Responsibilities and documentation issues - Essay Example

Case study Lei Pong Ling What are the issues relating to consent here? The issues relating to this case study are the patient’s mental status andage. A minor must present a consent from the Guardian, unless it is an emergency situation where life is at risk (Staunton and Chiarella, 2003: 118). The New South Wales “Children and Young Persons (Care and protection) Act, 1998” defines a child (except for the purposes of employment) as a person 16 years of age and a young person as someone aged 16 or over but under 18’ (Staunton and Chiarella, 2003: 120).

A child can give consent to treatment if the child is capable of understanding the nature and consequences of the treatment (Staunton and Chiarella, 2003: 120). However, in New South Wales, a child aged 14 who has no guardian, has been accepted, if the child is capable of understanding the medical and dental treatment, for his best benefit (Staunton and Chiarella, 2003: 120). What are the issues relating to consent here? First language other than English in which the patient or guardian needs to sign the consent can be an issue, at times.

In such a case, a legal interpreter needs to be arranged to describe procedure (Hamlin et al.,2009: 33). However, in Lie’s case, it is an emergency situation and his level of consciousness is decreasing and he requires emergency intubation. Therefore, no parental consent is required. (Staunton and Chiarella, 2003: 122). Case study 2: Mr Paul Avalon What are the consent issues here? Mr Paul‘s consent issues include the patient’s level of consciousness, life - threatening emergencies, mental status, medical condition and language.

What issues of documentation are raised here? All nursing care given to the patient needs to documented and retained in the patient medical record. For example, the procedure that has been preformed (a primary percutaneous transluminal coronary angiograplasty) and any prosthesis implanted into the patient etc. What are the consent issues here? The patient is not capable of giving consent for a surgery and there is no mention of his family being present. In Mr Paul’s case, it was an emergency situation which called for an urgent cardiac bypass surgery.

Therefore, no consent is required where the patient is seriously ill (Staunton and Chiarella, 2003: 118). What is your responsibility? The nurse who is acting as an advocate on behalf of the patient, must ensure that the patient’s physical, emotional and ethical needs are met, and also protecting the patient’s safety while the patient is in the perioperative environment. Privacy and Confidentiality are also the nurse’s responsibility (Hamlin et al.,2009: 264). What documentation issues are raised here?

Documentation is an important part of the work of the perioperative nurse. The records of the patient care, are the evidence required in lawsuits (Hamlin et al.,2009: 273). The documentation that is involved are with regards to the patient assessment, nursing and other interventions, name of the procedure name with the surgeon’s signature, anesthetic record, count sheet, result and summary of the examination performed prior to bypass surgery and the prosthesis record (Hamlin et al.,2009: 273).

Reference list Australian College of Operating Room Nurses (ACORN) 2010 ACORN standards for perioperative nursing. ACORN, South Australia. Hamlin, L., Richardson-Tench, M. and Davies, M. 2009 Perioperative nursing an introductory text. Elsevier, Sydney. NSW Health Policy directive (2010) Operating suite and other procedural areas - handling of accountable items – standards procedures Staunton, P.J. and Chirarella, M. 2003 Nursing and the law. 5th edn, Elsevier, Sydney. The Australian Council for Safety and Quality in Healthcare, (2006)Ensuring Correct Patient, Correct Site, Correct Procedure: Safety and Quality Council, The Department of Veterans Affairs National Center for Patient Safety (USA)