Assessment in the Nursing Process
Discuss about the Implement, Monitor And Evaluate Nursing Care Plans.
- Functions according to the policies, law and procedures that affect the practice of an Enrolled Nurse
- Practising nursing in a manner that ensures confidentiality, rights , respect and dignity of all patients
- Accepting responsibility and accountability for his or her own actions
- Interpreting information widely in order to contribute to appropriate planning of patient care
- Collaborating with other health care providers in development of patient care plans
- Using documentation and communication skills to report and pass information about patient care
- Providing nursing care based on research
- Engaging in continuous self-development as part of professionalism.
- Practising within quality and safety improvement standards and guidelines.
- Contribute to nursing assessments and planning of patient care
- Providing nursing care and evaluating the outcomes of care for all patients and their relatives
- Coordinating teams of health care assistants under supervision by the Registered Nurse(RN)
- Undertaking nursing responsibilities such as monitoring any changes in the conditions of the patient and administering prescribed medicines.
- Providing health education to patients and their relatives on a particular condition to ensure quality improvement through patient healing.
- Assisting all patients carry out their Activities of Daily Living.
The nursing process refers to a modified scientific technique applied by all nurses in ensuring delivery of quality and holistic care to all patients. Nursing process employs clinical judgement and critical thinking in order to strike an epistemology balance between research evidence and personal interpretation and research evidence. Critical thinking is used in nursing process to categorize and prioritize patient issues and implement an appropriate course of actions (Doenges, Moorhouse and Murr, 2014).
The first step is assessment which involves data collection, data verification, and organization of patient data, interpretation and documentation of patient information. On assessment, both subjective and objective data are used from primary and secondary sources (Gulanick and Myers, 2013).
The second step of nursing process is diagnosis which involves analysis and synthesis of the collected information or data from the patient. This step involves development of a nursing diagnosis which is done according to the North American Nursing Diagnosis Association (NANDA). A nursing diagnosis is a clinical judgment about the patient, the community or family responses to potential or actual problem or process. It provides a foundation for selection of appropriate nursing interventions for achievement of the set goals or outcomes (Doenges, Moorhouse and Murr, 2014).
The third step of nursing process is planning which involves guideline formulation in order to implement the proposed course of actions. Classification of nursing interventions is also useful tool of planning for patient care. In this step, goals are set for each intervention that is to be implemented. The fourth phase of nursing process id implementation which involves execution of the plan of care. Activities that have been to achieve the set goals are performed. The fifth step is the evaluation whereby the nurse determines whether the set goals have been met fully or partially (Doenges, Moorhouse and Murr, 2014).
- It provides an organized framework for meeting health needs of the patient
- It enable systematic and step-wise problem-solving approach hence minimizing dangerous omissions or errors to save time and documentation.
- It promotes the active involvement of the patient healthcare hence enhancing satisfaction for all health care consumers.
- It enables nurses have control over their own action of practice hence giving them an opportunity to apply their expertise, knowledge and intuition dynamically and constructively hence increasing the likelihood of positive patient outcome.
- Patient and Family Education
- Communication of patient’s health condition
- Documentation of patient care
- Administering medications to the patient following the 7R’s rule.
Some of the procedures and policies used when planning for care of residents in nursing home include individual agreement, provision of individualized care, patient participation, involvement and engagement in nursing care and provision of events and activities that reflect the life story of the patient. I will get consent by first explaining all the policies and procedures involved in home nursing so that the patient can make a voluntary decision. I will maintain the privacy and confidentiality of patient data by ensuring that it is only accessible to authorized personnel. I can put the information in lockable cupboards or on computers where it is secured with a password (Doenges, Moorhouse and Murr, 2014).
Diagnosis in the Nursing Process
To gain his consent, I will first explain to him the dangers associated with not showering for a long time regarding his own health. I will also assure him of privacy and confidentiality that in case he is assisted to take a shower no one is allowed to discuss about him with anyone else in the health care settings.
Oral pain and difficulties in chewing in a patient could be a result soreness, inflammation, dry mouth, gum disease, or decay, oral infection, stiffness and pain of jaw muscles.
To ensure that the patient meets the essential nutritional requirements, I would collaborate with a nutritionist. The strategies I would use include ensuring oral hygiene, encouraging the patient to eat a balanced diet regularly, encouraging adequate dental care and screening the patient for weight gain or loss. Nursing Diagnosis-imbalanced nutrition less than body requirement related to dysphagia and oral pain as evidenced by patient weight loss (Gulanick and Myers, 2013).
Hypertension, hypotension, constipation, kidney problems and mental changes.
- Blue-cardiac arrest
- Red-fire
- Orange-assistance needed
- Green-Emergency Operations Plan Activation
- Pink or purple-child missing
Some of the emergency equipment that should be there in a shift include complete emergency trolley, stethoscope, cardiac monitor, orthopedic equipment, suture tray, and glucometer.
Oliguria is caused by kidney problems which results from inadequate fluid intake. Fluid intake and output chart is required to record the fluid intake and output.
Inserting an indwelling urinary catheter for urination and providing bed pans or use of diapers for opening of bowels.
- Ensure that the patient has had a balanced diet
- Give due medications if applicable
- Prepare patient’s bed for sleeping
- Ensure the patient is comfortable and relaxed before sleeping
- Position the patient appropriately for sleeping
- Cover the patient to ensure he or she is adequately warm.
