Identify five (5) of the legal requirements for Nursing Documentation.

legal and ethical parameters to nursing practice Scenario On 15th April 2015, EN Rose Baxter is working on the day surgical ward alongside RN Simone Jones and has been allocated the following two clients, both booked for surgery today. Client 1. Mr John Smith DOB 6/9/1945 Mr Smith is a diabetic- type 1, fasting from midnight for surgery at 0800 for removal of skinlesions. As Mr Smith is diabetic, his treating doctor has ordered an antibiotic (intra venous Cephalexin 500mg), to be delivered during his surgery as a prophylactic. (He has an increased risk of wound breakdown associated with his diabetes). Client 2. Mr John Smythe DOB 6/9/1945 Mr Smythe has been fasting from 0200 for surgery to remove polyps from his bowel. Culturally, Mr Smythe is a practicing Buddhist and has requested no narcotic analgesia, preferring to meditate to relieve any pain. Mr Smythe is partially deaf and cannot hear well without hearing aids. He has a medication alert on his chart as he has an allergy to Cephalexin, and when EN Baxter admits him she places an allergy alert band on his wrist. Neither of the clients has been flagged during the admission process as having similar names and identical dates of birth. EN Baxter reports this to RN Jones and places an alert on each client and their medical record to notify all staff. At 0800 Mr Smith is called for theatre and EN Baxter checks his blood glucose level (BGL) before his transfer to theatre. As she approached him with the BGL kit he held out his hand ready for the fingerprick test and recording of his BGL. EN Baxter hands over his diabetic status and BGL to theatrestaff. Ten minutes later, at 0810, the theatre staff have called for Mr Smythe to come down to theatre. The doctor gave EN Baxter the pathology slip for the skin lesions, and the medication order to start the IV antibiotic, Cephalexin (in error he gave Mr Smiths pathology request and Medication order). Questions: 1. Identify five (5) of the legal requirements for Nursing Documentation. 2. Code of Conduct Statement 1 states; Nurses practice in a safe and competent manner. Identify how the enrolled nurse applied the Code of Conduct statement 1, in the Scenario? 3. What type of consent did Mr Smith give and how did he consent when his BGL was taken before transfer to theatre? 4. Code of Ethics for Nurses in Australia value statement 6 states; Nurses value a culture of safety in nursing and health care Identify how the enrolled nurse applied the Code of Ethics statement 6 in the scenario. Include in your response the nurses support of Mr Smythes cultural beliefs about analgesia. The recovery staff in the healthcare facility that Mr Smythe is admitted to, are known for their heavy handedness with narcotic analgesia and many clients return to

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