Nursing Process - Assignment Example

Nursing Process Affiliation Part The nursing process The nursing process is systematic and progressive process aimedat provision of quality and holistic care for the patients. Jean Orlando was crucial in his contribution towards the nursing process. Concisely, he noted that the patient should always be the center of care. Essentially, he further reiterated that the nursing care provision should be directed towards improving the patient condition. The care involved had a particular direction to a certain goals and objectives. Using this framework, the nurses beliefs, knowledge, and acquired skills are detrimental in the diagnosis of health problems and coming up with mechanisms to respond to such health concerns. Its utilization provides some order and dictated decision making. Various nursing theorists such as Johnson, Orlando, and Hall postulates it as a structured delivery care process. It involves data collection focusing on the strengths and weakness of the clients and working towards intervention, improving eventual patient outcome. The process rotates around five processes. The processes are cyclic, each step having an immense contribution to ultimate patient care and outcome. In the evaluation phase, the nurse gathers detailed subjective and objective information concerning the client. The five senses are put into consideration in the process of examination, and full physical examination done using the techniques of percussion, palpation, observation and auscultation. After data collection, the nurse comes up with a nursing diagnosis. The nurse does interpret the findings and make ideal, and relevant clinical judgments are pertaining to the client actual, potential or risk problems. The North American Nursing Diagnosis Association is fundamental in the provision of scientific directives. Next, the nurse performs a vital plan of care to achieve the desired goal (Kaufman, 2012). A nursing care plan comes hardy when it comes to the intervention purposes. The phase ensures the continuous care of the patient, follow-up, and holistic approach to patient care. During the planning phase, the nurse needs to consider the elements of initial care, ongoing and discharge plans. The fourth stage is the implementation phase. It does involve actual delivery to the patient. For this case, prioritization of the interventions has to be put in consideration, acting as a link between medical and nursing care. The evaluation stage acts as an appraisal step. Determination of whether the planned goals were met does occur. Notably, documentation is vital in every stage. Notably, the nursing process is systematic, since it follows the five steps systematically. It inculcates the element of dynamism through the interdependence and overlapping nature of the steps. It remains universally applicable in the nursing care provision all over the world. The nursing care aims at provision of ideal care to the clients. Direct care involves all the activities whose aim is to meet the basic needs and activities of daily living (In Hinkle, In Cheever, Brunner, & Suddarth, 2014). For instance, taking vital signs, monitoring of input and output, daily weight, feeding patterns, physiotherapy activities and emergency life support. Indirect care encompasses maintenance of essential supplies and consumables, medical equipment availability and provision of an environment that facilitate healing. The nurses implement independent activities. They do so without any direct supervision, for instance, basic nursing care, dressing the wounds, taking vital signs, and feeding patterns initiations. Dependent actions have a close reliance on the orders from the physician, for example, the decision to perform a surgical procedure to a client. Most significantly, collaborative activities involve the multidisciplinary approach. The heath care team performs such actions mutually. For instance, aspects of counseling and continuous medical education. Clinical judgment works on the elements of practical interpretation regarding the ideal client needs, demands, problems, and concerns. A nurse should be in possession of sound judgmental skills, excellent analytical skills, creativity and sound scientific base. The nursing process is scientific based. Furthermore, its cyclic nature ensures that the process of care delivery takes a well-initiated process. The nurse practices autonomy in patient care but limits the decisions within the scope of practice (Treas & Wilkinson, 2013). The eventual effects are positive outcomes from the patient diagnosis, promotion of evidence-based practices and improvement in the relationship between the nurse and the patient. The process of evaluation involves initial predetermination of whether the client nursing goals have been met fully, partially, or never met. Evidently, the step is a continuous process whose aim is to assess the ultimately expected outcomes. A registered nurse must be at the forefront of establishing the level of achievement. Such follow-up is integral in the promotion of quality health care. Verbal and nonverbal communication can aid the registered nurse in predomination of the initial activities necessitating further interventions, and those that have been achieved. Further, the nurse can utilize basic observation or secondary information from the close