Tag: the nursing process

The Nursing Process

The nursing process is a systematic guide to patient-centered care through 5 sequential steps: assessment, diagnosis, planning, implementation, and evaluation.

Retrieved from https://nurseslabs.com/nursing-diagnosis/ on 7th November 2021

Characteristics of the Nursing Process

  • Dynamic & Cyclic – a process in which each phase interacts with and is influenced by the other phases
  • Open & Flexible – easily adaptable to different circumstances and emergencies
  • Universally Acceptable – allows nurses to practice nursing with all individuals within any type of practice setting
  • Patient Centered -the nursing process approach requires care respectful of and responsive to the individual patient’s needs, preferences, and values; the nurse functions as a patient advocate, enables the patient to make informed decisions, and maintains patient-centered engagement within the healthcare setting
  • Problem Oriented – aims to tackle arising and possible problems
  • Interpersonal & Collaborative – provides the basis for the therapeutic process in which the nurse and patient respect each other as individuals, both of them learning and growing due to the interaction
  • Systematic – has an ordered sequence of activities, each of which depends on the accuracy of the activity that precedes it whilst influencing the activity following it
  • Goal Directed – the interaction between the nurse and the patient is based on a common goal
  • Planned – provides a basic structure on which nursing care can be provided
  • Holistic – takes into account all aspects of the patient

Benefits of the Nursing Process

  • Improves the patient’s quality of care
  • Promotes active patient participation in own health through continuous evaluation
  • Promotes nursing efficiency through better time and resource use
  • Saves time and energy through the creation of a care plan to follow up with
  • Reduces omissions and duplications
  • Acts as a guide outlining consistent and responsive care
  • Helps in identifying the patient’s goals and required strategies
  • Promotes collaboration in the management of the patient’s health-related problem
  • Promotes positive patient outcomes
  • Promotes patient safety
  • Promotes patient satisfaction

Step 1: Assessment

  • collect and document data on the patient’s health status
  • identify the patient’s strengths as well as limitations
  • repeat continuously throughout the nursing process

Step 2: Diagnosis & Planning

  • sort and analyze data collected on assessment
  • identify actual, potential, or health promotion nursing diagnosis
  • put together a nursing care plan tackling identified diagnosis

Step 3: Implementation

  • implement the nursing care plan with the aim of achieving the required goals and outcomes
  • continue carrying out assessments evaluating the patient’s response to treatment and care
  • modify where necessary
  • document

Step 4: Evaluation

  • perform at specific intervals and continue until patient achieves health goals or is discharged
  • target the restoration of self-care abilities if required
  • assess the client’s response to the carried out nursing interventions
  • assess response to goals and/or planned outcome criteria documented in the Diagnosis phase
  • determine the patient’s progress towards aimed goals and the effectiveness of the nursing care plan being carried out

Nursing Care Plan Example…

Retrieved from https://www.pinterest.ph/pin/611222980657579285/ on 7th November 2021

Nursing Care Plan Template…

Retrieved from https://www.pinterest.com/pin/732679433111887637/ on 7th November 2021

NOTE: While it is still being barely done, it is a great idea to implement the Nursing Process into your nursing documentation, including the words Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Nursing Plan Examples based on the Nursing Process

Scenario: Patient Presenting with Hypothyroidism

  • Risk of Malnutrition

ASSESSMENT:

  • assess how hypothyroidism is currently being controlled
  • assess patient’s weight
  • assess whether the patient is taking enough fibre in her dietary intake so as to prevent constipation
  • check BMI and assess whether patient is at risk of obesity
  • ask about daily caloric intake

DIAGNOSIS:

  • imbalanced nutrition

PLANNING:

  • aim for more nutritious lower caloric intake and weightloss or weight maintenance, depending on the patient’s current weight status

IMPLEMENTATION:

  • educate patient about the risk of obesity which comes with hypothyroidism
  • teach patient the importance of planning meals beforehand
  • teach patient the importance of taking frequent smaller meals rather than a big meal
  • encourage patient to keep a food diary so all nutritional and caloric intake can be monitored and adjustments may be made
  • involve dietitian if necessary, who can help provide meal plans to prevent over-eating
  • encourage exercising
  • encourage fluid intake
  • ensure the patient has a good support system through family or friends who can help by offering support

EVALUATION:

  • compare patient weight with previous weight readings
  • maintain fluid intake and output charting
  • review food diary
  • review care plan
  • Risk of Constipation

ASSESSMENT:

