Nursing process

Nursing: Part 1

Nursing process are standards and guidelines which are used by nurse practitioner to deliver quality care, healthcare that is patient centered. Nursing profession is a complex profession which brings aspects of art and sciences together. Nursing profession is concerned in protecting, promoting people’s overall wellbeing including physical, emotional and psychological wellbeing. The concept of nursing process is eccentric to all nurses; the process involves five steps; a) Nurse assessment; b) nursing diagnosis; c) nursing planning and identification of outcome; d) nursing implementation; e) nursing evaluation (Lee, 2010).

The first step of nursing process is assessment. This entails collection of information and data related to a certain matter or event. Nurse practitioners are required to conduct holistic care on the patient including their cultural background, their religious and social norms. This is to ensure that the interventions established are culturally and socially competent and to establish the exact care demands of a person (Svavarsdottir et al., 2014).  The information gathered during the assessment phase are organized and documented, for use in the future. The second step is nursing diagnosis. This entails reviewing the information collected during the assessment more critically. This way, the actual issue of concern is identified, and prognosis is done in accordance to the clinical manifestation of disease.  This is also involves identification of risk factors that motivates progression of the disease (Lu et al., 2015).

The next step is nursing planning which involves designing interventions by establishing priorities, identifying objectives that will facilitate provision of expected outcome. The planning process entails identification of interventions as established by evidence based research (RodraA-guez-Martan et al/, 2015). An effective action plan is one which is guided by Maslow’s hierarchy of needs.  This involves provision of care as guided by the ladder of needs, and until all patient demands or needs are identified.  Evaluation process is the last step of nursing process. It involves measuring of interventions and expected outcome to check if they are congruent with implementation plan. If the outcome is not positive, the interventions can be altered accordingly (Vaillant-Roussel et al., 2014).

 Nursing Interventions Classification (NIC), direct nursing interventions include activities which directly interact with the service user. These include interventions such as administering therapy to patient suffering from dementia or Parkinson disease (Svavarsdottir et al., 2014). Indirect nursing interventions are nursing practices that aim at improving patient’s health, but the patient is not directly involved. For instance, the healthcare facility can introduce an automated system to curb medication errors. Additionally, nursing interventions can be grouped into three categories (Lee, 2010). The first category is the interdependent interventions which include activities implemented through partnership and effective communication among the healthcare staff. These include actions such as recommendation of non invasive surgery for patients suffering from renal diseases. These interventions are only carried out if all other alternative therapy has failed, and it involves lots of consultation.  The dependent interventions include all nursing practices done only under instructions from the higher authority. This could be termination of service user medication due to medication error or allergic reactions to medications. Lastly, the independent intervention which entails nursing actions performed by nurses without need for permission from the higher authority; and includes all nurse practices under nurse practice (Vaillant-Roussel et al., 2014).

 The importance of nursing process is that it guides registered nurse when making healthcare decisions. This is particularly important when making patient centered and culturally competent decisions. This process ensures that the registered nurses can identify the nursing issue, its etiology as well as analyze appropriate risk factors. From the information collected, registered nurse is in a position to design a patient centered plan of action, in an organized and structured process. In this framework, the expected outcomes are focused and oriented towards providing quality care. In each step, the registered nurse must document the information for effective communication and for future use. Evaluation process is important because it helps in analyzing the effectiveness of an intervention. If the action plan goals are inadequately achieve, then the healthcare providers should collaborate and work jointly to identify the underlying barriers which need to be re-evaluated and addressed (Svavarsdottir et al., 2014).

 Some of the variables associated with ineffective outcomes include inaccurate assessment and data gathering processes; because some relevant information such as cultural aspects is more likely to be overlooked. In other situation, the interventions and the expected outcome could be unreasonable and somewhat unrealistic. In this case, the registered nurse is required to address the interventions and the expected outcome to ensure that they are congruent. This is done through modification of the assessment plan, diagnosis or even the implementation process. If necessary, the registered nurse can include other healthcare staff to contribute on the most effective ideologies which will bring forth successful interventions as outlined by evidence based research. This also involves thorough and adequate research which will inform the registered nurse adequately on ways and an appropriate strategy to identify the health issue, effective action plan and approaches to obtain the best conclusions (Lu et al., 2015).

