Nursing Process PDF

NURSING PROCESS->The core tenet of the nursing process is that it looks first at the patient and then reflects on the required care rather than deciding what care the patient needs and then looking at the patient and how this might be implemented. CARE PLANNING facilitates a nurse to iden...

NURSING PROCESS->The core tenet of the nursing process is that it looks first at the patient and then reflects on the required care rather than deciding what care the patient needs and then looking at the patient and how this might be implemented. CARE PLANNING facilitates a nurse to identify a patient’s problems and select interventions that will help solve or minimize patient problems CARE PLANS are the written records of the care planning process Care planning is the action while care plans are a record of action The third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care. The planning of nursing care occurs in three phase The four critical elements of planning include: Establishing priorities Setting goals and developing expected outcomes (outcome identification) Planning nursing interventions (with collaboration and consultation as needed) Documenting What does the “A” in ADPIE mean? The "A" in ADPIE stands for Assessment, the first nursing process step. It requires critical thinking skills and collects subjective and objective data. Subjective data includes verbal statements and recounts from the patient or the primary caregiver regarding their current complaint, past medical history, medications, and more. Objective data is measurable, tangible data, such as vital signs, intake and output of fluids, height, and weight. Electronic health records may also assist. What does the “D” in ADPIE mean?  The "D" in ADPIE stands for Diagnosis. Formulating a nursing diagnosis by employing clinical judgment assists in planning the consecutive steps in patient care. According to the North American Nursing Diagnosis Association (NANDA), a nursing diagnosis refers to the RN’s clinical judgment about actual or potential health problems. A nursing diagnosis helps prioritize and plan care and encompasses Maslow's Hierarchy of Needs. This hierarchy is based on the basic fundamental needs of all individuals. Basic physiological and safety requirements must be met before higher goals, like love, belonging, self-esteem, and self-actualization can be achieved. Physiological and safety needs provide the basis of nursing care and nursing interventions. Thus, these basic needs are at the base of Maslow's hierarchy pyramid, creating the foundation for physical and emotional health. Once this hierarchy of needs for the individual is assessed, the nursing diagnosis can be made and applied effectively on an individual basis. What does the “P” in ADPIE mean? The "P" in ADPIE refers to the Planning stage of the nursing process, which is when goals and outcomes are formulated, according to current evidence-based practice (EBP) guidelines, that directly impact patient care. Goals at this stage are always patient-centered to achieve a positive patient outcome. Nursing care plans are essential as they provide personalized care tailored to an individual's unique needs. Overall health conditions and comorbidities are crucial in constructing a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare system. The goals may be specific, meaningful, attainable, realistic, and timely. Therefore, when selecting a goal, it has to be clear, described in detail, and can be accomplished, in a logical time frame. What does the “I” in ADPIE mean? The "I" in ADPIE refers to Implementation, which is the step that involves the actual carrying out of interventions outlined by the plan of care. This phase requires interventions, such as applying a cardiac monitor or oxygen, medication administration, and standard treatment protocols. What does the “E” in ADPIE mean? The "E" in ADPIE stands for Evaluation and is the final step of the nursing process. It is vital to a positive outcome. When healthcare providers intervene or implement care, they must evaluate their implementation to ensure the desired outcome has been met. The initial care plan may be adapted and revised based on new assessment data to achieve the goal and ensure positive patient outcomes. Continuous reassessment may be needed depending upon the overall patient condition. CHARACTERISTICS IF THE NURSING PROCESS Cyclic and dynamic nature  Client centeredness Focus on problem-solving and decision-making Interpersonal and collaborative style Universal applicability Use of critical thinking ->It is a process in which