caretakers. There are diverse factors that influence the achievement of the desired outcome. Availability of finance to cater to the new needs, too much questioning during the history taking process and inadequate hospital equipment may hinder the achievement of desired outcomes in the nursing care plans. Evaluation process results act as the dictates to communicate whether the client is progressing towards the level of wellness and desired outcomes achievements. It is a clear communication of the quality care provided, heath improvement or deterioration levels. Modification of plan of care is mandatory if the evaluation results reveal lack of any progress in achieving the planned objectives. First, the client needs are reassured. The nursing diagnosis is formulated regarding the new needs detected. Consequently, the client will have new goals expectation, implementation plan, and nursing actions. Setting priorities is fundamental in the achievement of sequential patient needs. The Registered Nurse `determines the nursing diagnosis that requires immediate attention. Nurses classify them in terms of priority, medium and low priority interventions. High priority is life threatening and demands immediate attention. The Maslow’s needs tool is a curial tool in setting and grading such priorities. However, clients’ factors must be put into consideration, for instance, values and norms, resources available, health problems urgency, physician needs and client preferences. Primarily, the nurse further classifies the patients’ needs into diagnosis, citing actual diagnosis, probable and risk diagnosis (Blaney, 2010). The goals can be set to be broad or specific, for example, to improve the nutrition status or ensure the client gains at least one kilogram of weight within three weeks. Short terms goals need to achieved within six weeks while long-term goals achievement duration is beyond one month. Part 2 History taking Assessment Informant: Patient Name: Robinson Lukas Age: 78 years Residence: Spring Valley estate, Maryland Reason for Current admission: The patient was well, until a month ago when he developed instances of pressure sores secondary to consistent immobility. He is a known patient on oral antihypertensive, of which he complies with the regimen prescribed. His admission focused on administration of intravenous antibiotics, debridement and subsequent wound dressing. General appearance: An elderly man who is emaciated and weak, possibly due to hypertension. Appears lethargic and exhausted. He is unable to walk but himself, unless under support. Vital signs: Temperature- 36.9 degrees Celsius, Blood Pressure- 140/80mm/Hg, Respirations: 25 beats per minute, Pulse-78 beats per minute. Focused Physical assessment Respiratory: experiences shortness of breath occasionally, dyspnea, paroxysmal, nocturnal dyspnea, Cardiovascular: pulse is unstable, non-reassuring heart beat noted, mild angina evident (pain of scale 6/10 in a scale of 10) Musculoskeletal- peri-orbital edema present, decreased skin turgor, decubitus wound present at the ischial spines, Gluteal skin has a characteristic of some redness. Clubbing of fingers evident too Renal- Lately, has experienced polydipsia, at least six times during the night. Dysuria and dribbling of urine evident during micturition. Gastrointestinal: tolerates soft foods only. Actual nursing diagnosis Difficulty in breathing related to cardiac overload and pressure/fluid accumulation in the lungs secondary to congestive heart failure as evidenced by distress and consistent cough. Rationale why it is a priority diagnosis: effective breathing is a vital component of human survival. Tissue perfusion relies heavily on the breathing patterns. Failure to have ideally perfused body system may expose the client to opportunistic infections and electrolytes imbalances. Furthermore, lack of adequate oxygen may result to tissue ischemia, rendering them useless. Assessment data: General body weakness, easily becomes fatigued on exertion, consistent productive cough evident, presence of tachypnea Desired outcome: Patient will experience an improvement in respiratory pattern within 24 hours and through his hospitalization process, and be effective without any fatigue element or straining. This is both a short term and long term physiologic goal. Nursing interventions: Maintain bed elevation at 60 degrees to ease in breathing process (nurse mediated) Assist the client, and educate him on the various ways of utilizing relaxation techniques while in bed (Dependent) Continuous examination of chest for respiratory movement and the symmetrical nature (Nurse mediated) Chest exercises to ease in breathing process, prevent hypostatic pneumonia and general bed exercises to prevent aggravation of pressure sores (multidisciplinary) Encourage the patient to have small deeper respirations. Administration of oxygen via nasal cannula will be vital of the condition aggravates. Any suctioning will prove detrimental should there be secretions present. Evaluation After 24 hours of consistent interventions, patient reported that he was in a position to breathe effectively, no instance of shortness of breath or chest congestion. Sections 3 Learning involves the acquisition of new ideologies and skills aimed at improving the behavioral patterns. In the processing plan for education, the