, auscultate, percuss, and then palpate. The importance accurately recording the patient’s height and weight is critical. This allows care providers to assess nutritional status, properly prescribe medication, and evaluate body fluid loss or gain when necessary. [2] A nutritional assessment has four sections: health history, laboratory results, physiological assessment, and body dimensions.

When listening to heart and breathing sounds, nurses close their eyes to eliminate distractions. During pupil assessments, they follow the PERRLA framework: Pupils Equal, Round, Reactive to Light, and Accommodation. When assessing cognitive ability, nurses follow the CURVES framework: Choose and communicate, Understand, Reason, Value, Emergency, and Surrogate. If a nurse suspects abuse, he or she follows the SEE framework: collect Screening and Evidence information, and make the Effort to report the finding to the appropriate authorities.

Documentation Tips

When recording patient information, nurses submit only facts and omit any personal opinions. All documentation follows the PIE framework: Problem, Intervention, and Evaluation. When documenting a patient’s reason for seeking care, nurses must be careful to record the statement in the patient’s own words.
If a nurse is unsure if others will understand abbreviations, he or she spell out the term completely. Additionally, nurses avoid using the null sign (Ø). This symbol is on the Institute for Safe Medication Practices (ISMP) List of Error-Prone Abbreviations, Symbols, and Dose Designations. Instead, nurses use the standard number zero (0) or the word zero.

Nurses document procedures immediately after completing them. [2] They record adverse events immediately as well. Finally, nurses must make sure that the document remains secure, as every patient is entitled to privacy.

Communication Tips

Effective communication is critical for producing positive outcomes when engaging with patients and their family members and when transferring care to other medical professionals. [2] When starting a shift, nurses introduce themselves to new patients and greet existing ones. Nurses then inform patients about what will happen during the shift and review the current treatment plans.

When engaging with patients, it’s important that nurses use clear communication and understand all verbal exchanges. When necessary, appropriate humor helps to ease patient concerns. If a nurse suspects abuse, he or she asks open-ended questions such as “Do you feel safe?” or “Are their times when you don’t feel safe?” Finally, when transferring care, nurses follow the SBAR framework: Situation, Background, Assessment, and Recommendation.

Caring for patients is a central tenet of quality nursing. [2] To produce positive patient outcomes, nurses use evidence-based principles and work together to achieve organizational objectives. More importantly, experienced nurses must take the initiative to mentor new nurses in learning current nursing practices.

Learn More at Ohio University

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Recommended Readings

8 TED Talks for Nurse Practitioners
6 Best Practices for Nurse Educators to Teach Patients About Their Health
10 Innovative and Influential Nurse Leaders

Sources:

[1] http://www.nursingcenter.com/clinical-resources/nursing-tips
[2] https://www.amerinursetoday.com/helping-new-nurses-set-priorities/
[3] https://nurseslabs.com/tips-improve-clinical-documentation/

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