information is gathered ,sifted synthesized and evaluated to understand a subject or issue INTIMATE CARE Emotions you may express Uncomfortable Disgust Embarrassed when one is exposed parts of women/male clients’ bodies, such as genitalia and breasts, or when topics related to sexual health were raised during care delivery How will I wash this body – will I get sick Good personal hygiene is imperative for individuals ‘health and wellbeing’ Client hygiene is an extension of providing client safety and protecting the client’s defence mechanisms The health of the body’s first line of defence (skin and mucous membranes) is promoted by client hygiene It promotes comfort and relaxation, improves self-image, and promotes healthy skin Purpose for Bathing Remove transient microorganisms, body secretions and excretions, and dead skin cells which minimizes skin irritation and reduces chance of infection Produce a sense of well-being/ promote positive body Promote relaxation and comfort Prevent or eliminate unpleasant body odors –axillae and pubic area Stimulation of circulation - Warm water and gentle strokes from distal to proximal increase circulation and promote venous return Promotion of Range of Motion of extremities while bathing Hygiene is a personal entity, and everyone will have their requirements and standards of cleanliness –as a result “nurses must take care not to impose their own norms on patients and ought to respect their autonomy in decision concerning care “ Nurses are responsible for ensuring that the client’ s hygienic/ bathing needs are met. The type of hygienic care provided depends on the client’s ability, needs, and practice. Nurses should understand the purpose of hygienic procedures as well as Assessment that should be done prior to, during, and after the procedures  Physical Assessment Psychological safety Cognitive impairment, –assessment->Self esteem, Mobility difficulties, self/body, image, severe anxiety, pain Neurological impairment Musculoskeletal impairment Sociocultural Religious beliefs, Altered level of consciousness gender Altered nutrition Environmental what facilities are Immobility available, temperature and climate Dehydration Skin Assessment Altered sensation Colour Secretion on the skin –high Temperature temperature-sweating Moisture Mechanical devices –casts Tugor-elasticity Altered venous circulation Any bruises scare, blemishes or alteration in Sedation colour Types of Baths Cleansing Bate COMPLETE BED BATH ->Nurse baths entire body of dependent patient in bed SELF-HELP BATH->Patients confined to bed can bathe themselves with some help PARTIAL BATH-> Parts of the body are washed by the patient and some by the nurse TUB BATH->Much easier for bathing and rinsing than in a bed->Varies in style SHOWER->Used by ambulatory patients who require only minimal assistance ->Can be used with a shower chair Therapeutic Baths Medicated solutions may be used in bathing->Range from warm water baths, cool water baths, cornstarch, oatmeal, Aveno, alcohol GUIDELINES FOR BATHING Communication – hello my name is Consent Dignity-/ RespectMaintain SafetyMaintain warmth Promote the patient’s independence as much as possible Communication - how are they feeling etc Skin ( Piercing) Hair Nails Teeth (dentures) Oral and nasal cavities ( page 92 -93 manual) Eyes Ears ( earing aids ) Perineal-genital area Foot care Suggested Washing Order The upper part of the body - Face including neck and ears, Arms, Chest and Abdomen If the patient can sit forward the nurse can wash patient back The lower part of the body –Legs, Genital Area Buttocks Wash back if patient has to be turned or unable to sit forward Dressing , Hair and Make up  Communiation PERINEAL CARE Can be embarrassing for the nurse and the patient. Should not be overlooked because of embarrassment. If the patient can do it themselves—let them. Hand them the washcloth and ask if they would like to “finish their bath.” Perineal Care Those patients who may need the nurse's assistance: Vaginal or urethral discharge Skin irritation Catheter Surgical dressings Incontinent of urine or feces Perineal Care ProcedureWomen Wipe labia majora (outer) from front to back in downward motion using a clean surface of wash cloth for each swipe. Wipe labia minora (inner) from front to back in downward motion using clean surface of wash cloth for each swipe Wipe down the center of the meatus from front to back. If the catheter is in place, clean around the catheter in circular fashion, using a clean surface of wash cloth for each swipe. Wash inner thighs from proximal to distal PERINEAL CARE - MALE Retract foreskin