  • ask patient how much stools are being passed and whether constipation is being experienced

DIAGNOSIS:

  • constipation

PLANNING:

  • aim to reduce constipation, which is a side effect of hypothyroidism

IMPLEMENTATION:

  • encourage patient to drink more water
  • encourage exercise
  • encourage increased fibre intake
  • if necessary, a stool softener such as Movicol may be recommended

EVALUATION:

  • review situation with the patient
  • review care plan
  • Possible Lack of Health Literacy about Hypothyroidism

ASSESSMENT:

  • talk to the patient and assess health literacy in general and about hypothyroidism

DIAGNOSIS:

  • lack of health literacy

PLANNING:

  • teach patient about the condition and the importance of medicine compliance for life

IMPLEMENTATION:

  • explain in simple terms what hypothyroidism is
  • explain that since her body is not producing enough thyroid hormone, this needs to be taken orally
  • explain that thyroxine needs to be taken for life, and that it shouldn’t be stopped even if one is feeling well
  • explain that follow-ups are very important since clinicians need to ensure that a therapeutic dose of thyroxine is achieved and maintained

EVALUATION:

  • question the patient about the information you have relayed, and ensure that adequate knowledge has been grasped
  • re-explain where needed
  • Possibility of Fatigue

ASSESSMENT:

  • assess patient for fatigue
  • if fatigue is being experienced, explain that it is one of the side-effects of hypothyroidism

DIAGNOSIS:

  • fatigue

PLANNING:

  • aim for better performance during the day and adequate rest during the night

IMPLEMENTATION:

  • encourage patient to rest frequently, spacing daily activities throughout the day
  • encourage patient to notice at what times it feels easier to maintain activities, so that better day planning can be implemented according to their energy levels
  • reassure patient and encourage not to push themselves too much, but to go along with their capabilities
  • teach patient that exercise, although may feel too tiring, helps in muscle build-up and strength

EVALUATION:

  • assess if patient is feeling better with regards to fatigue
  • re-evaluate care plan and adjust where necessary
  • Patient Prone To Feeling Cold

ASSESSMENT:

  • ask if patient is feeling cold often, and check whether any skin issues are arising due to coldness

DIAGNOSIS:

  • patient feeling cold

PLANNING:

  • aim for better clothing options/planning and advise regarding skin breakdown

IMPLEMENTATION:

  • encourage patient to always carry with an extra jumper or jersey, and to avoid going out when it is very cold or late in the evening if possible
  • teach patient to prevent skin breakdown by encouraging use of soap for sensitive skin and adequate skin care

EVALUATION:

  • re-assess situation
  • re-evaluate care plan and adjust if necessary

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Patient Hospital Admission

Patient hospital admission refers to the admission and acceptance of a patient into a health facility with the aim of staying under observation, undergoing necessary diagnostic investigations, and receiving required medical or surgical treatment. Patient hospital admission can be either elective – where a procedure is planned beforehand, or an emergency.

Elective Admission

In an elective patient hospital admission, a healthcare professional agrees with the patient on a convenient date for admission. This enables the patient to prepare in advance for the procedure.

Emergency Admission

In an emergency patient hospital admission, the patient is usually brought in by relatives or friends in a critical condition. In such an admission, the patient is usually transported by a wheelchair or a stretcher to an adequate ward for immediate evaluation and treatment.

Elective Patient Hospital Admission Procedure

  1. Welcome the patient and any accompanying relatives to the ward and introduce yourself and any other present HCPs
  2. Gather all required documents such as admission papers and other important information or documentation from the accompanying nurse
  3. Confirm patient identity through given details
  4. Ensure that the patient and accompanying relatives feel welcomed and comfortable
  5. Gather any additional required information by the patient and/or the accompanying relatives
  6. Provide a hospital bed located at an ideal room for the patient in question, based on the patient’s health requirements and condition
  7. Provide assistance to the patient to change into pyjamas or hospital gown and ensure identification bracelet and any other required tags eg. allergy bracelet is provided
  8. Take baseline vital signs and document
  9. Collect any required specimens if needed
  10. Administer any urgent medications
  11. Ensure patient valuables are taken care of
  12. Ensure informed consent is obtained, signed by the patient
  13. Inform relatives about visiting hours and about anything that they may need to bring in for the patient on their next visit
  14. Following relatives’ departure from the ward, orient patient to the ward and to the surrounding environment
  15. Provide nursing care based on The Nursing Process
  16. Input the patient’s particulars in the admission and discharge book
  17. Document admission into the patient’s nursing documentation sheet
  18. Input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system