Part 2: Nurse Care Plan

Assessment

Patient A resides in a residential care. The patient is 78 years old and has been experiencing mobility complications. For this reason, the patient movement is restricted and opts to use mobility supportive device i.e. wheel chair for movement. The patient is able to carry out the daily living activities such as bathing, dressing and feeding. The patient seems distressed and is often in isolation. The patient medical history is that he has suffered from Congestive Heart Failure (CHF); and has been diagnosed with associated pathologies such as hypertension, weakness in the lower extremities and hyperlipidemia.  Previously, the patient was prescribed the following medication such as Atorvastatin 20mg, Lopressor 50mg, Quinapril 20mg and Furosemide 20mg.

The patient current medication includes double dosage of Quinapril and Furosemide at 40mg, Metoprolol 50mg which are administered orally, and 1.5g in 0.9% normal saline (50Ml) given three times a day. Recent regular check up, the registered nurse reported a pressure ulcer on the patient’s right side of the buttock. The ulcer coloration is red with yellow spots, and is estimated to be 10mm by 8mm; and also produces foul smell. Result from culture analysis indicates that the wound is infected by Methicillin resistant Staphylococcus aureus. The physician ordered for debridement of the black tissue, and daily dressing using antimicrobial gel (SilvaSorb).

NANDA-1 nursing diagnosis

Acute pain due to trauma on the tissue is reported; scored at 6 on 0-10 pain scale.

Risk for pressure ulcer due to tissue trauma associated with minimal movement to reduce the pressure.

Assessment data

Vital Signs: Temperature 36.70C; RR 23/Min; HRT 89 BPM; Bp 120/80.

Skin; Dry and Pale, Pupils dilated, experiences muscle cramp; Joint Movement, gastrointestinal system, urogenital systems and neurovascular system are intact.

Expected outcome

 The expected outcome are Cognitive outcome- verbalize relieve pain  to 2 in a 0-10 verbal pain scale and discomfort while sitting or sleeping; physiologic and affective outcome- the patient is educated on ways to prevent  progression of pressure ulcer and minimize occurrence of such incidences in the future. The skin integument healing system could take a longer time frame due to the patient attributes i.e. age and chronic infection which reacts negatively to the patient immune system. In this context, the pan relief is expected to be achieved within 48hours, and healing of the wound within 5 days.

Nursing intervention

Nurse initiated: Identify the main risk factor for pressure ulcer. This includes recording of agility to monitor patient pattern of movement; and evaluate other mobility supportive devices available other than use of wheel chair.  Use of alginate dressings to reduce exudates as well as lengthening the wound wears time.

Rationale: This is to establish the most effective strategy to minimize progression of pressure ulcers, and improvise ways to ensure that patient moves frequently or avoid sitting for a long period of time. This is to ensure that the patient does not remain in one position for a long time.

Interdependent intervention:  protect the ulcer with silicone dressings to relieve pain, effective transition of patient to the residential facility including exchange or effective communication with the residential facility nurse to ensure that the identified nutritional and exercise strategies are adhered to.

Rationale: This is to ensure that the patient feels comfortable during the healing process.   This also ensure that evidence based practice is followed; with the aim of rapid healing process and reduce the progression of disease through interdisciplinary efforts.

Dependent intervention:  administration of antibiotics as reported evidence based practice. Rationale: this will help the patient self manage the ulcer pressure, as well as reduce the progression of disease.  Use of hydrogel with the aim of soothing painful pressure ulcers; use of antimicrobial dressings so as to control the odor and bioburden. Clean of the peri-ulcer tissue to devitalize the dead tissue and to control the known microbial infection well known for colonization.

 The patient will be educated on ways to modify behavior such as mild physical exercises and nutritional modification which will facilitate faster healing rate. For instance, the patient can be taught on approached to redistribute pressure. This includes periodic intervals turn as guided by the patient’s wish or tolerance and the type of support surface.  Evidence research practice indicates that the patient should be repositioned after every two hours. The support surface can be modified using repositioning mattresses e.g. visco-elastic foam, pillows, chair cushion.

The patient should be educated on ways to maintain the skin hydrated and the nutritional supplements compatible with the patient healthcare.  This includes a lot of protein supplements to facilitate faster healing rate. Additionally, the patient should be advised on ways to take care of the skin. This includes applying of emollients as indicated by the manufacturer.