of penis if uncircumcised Wash around the urinary meatus in a circular motion, using clean surface of washcloth for each stroke and around the head of penis in circular motion Wash down shaft of penis toward the thighs changing washcloth position with each stroke Wash scrotum – front to back Replace foreskin, as appropriate Turn patient on side to wash anus from front to back and dry Wash inner thighs Hair Care A person’s appearance and feeling of well-being often depends on the way their hair looks and feels Ways to Shampoo  If patient can get up and into a shower or sink, use a handheld nozzle If patient can not get up, place on stretcher and roll to a shower area “Shampoo in a Bag” or dry shampoos are available Hairdresser Shaving Improves self-esteem and emotional needs of the patient Provide Safety When using a razor blade, the skin must be softened to prevent pulling, scraping, or cutting Place a warm washcloth over the area and then apply some gel, cream, foam. Hold the razor at a 450 angle Pull the skin taut Shave in the direction of hair growth Electric razors must be used on patients who are at risk for bleeding or confused Assessment: Skin for elevated moles, warts, rashes, patchy skin lesions, or pustules Moisture Associated Skin Damage ( MASD) MASD is used as an umbrella to cover skin damage caused by different types of moisture sources, including urine or faeces, perspiration, wound exudate, mucus, and saliva. Incontinence- associated dermatitis (IAD)(keep the area dry and clean only water/ no dressing no soap))*moisture related skin damage, sometimes referred to as perineal dermatitis, is an inflammation of the skin associated with exposure to urine or stool. Elderly adults, and especially those in long-term care facilities, are at risk for urinary or fecal incontinence and IAD. How is IAD treated? Wash the area with a cleanser that balances your skin's pH level. Add moisture back into your skin. As part of the prevention and management of IAD it is important that skin cleansing (TENA WASH) takes place/ cleanse, protect and restore. Cleansing of the skin should occur following every episode of incontinence to ensure that the natural function of the skin is maintained. Protect (cavilon spray, put in on and let it dry) pag 161. Nursing Assessment: Recognising IAD Inspect skin ( perineum, perigenital areas, buttocks, gluteal fold, thighs, lower back, lower abdomen and skin folds May feel warmer and firmer than surrounding unaffected skin Lesions may include vesicles or bullae, papules or pustules Epidermis may be damaged to varying depths Entire epidermis may be eroded exposing moist, weeping dermis Signs of fungal or bacterial infection Appears initially as erythema...ranging from pink to red Darker skin tones..skin may be paler, darker, purple, dark red or yellow Poorly defined edges May be patchy or continuous over large areas PRESSURE AREA CARE AND PREVENTION Remember 6 Cs - To prevent the occurrence of pressure ulcers, it is important that nurses ( you) understand what a pressure ulcer is and the underlying factors that cause them. Definition- Pressure Ulcer (PU)-> Pressure ulcers have been described as ‘localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful. Risk factors for developing a pressure ulcer include cognitive impairment, reduced mobility, and inadequate nutrition and hydratio ETIOLOGY FACTORS: Pressure (squeezing together soft tissues) Shear (tear the blood vessels) Friction (opposes the movement of one surface across another) Pressure Points Weight bearing bony prominences are most susceptible to pressure ulcer development. These prominences are covered by skin and small amounts of subcutaneous tissue SYMPTOMS: part of the skin becoming discoloured - people with pale skin get red patches, while people with dark skin get purple or blue patches  discoloured patches not turning white when pressed a patch of skin that feels warm, spongy or hard pain or itchiness in the affected area -Pressure ulcer risk assessment is considered the first step in their prevention. A process that involves measurement of risk to determine priorities and to enable identification of appropriate level of risk treatment”Should be undertaken within 6 hours of hospital admission or first or during the first visit in the community. Coleman et al’s (2013) identified three primary domains of risk factors for pressure ulcer development: » Immobility – the person’s ability to move themselves to relieve pressure. » Skin status – any current skin breakdown, previous history of skin breakdown and any underlying skin conditions present that compromise