Application of the Nursing Process
Part 1
Nursing process is a systematic, organised, and holistic patient-centred approach in delivering care to patients. The nursing process has five steps that include assessment, diagnosis, planning, implementation, and evaluation.
The second step in the nursing process is diagnosis. In this step, registered nurses make clinical judgments based on data gathered in the assessment step about the client’s health problem and the potential health problem of the client. Nurses also make judgements on the ability of the clients to adopt practices that can improve their health. For instance, the assessment of the old man in the scenario gives the following results: presence of pressure ulcer over the ischium, infection with methicillin-resistant staphylococcus aureas, advanced age, and history of immobility and long sitting hours. Based on the information, the diagnosis would be impaired skin integrity and risk of impaired skin integrity.
The third step of the nursing process is planning. This step involves developing a plan of action aimed at improving the client’s condition. Achievable and measurable goals for every intervention are set at this step. Based on our scenario, the nurse would plan to undertake the following actions: using cleansing agents with mild temperature and PH similar to that of the skin, applying seat cautions over bony parts to prevent development of pressure ulcers at the parts, development of schedule for turning the patient in order to change his position so as to minimise risk for pressure ulcers, debridement of necrotic tissue, provision of adequate nutrients, inspecting of the wound regularly, dressing of the wound, and administering drugs. Some of the goals include; the wound should heal by the end of one month after admission and the patient’s weight should increase by at least 3kg by the end of the fourth week after admission.
The fourth step is implementation. In this step, care is given to the patient according to the plan prepared in the planning step. Nursing care is classified into two main types: direct and indirect care. Direct care refers nursing activities pertaining to treatments are performed through interaction with the patient (Iowa Intervention Project, 1996). On the other hand, indirect care refers to the care given whereby the care providers do not interact with the patients but conduct the activities on behalf of the patients (Iowa Intervention Project, 1996). The action plans made in the planning step are implemented in the implementation step.
The last step of the nursing process is the evaluation step. This is the step that is characterised by evaluation of the effectiveness of interventions given to the patient. In this step, nurses can modify the interventions given to the patient depending on how the patient responds to interventions given in the implementation step. In our scenario, this step would involve monitoring of wound, monitoring of the turgidity of the skin of the patient, and taking the patient’s weight regularly.
Nurse-initiated (independent), dependent, and interdependent interventions are needed to address the patient’s condition. In terms of nurse-initiated interventions, nurses attending to the old man at the hospital can give certain interventions depending on the nursing assessments done. Some of the nurse-initiated interventions applicable in the old man’s case are pain management and pressure management. In this case, nurses do not need to rely on physicians for undertaking the two interventions. Instead, they undertake them based on their assessment. For interdependent interventions, nurses would collaborate with other health practitioners such as dieticians to counsel the old man in terms of appropriate diet and lifestyle for his condition. On the other hand, the dependent intervention applicable to the old man’s case is administering of medication and dressing of the wound. Since the patient has been examined by the physician and the physician has prescribed medication, nurses should administer the medication according to the prescription given by the physician.
Nursing process entails an assessment step that is a scientifically-proven, evidence-based, comprehensive, and systematic means of obtaining data pertaining to a patient’s condition. The data provides the basis on which registered nurses make nursing judgement pertaining to the patient’s condition. The accuracy of assessment procedure influences patient outcome. In addition, the nursing process provokes critical thinking. This enables nurses to obtain data, interpret, and evaluate the interpretations. As a result, nurses are able to make appropriate judgements. Nursing process also enables nurses set priority of care for a given patient or group of patients. This is because nursing process entails a step for diagnosis. Diagnosis informs about various needs of the patient. It is through diagnosis that registered nurses are able to identify the various needs and apply appropriate criteria for prioritizing care. Urgent needs are addressed first before other needs. For instance, if a patient is admitted to an inpatient care while unconscious due to hypoglycaemia and is found to be diabetic, blood sugar level should be addressed first before conducting nutrition education. In other words, life-threatening conditions are given priority. For a group of patients, application of the nursing process enables nurses to identify various needs of all the patients. Consequently, addressing each patient’s need can be done using standard criteria that give priority to patients based on the urgency of their needs.
Registered nurses evaluate the overall use of the nursing process by assessing the impact of the nursing process on a given population in terms of the severity and distribution of behaviour change and various health conditions. In addition, they assess the rate at which patients return within a short period after discharge. Achieving desired patient outcome is influenced by communication and coordination among health care practitioners, degree of cooperation between nurses and patients’ relatives, degree of motivation of nurses and other health practitioners, and the availabilities of health care delivery equipment. Whenever intended outcome is not met, registered nurses conduct a fresh assessment. The nurses then develop new diagnosis. Care plan is then modified by altering the duration of care, medication, or assigning the patient to a different health practitioner.