registered nurse has to consider various considerations to determine the teaching formats. First, knowledge of developmental factors is essential. They include aspects of psychosocial, physiology, metal responsiveness and idea age. An age appropriate teaching method is fundamental to ensure maximum comprehension levels. Consider any delayed milestones during childhood and current knowledge base so that you can build upon the same. Concisely, education levels determine the attitude towards learning process. The intellectual ability will determine the patient approach. Encouraging the learner in expressing the past teaching experiences will further aid in coming up with an educational method. Most significantly, any deficit in the senses of sight, touch or hearing are likely to affect the teaching process. In-depth assessment of the emotional health of the client relays the client teaching formalities. Instance, high anxiety levels may derail the process. Besides, the registered nurse needs to re-evaluate the motivation levels of client, self-perception and culture. Concisely, some cultures do not welcome any new educational materials that insist on change. They perceive such information as threatening. Therefore, as aforementioned, consider any culture prior to determining the best method to relaying health education (Center for Disease control and Prevention, 2012). After such initial assessment, consider the diverse strategies available, inclusive of oral, written or even electronic means. If the client cannot read, then role-play will prove to be the best. Utilization of discussion techniques will be the most efficient method to respond to a client with psychomotor deficits. Geriatric clients have various challenges that come along with the aging process. Therefore, consider all such aspects before adopting the best teaching method. Upon consideration of the above factors, it is evident that the Registered Nurse will have an easy time planning to pass the ideal discharge information to the client. The various teaching plans available include formal oral discussions, whereby interaction between the educator and client are minimal. Informal talks are excellent methods too. Written materials such as leaflets or pamphlets contain detailed information, provided by the Registered Nurse prior to education session, and then later comes with some training program later. Demonstrations, use of visual charts, audio-visual methods and books are also vital tools. In summation, the client is allowed to choose the best modality depending on his or her heath needs. The initial learning step did involve the basic assessments of the client needs. Further, motivational levels and interests in learning were established. The standard of education, language skills, potential to learn, and the resources available were of utmost importance. Notably, factor in what the patient knows and he is not aware. Next, identify the challenges he is facing in the course of his treatment regimen (Baumann, 2011). Finally, any element that may hinder the learning process, for instance, loss of hearing or impaired sight must be factored. All these considerations have to be met prior to determining the information to include in the teaching plan. Analyze all such gathered data and come up with a teaching plan in agreement with the learning abilities of the client. The teaching plan must be an evaluative tool, having all the vital components of known to unknown, from simple to complex. After evaluation of each teaching session and the understanding levels, the nurse can modify the teaching plan once again, to suit the newer needs. However, the content of the information inclusion all relies on the patient needs and availability of teaching materials. Evaluation is a mandatory step in the learning process in a bid to collect the ideal feedback aimed at improving, developing, and adjusting the teaching methods in future. Therefore, a registered nurse must be keen enough to detect any deviation sin knowledge acquisition. For the case of this patient, simple mechanisms will reveal whether the process was successful or what else need to be done. The nurse can request for return demonstrations from the client, instructions restating in own words, asking open and self-leading questions, requiring him to fill some questionnaires or assess physiological responses such as weight. The evaluation process should be continuous, from admission to discharge as it aids in the creation of a form of continuous process. References Blaney, W. D. (2010). Taking steps to prevent pressure ulcers. Nursing, 40(3), 44-47. doi:10.1097/01.NURSE.0000368818.35594.6a Center for Disease control and Prevention (2012), A Framework for Program Evaluation, retrieved from http://www.cdc.gov/eval/framework/index.htm In Hinkle, J. L., In Cheever, K. H., Brunner, L. S., & Suddarth, D. S. (2014). Brunner & Suddarths textbook of medical-surgical nursing. Kaufman, C. (2012). Designing a nursing care plan for a lifetime. Nursing, 42(7), 54-60. doi:10.1097/01.NURSE.0000414628.00260.02 Treas, L. S., & Wilkinson, J. M. (2013). Basic nursing: Concepts, skills, & reasoning. Philadelphia, PA: F.A. Davis. Baumann, S. L. (2011). Learning as an Acquisition-Process in Healthcare and Nursing Education. Nursing Science Quarterly, 24(1), 64-65. doi:10.1177/0894318410389062 Read More