Emergency Patient Hospital Admission Procedure

  1. Perform hand hygiene
  2. Gather emergency equipment– vital signs apparatus, resuscitation trolley, oxygen, venepuncture equipment, suction apparatus, and an adequate bed in a suitable location based on the patient’s condition
  3. Welcome the patient and accompanying relatives to the ward and introduce yourself and any other present HCPs
  4. Gather all required documents such as admission papers and other important information or documentation from the accompanying nurse
  5. Confirm patient identity through given details
  6. Assess patient’s overall condition efficiently
  7. Receive patient into a previously prepared bed, keeping the patient’s current condition in mind
  8. Provide assistance to the patient to change into pyjamas or hospital gown and ensure identification bracelet and any other required tags eg. allergy bracelet is provided
  9. Take baseline vital signs and observe further the patient’s overall appearance and reaction, level of consciousness, skin integrity, pain, breathing pattern, and any other complaints, and document
  10. Collect relevant history from the patient or accompanying relatives
  11. Ensure informed consent is obtained, signed by the patient (include detailed information about required emergency procedures is given to ensure informed consent)
  12. Ensure patient valuables are taken care of
  13. Inform relatives about visiting hours and about anything that they may need to bring in for the patient on their next visit
  14. Following relatives’ departure from the ward, orient patient to the ward and to the surrounding environment
  15. Collect any required specimens if needed
  16. Administer prescribed medications
  17. Input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system
  18. Document admission into the patient’s nursing documentation sheet

The Nurse’s Role in the Admission Process

  • Ensure the patient’s physical and emotional needs are met
  • Ensure the patient is assigned to a bed adequate to his/her personal needs and condition
  • Ensure that the patient’s admission report is completed
  • Ensure the patient is assessed using The Nursing Process
  • Provide a holistic approach to patient care based on the Activities of Daily Living guide whilst considering the patient’s psychological, social, spiritual, and cultural needs
  • Ensure the patient’s comfort and aim to reduce anxiety in both the patient and accompanying relatives
Patient Hospital Admission
Retrieved from https://nurseslabs.com/nursing-diagnosis/ on 7th November 2021
Retrieved from https://nurseslabs.com/nursing-diagnosis/ on 7th November 2021

Transferring the Patient

During a hospital stay, the patient may require transferring from one ward to another within the same healthcare facility.

Transfer in

In a Transfer-In, a patient is moved from one unit to another, eg. from a medical to a surgical ward.

When a patient is being transferred in:

  1. ensure a suitable bed is available to receive the patient
  2. ensure all necessary equipment depending on the patient’s condition is readily available
  3. ensure the patient, accompanying nurse, and any accompanying relatives are received warmly
  4. ensure correct handover, transfer of notes, and any patient personal belongings are received from the accompanying nurse
  5. confirm patient identity with accompanying nurse
  6. clarify any queries pertaining to the patient’s condition
  7. introduce yourself and other present HCPs to the patient and accompanying relatives
  8. assess patient’s overall condition efficiently
  9. ensure the patient is assessed using The Nursing Process
  10. orient patient and relatives to the ward and to the surrounding environment
  11. input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system, including time of admission
  12. document transfer into the patient’s nursing documentation sheet

Transfer Out

In a Transfer-Out, the patient can be transferred from one ward to another, or from one facility to another.

When transferring a patient out:

  1. confirm transfer with receiving unit
  2. assess the patient’s condition
  3. arrange for a nurse to accompany the patient
  4. plan for an appropriate transferring vehicle if required
  5. collect all patient data
  6. reduce the patient’s and accompanying relatives’ anxiety by explaining reason for transfer
  7. obtain informed written consent for transfer
  8. assist in the packing of the patient’s personal belongings
  9. ensure patient’s medication, diagnostic results, and transfer notes, are all compiled as required
  10. assist patient in dressing up adequately for the transfer
  11. assist patient into a wheelchair or stretcher, and into an ambulance, if required
  12. ensure patient’s notes and belongings are handed over to the accompanying nurse
  13. input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system, including time of transfer
  14. document transfer into the patient’s nursing documentation sheet

Discharging the Patient from the Hospital

Discharge planning should start shortly after the patient is admitted, and is usually done at the discretion of the medical team, based on the patient’s overall health condition, or if the patient requests to be discharged. The patient and his/her relatives should always be informed about intended discharge plans.

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