Part 2 (Nursing care plan)
Impaired skin integrity RT immobility and old age AEB presence of pressure ulcer
Since the patient has an open pressure wound over the ischium, the skin integrity over that part of the body is already compromised. The patient also has a history of hyperlipidaemia, CHF, and hypertension. However, since compromised skin integrity poses risk for infection, there is a need to address the wound first (Olson, 2012). In addition, the infections of the pressure ulcer may lead to poor patient outcome.
- Age of 78 years
- Poor skin turgor over bony prominences
- Immobility
- Pressure ulcer
- Wound culture result showing presence of methicillin-resistant staphylococcus aureus
Goals
The pressure wound should heal after one month of treatment. This outcome is a physiologic outcome since it relates to an aspect of the physiologic condition of the patient. The patient is suffering from stage four pressure wound. The wound takes long to heal since it is severe. In addition, appropriate nutrition and changes in positioning of the patient are important in enhancing the healing process. Therefore, one month would be adequate for restoration of the skin integrity (Karp, 2009).
Nursing Intervention
The interventions for this case include the following;
- Monitoring the wound site at least once a day for changes in colour, swelling, pain, warmth, redness, and warmth.
- Nutritional management
- Dressing the wound with SilverSorb antimicrobial wound gel
- Intravenous administration of 1.5 grams in 50mL of 0.9% normal saline Cefazol (Ancef)
Scientific Rationale for the Interventions
Regular wound inspection helps nurses to identify infections at an early stage (Storch, & Rice, 2005; Olson, 2012). Changes in warmth, redness, colour, swell, and pain are related to infections. Nutritional status determines the likelihood of wound to heal. The wounds of patients with poor nutritional status take longer time to heal than those of patients that take adequate nutrients. Wound healing requires adequate intake of nutrients that promote the healing process such as zinc, protein, calories, and vitamins (Molnar, 2005). SilverSorb dressing helps in treating bacterial infection at the wound site (Storch, & Rice, 2005). Intravenous administration helps in boosting body resistance to bacterial infection.
Evaluation of the Interventions
Nurses would evaluate the care given by doing the following:
- Monitoring complaints on wound pain
- Monitoring the changes in the colour and degree of swelling of the wound
- Monitoring changes in skin turgidity around the wound and the general skin
- Monitoring changes in weight of the patient
Part 3
The process of developing a teaching plan starts with deciding the appropriate format to use. The format for the teaching plan requires inclusion of the intended outcome, time, the nature of the patient, the nature of the condition of the client, and the content that registered nurse intends to cover in a teaching session. The nurse also needs to decide on whether to deliver the teaching through written or verbal means. This decision is influenced by the level of literacy of the client. For clients who cannot read, written plan is not recommended. Registered nurse can also analyse and organise the information collected about the patient so that the information can be used to assess the patient’s level of understanding about the patient’s condition. Factors such as culture of the patients are also important.
The registered nurse also needs to decide the information to be included in the content of the teaching plan. The registered nurse can know which information to include in the teaching content based on the most urgent need of the client. For instance, based on our scenario, the most urgent need for the client is the knowledge on how to maintain wound, appropriate diet, and ways of changing sitting positions in order to minimise risks of impairment of skin integrity.
Registered nurses decide on when and how to evaluate the teaching or learning process depending on the amount of content delivered to the patient. Each learning session has expected outcomes. Therefore, nurses carry out evaluation of the teaching process after the end of each learning session. The method of evaluation depends on how effective a method is in determining the extent to which the teaching goals and objectives are met. In addition, the method of evaluation also depends on whether the format of the teaching used. For instance, if teaching is conducted verbally, evaluation should also be conducted verbally.
The intended teaching outcome also influences how and when to evaluate teaching process. For instance, if the teaching process is intended to change the attitude of the patient, registered nurses should evaluate the patient by observing them to see if the patient has changed his or her practices. Knowledge, attitude, behaviour, and skills are the main elements that can be evaluated in order to appropriately evaluate the patient’s learning process.
References
Iowa Intervention Project. (1996). Nursing interventions classification (NIC) publications: An anthology. Iowa City, Iowa: Center for Nursing Classification, College of Nursing, University of Iowa.
Karp, G. (2009). Life on wheels: The A to Z guide to living fully with mobility issues. New York, NY: Demos Health.
Molnar, J. (2005). Nutrition and Wound Healing. London: CRC Press.
Storch, J. E., & Rice, J. (2005). Reconstructive plastic surgical nursing: Clinical management & wound care. Oxford, UK: Blackwell Pub.
Olson, L. (2012). PART 12: PRESSURE ULCERS. Nursing Care of the Hospitalized Older Patient, 56.
