Nursing Process and Patient-Centered Care PDF

Nursing Process and Patient- Centered Care  Nursing - An art and science that uses a systematic approach to identify and solve the potential problems to maintain basic human function - Highest possible level of independence  Nursing process - Foundation for nursing practice - Pro...

Nursing Process and Patient- Centered Care  Nursing - An art and science that uses a systematic approach to identify and solve the potential problems to maintain basic human function - Highest possible level of independence  Nursing process - Foundation for nursing practice - Problem solving approach - On-going cyclic process that responds to changing requirements of the patient  Nursing process Steps: Assessment Nursing Diagnosis Planning Implementation Evaluation  Assessment - Admission until discharge - Problem-identifying - Collecting data  Assessment - pharmacology Drug history - Evaluate the need for medication - Obtain OTC, prescribed, herbal meds - Identify problems related to drug therapy  Assessment 3 sources: - Primary source - Secondary source - Tertiary source  Primary Sources: Patient/Caregiver: Direct information on current/past medications. Medication Containers/Lists: Physical proof of medications taken. Electronic Health Records (EHR): Documented prescriptions and medical history.  Secondary Sources: Pharmacy Records: Dispensing history from the patient's pharmacy. Previous Medical Records: Past medical charts for corroboration. Prescription Databases: Details on controlled substances prescribed.  Tertiary Sources: Drug Reference Books/Databases: Verification of drug details and interactions. Consultation with Healthcare Providers: Expert input for confirmation. Patient Education Materials: Additional drug information for context.  Nursing Diagnosis - A clinical judgment about individual, family, or community responses to actual or potential health problems/ life processes - Provide basis for nursing interventions  Nursing Diagnosis 4 types: - Actual (3-part statement) - Risk/High-risk - Health promotion and wellness (readiness for enhanced) - Syndrome  Nursing Diagnosis Common Nsg Dx: Pain related to hesitancy in taking prescribed pain medication because of fear of addiction Acute confusion related to adverse reaction to medication  Nursing Diagnosis Common Nsg Dx: Ineffective health maintenance related to not receiving recommended preventive care Deficient knowledge related to effects of anticoagulant medication on clotting mechanism  Nursing Diagnosis Common Nsg Dx: Noncompliance related to forgetfulness Risk for injury related to side effects of drug  Nursing Diagnosis Common Nsg Dx: Ineffective self-health management related to lack of finances or health care coverage to purchase medications Readiness for enhanced knowledge related to medication schedule and medication side effects  Planning - Formulated to meet patient’s needs - Patient goals not nursing goals - SMART - Maslow’s Hierarchy of Needs  Planning - update - NCP to critical pathways - Standardized, automated care plan with standards, interventions, goals and outcome - Evidence-based medicine Planning - pharmacology - Identification of therapeutic intent of medication - Identify common adverse effects that requires education - Identification of dosage and route of administration Planning - pharmacology - Scheduling of administration - Teaching patient to keep written records - Education as needed about techniques of self- administration  implementation - Carrying out plan of care - Meeting the needs of the patient, providing safety, monitoring for complications, ongoing-assessment  Implementation 3 actions: - Dependent - Interdependent - Independent  Implementation- pharmacology - Selection of correct supplies - Verification of aspects of the medication - Premedication assessment - Administration - Education (noncompliance)  Implementation- pharmacology Inclusion of a family member: act as a psychological support actually administer all or part of therapy observe effectiveness and S/E implement other changes or preparation  Evaluation - Determining whether expected outcomes were met - Involves patient and SO - Provides means for input of new significant data  Evaluation- pharmacology - On-going assessment to patient’s response to medications, signs and symptoms, therapeutic effects  Patient Education Domains of learning - Cognitive domain - Affective domain - Psychomotor domain  Cognitive domain - Thinking portion and incorporation of experiences - Formulating new meanings  Affective domain - Feelings and beliefs on what has been understood - Value of medication Psychomotor domain - Learning of new procedure or skill - Demonstration of procedure  Patient Teaching - General - Side effects - Self-administration - Diet - Cultural considerations Principles of teaching & learning - Carries legal implications - Basic patient right - Involves establishing goals with patient and family Principles of teaching & learning - Focus the learning - Consider learning styles - Organize teaching sessions and materials (teach back) - Motivates individual to learn - Determine readiness to learn Principles of teaching & learning - Space the content - Use repetition to enhance learning - Consider education level - Incorporate culture and ethnic diversity Strategies for health teaching - Teach appropriate use of the internet - Encourage adherence - Communicate goals and expectations Discharge planning & teaching - Summary statement of patient’s unmet needs Discharge medication teaching - Explain proper method of taking prescribed medication - Stress need of punctuality - Teach storage of medication - Provide written instructions (large bold letters) Discharge medication teaching - Identify anticipated therapeutic response - Instruct how to monitor response to drugs - Give list of signs and symptoms  MEDICATION ADMINISTRATION & SAFETY  Legal & ethical considerations - a privilege, not a right which includes accountability STANDARDS OF CARE – guidelines developed for the practice of nursing PATIENT CHARTS - Chart or electronic medical record - Primary source of information - Communication link - Legal document PATIENT CHARTS - CONTENT - Summary sheet/ info - Consent forms - Medical order sheet - History & physical examination - Progress notes - Nurses’ notes PATIENT CHARTS - CONTENT - Laboratory tests record - Graphic record - Flow sheets - Consultation reports - Medication administration record/ medication profile - Patient education record PATIENT CHARTS - CONTENT “If you didn’t chart it, it didn’t happen” “If not documented, it is not done”