the person’s skin health. »Perfusion – any central vascular concerns such as cardiac conditions or stroke. Assessment ToolsIdentify ‘AT RISK’ patients You must apply the principles of “ASSKING” risk assessment-skin inspection-surface-keep moving-incontinence/moisture-nutrition/hydration-giving information WATERLOW RISK ASSESSMENT Norton Score Braden Score Pressure ulcer prevention care plan. Repositioning Chart Wound assessment chart Water-low Risk Assessment Score Should be used as an adjunct to clinical decision of whether the patient is ‘at risk’ of pressure ulcers Must be done within 6 hours of hospital admission and repeated every time there is a change in patient’s condition (deterioration/ improvement) or at least once a week  If a patient is identified ‘at risk’, actions must be clearly documented and a Pressure ulcer prevention (PUP) care plan started immediately.This must be agreed with the patient/carer and reviewed dail Skin Assessment : What to Look for on the Skin An area of skin that is noticeably different than the surrounding area It may look red, and the redness does not “fade” when the skin is touched, and released (blanched) For patients with dark skin, the skin may look darker or lighter than the surrounding skin. Skin may look a little: red, blue, or purple in color Surface Select a support surface that meets the individual’s needs Consider the individual’s need for pressure redistribution based on following factors: level of immobility and inactivity need for microclimate control and shear reduction size and weight of the individual risk for development of new pressure ulcers number, severity, and location of existing pressure ulcer(s) Treatments for pressure ulcers Treatments for pressure ulcers depend on how severe they are. In most cases, they just need basic nursing care. In severe cases, they can lead to life-threatening complications, such as blood poisoning. Treatments for pressure ulcers include: applying dressings that speed up the healing process and may help to relieve pressure moving and regularly changing your position using foam mattresses or cushions, or dynamic mattresses and cushions that have a pump providing a constant flow of air eating a healthy, balanced diet debridement - a procedure to clean the wound and remove damaged tissue Why a Care Bundle? Support the implementation of evidence-based practice; Improve clinical processes by reducing risk; Reduce duplication through the use of a standardized tool- promote safety Reduce variation in health service processes in the delivery of care  Nursing Interventions Relieving Pressure Plan a 24 hour schedule for position changes. ◦prevent pressure ulcers in immobilised patients, promotes healing- 30 degree tilt ◦Reposition the patient every 2 hours around the clock or as indicated in assessment. Use pressure relieving devices as available- mattresses, beds, chair cushions, Theatres use special gel pads Caution, select the correct mattresses product for the patient - based on weight, and risk profile Not a substitute for positioning unless rotation bed Encourage patient to relieve pressure area points - educate Extra Pillows often used to support a patient's position – 30-degree tilt Strict attention to continence and hygiene, improve skin integrity, moisturiser Improve Mobility Encourage patients to be as active as possible. Perform passive range of movement on all joints. Pain relief Fear of falling Liaise with a physiotherapist. Family Clinicians should employ a skin care regimen that is consistently employed: to remove irritants from the skin (cleanse); to protect from exposure to irritant substances (protect); to maximise the intrinsic moisture barrier function of the skin (restore) Use a valid and reliable nutrition screening tool to determine nutritional risk. Adequate nutrition is essential to manage pressure ulcers with individualised dietary prescription based on thorough nutrition assessment Care Bundle ‘aSSKINg’ (assess risk; skin assessment and skin care; surface; keep moving; incontinence and moisture; nutrition and hydration; and giving information or getting help) model can support nurses to plan and implement pressure ulcer care. How your BMI is calculated BMI is calculated by dividing an adult's weight in kilograms by their height in metres squared. For example, if you weigh 70kg (around 11 stone) and are 1.70m (around 5 foot 7 inches) tall, you work out your BMI by: 1.squaring your height in metres: 1.70 x 1.70 = 2.89 2.dividing your weight in kilograms: 70 ÷ 2.89 = 24.22 Your result will be displayed to one decimal place, for example, 24.