Rationale: this includes nutritional modification and mild physical activeness to cure, reduce progression and prevent further formation of pressure ulcer.

Part 3: Patient teaching plan

Research indicates that the best healthcare services involve partnership between the service user and the service provider. This is because it establishes a strong bond of trust; thereby strengthening their relationship which improves quality of care. The core factor for a successful partnership is communication. Appropriate communication ensures that the patient’s demands are identified by the service provider, and they are adequately addressed. The best approach of communication is through patient education program (Vaillant-Roussel et al., 2014). This program empowers patients such that they can self manage the health complication with ease. This improves their self esteem and self image. In this context, the registered nurse is mandated to design a teaching plan that would educate the patient with ease. During the designing process, several variables must be put into consideration including the patient age, gender, ethnic background due to language barrier, education and socio economic background. This is important because the nurse can identify with the patient, and can design education material which is custom made for that particular patient. These variables also help the registered nurse in choosing the format of teaching i.e. verbal, written or audio-visual format (Jackson, 2008).

 The registered nurses assess the patient specific demands from the patient medical history. Based on the findings from the assessment report, the registered nurse can apply at least three approaches namely cognitive, affective and psychomotor. The psychomotor approach is applied to patients whose educational background is low as it entails physical teaching of the interventions e.g. how to use mobility devices. The affective teaching is the most widely used approach because it is more patient centered. This approach integrates the social cultural beliefs into the clinical interventions (Kehrel, 2015).

 The cognitive approach is uses cognitive functions and is mainly used to assess the memory and adaptability of a patient. This approach is commonly used in youths and individuals whose cognitive function is in good condition.  Secondly, the registered nurse is required to set both short term and long term goals. People who are closely related to the patient such as care givers should be incorporated in the teaching process. Evaluation process is important because it checks if patients’ understands the concepts taught. This also facilitates to assess the patients strengths as well as weaknesses (Vaillant-Roussel et al., 2014). There are various tools for assessment including interviews, observations or use of questionnaires. These tools record data that will enhance the teaching plan of a patient. In cases where the patient fails to remember or understand the concepts, the registered nurse should revise the teaching design, and if necessary seek more information from literature and peers on the evidence based research and strategies to solve the issue, and to ensure that the patient can effectively manage their healthcare complication (Fleming, 2014).

References

Fleming, J. (2014). A Future for Adult Educators in Patient Education. Adult Learning, 25(4), 166-168.

Kehrel, U. (2015). The acceptance of process innovations in drug supply – An empirical analysis of patient-individualized blister packaging in stationary nursing facilities. International Journal Of Healthcare Management, 8(1), 58-63.

Jackson, M. (2008). Fundamentals of Nursing: Concepts, Process and PracticeFundamentals of Nursing: Concepts, Process and Practice. Nursing Standard, 22(32), 30-30.

Lee, N. (2010). The Research Process in Nursing – Sixth editionThe Research Process in Nursing – Sixth edition. Nursing Standard, 24(46), 31-31.

Lu, C., Tang, S., Lei, Y., Zhang, M., Lin, W., Ding, S., & Wang, P. (2015). Community-based interventions in hypertensive patients: a comparison of three health education strategies. BMC Public Health, 15(1). doi:10.1186/s12889-015-1401-6

Rodríguez-Martín, B., Stolt, M., Katajisto, J., & Suhonen, R. (2015). Nurses’ characteristics and organisational factors associated with their assessments of individualised care in care institutions for older people. Scandinavian Journal Of Caring Sciences, n/a-n/a.

Svavarsdottir, E., Sigurdardottir, A., Konradsdottir, E., Stefansdottir, A., Sveinbjarnardottir, E., & Ketilsdottir, A. et al. (2014). The Process of Translating Family Nursing Knowledge Into Clinical Practice. Journal Of Nursing Scholarship, 47(1), 5-15.

Vaillant-Roussel, H., Laporte, C., Pereira, B., Tanguy, G., Cassagnes, J., & Ruivard, M. et al. (2014). Patient education in chronic heart failure in primary care (ETIC) and its impact on patient quality of life: design of a cluster randomised trial. BMC Family Practice, 15(1). doi:10.1186/s12875-014-0208-3

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