Equipment that is used in Health Care Facilities to assist clients with mobility.
Weelchairs, crutches, scooters, walking sticks and walkers,
Complications of immobility- Venous stasis, depression, edema, glucose intolerance, pressure sores, hormonal imbalances, hypoventilation, dyspnea, risk for delirium, contractures
Pressure ulcers which is also called pressure injuries pressure sores, bedsores, and decubitus ulcers refer to localized skin damage and the underlying tissue that occur over a bony prominence due to pressure and sometimes a combination of friction and pressure (Doenges, Moorhouse and Murr, 2014).
Who is at risk of developing a pressure ulcer?-patient with poor mobility/immobility, poor nutritional status, compromised flow of blood, extremities of age, patient with dementia, pain and incontinence.
How can the nurse identify if a client is developing a pressure ulcer?
By performing a complete integumentary assessment on the patient.
Where do pressure areas occur? – Lower region of the backbone, heels, back, hips, bottom, back of shoulders and head.
Interventions for prevention of pressure ulcers-regular change of patient position, use of pressure-relieving devices, having a balanced nutrition and regular skin check-ups or assessment.
Planning and Implementation in the Nursing Process
Ensuring patency of the airway by elevating patient’s head, positioning in a semi-prone position, regular auscultation and suctioning. Maintaining patient fluid balance and nutritional requirements by assessing status of hydration, fixing NG tube and giving more fluids. Preventing urinary retention by palpating the bladder for fullness and inserting an indwelling urinary catheter (Gulanick and Myers, 2013).
To get the urine sample from the client, I will explain to him or her about the procedure, what it involves, whether it is painful or not and how to do it. I will explain the reason for the urine sample and its importance as far as client’s health is concerned.
Advantages for the creation and use of Clinical Pathways.
- Supports risk management, clinical effectiveness and clinical audit.
- Improves teamwork, multidisciplinary communication and planning of care
- Provides well-defined and explicit care standards.
- Optimizes on resource management and supports training
- It supports coordination and continuity of care across various sectors and disciplines of health care.
- Reduces costs by shortening the duration of stay in hospitals hence it empowers patients.
The required charts include feeding and nutrition chart, fluid input/output chart and observation chart. The best strategies for the diabetic patient administration of insulin, measurement and monitoring of levels of blood glucose, lifestyle modification strategies and patient and family education on diabetes.
The charts required in a patient with dementia include cognitive chart, Global Deterioration Scale, Functional Assessment Staging and Clinical Dementia Rating and Feeding chart. The strategies for improved outcome of dementia include psychotherapy, environmental modification to ensure patient comfort and safety and medical management which involves use of anti-dementia and psychotropic medications
Requirements of formal teaching- Formal teaching is systemic and organized. The teacher must preparing by making and compiling notes including the aims and objectives of teaching, selection of a teaching approach, presentation of the content and evaluation of the teaching using questions or giving some tasks to the learner to test his or her level of understanding of the content.
Evaluation of care plans involves relation of nursing interventions to patient outcome. It involves identification of standards and criteria, collection and evaluation of data, interpreting the findings of assessment and summarizing. The findings are then documented and nursing care plan is revised, continued or terminated based on the outcome (Gulanick and Myers, 2013).
A Activities of Daily Living-Feeding, personal hygiene, locomotion, transfers and dressing.
Immediate needs/problems –dyspnoea and hyperthermia,
Potential needs/problems-imbalanced nutrition less than body requirement and activity intolerance.
Nursing actions- controlling the body temperature by giving analgesics, patient oxygenation, feeding and cleaning the patient.
Dressing, Personal hygiene, Feeding and locomotion. This is because she is blind and confused hence unable to perform these activities for herself.
Immediate needs/problems –hyperthermia and tachycardia,
Potential needs/problems-to achieve a normal value of body temperature, pulse and respiration rate.
Nursing actions and charts required-observation charts are required. The nursing interventions include administration of analgesics and give oxygen. Giving laxatives to promote bowel opening and feeding the patient.
Self-care involves taking care of one’s own health. It can be maintaining personal hygiene and managing some common illnesses such as colds, headache or flu. It also involves life style modification through physical exercises and health nutrition to prevent development of conditions that affect one’s health.
I will assist the patient by closely monitor how he is doing the exercises. I will also explain to him the importance of the exercises to his health condition. I will demonstrate to him on how to do the breathing and coughing exercises.
The blood glucose level (BGL) of 18.5mmol/L is above the desired level.
Presence of ketones in urine shows that the insufficient insulin may allow an increase in the production of amino acids for energy.
3.5-5.5 mmols is considered to be the normal range for BGL’s.
PART D- Self testing for BGL’s- Wash your hands with soap and water then dry them then prepare the device for insertion of a fresh lancet. Ensure the glucometer and the strip are ready then get a sample of blood from your finger using the lancet device and place one drop on the strip in the glucometer. Once you have read the results dispose the used lancet in a sharps container.
References
Doenges, M.E., Moorhouse, M.F. and Murr, A.C., 2014. Nursing care plans: guidelines for individualizing client care across the life span. FA Davis.
Gulanick, M. and Myers, J.L., 2013. Nursing Care Plans-E-Book: Nursing Diagnosis and Intervention. Elsevier Health Sciences.
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