INTRODUCTION:
The Nursing Process is defined as a process that is applied to patient care in which those that are involved in the care of the patient, planned how to deliver the nursing care to that particular client. The nursing process consists of five stages or steps.
They include Assessment, Diagnosis, planning, implementation and evaluation.
This essay with be based on an adult female client by the name of Sarah, and age 50years old, who was rushed to the emergency department of the Phebe hospital with a history of generalized body pain, fever, weakness and decrease appetite for two days.
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She was placed in the short stay of the facility to do her vital signs and order her laboratory exams. The following vital signs were taken and recorded: Temperature, 38.6-degree census, pulse, 80b/m, Resp. 19c/m and blood pressure, 140/90hmm/mm.
Labs exam that was ordered are Malaria Test, HGB, U/A, RBS and Stool for the emergency findings, while the doctor on the call was Informed.
- ASSESSMENT
A stage of the Nursing Process involves the collection of information called data relating to the patient and their health needs.
This information collected during the assessment of a patient is gathered from the patient, relatives, carers, or from referral notes from another health facility.
After all the information and the lab results helped, the Doctor on call to diagnosed Sarah with Complicated Malaria as a Medical Diagnosis.
I referred to the patient’s case notes, which contained the past medical history, investigations such as LABS results, doctor’s notes etc.
The introduction was made by both the Doctor and me to Sarah and her relatives, in order to establish a therapeutic rapport with the client.
- DIAGNOSIS:
After Sarah assessment which included, data collection, interviewing patient and relative, and Labs results, a Medical Diagnosis were established by the Doctor.
Sarah had numerous signs and symptoms during her data gathering that a nursing diagnosis could be developed such as Fever, mobility, and generalized body pain, which could affect the activity of daily living
However, I was able to develop two nursing diagnoses as a working tool.
- In mobility as it relates to the generalized body pain
- Increased temperature as evidenced by fever.
In the diagnostic phase, information is processed, classified, interpreted, and validated. This process helps to manage the large volume of data gathered during the assessment.
Diagnosis helps the nurse to report the findings to the health care team and work collaboratively with each other to resolve the patient problem.
Note the difference between the Medical Diagnosis and Nursing Diagnosis, while preceding the next step of the Nursing Process which is planning.
- PLANNING
The planning phase of the nursing process is to develop a plan of care and determine which techniques should be applied to help you identify the problem.
Setting priorities, writing goals and planning nursing action. The care plan should be prepared for all patients. This is to be used as a guide and had to be individualized per each client and their need.
However, it presents an opportunity for a care plan to become less individualized and be used correctly, which could have an effect and defend objectives.
In Sarah, case goals were set to increase movement, in order to reduce the body pain caused by the malaria parasite. A care plan usually determines the outcome of the patient and discharge plan.
The nursing care plans must be realistic and achievable, they must be set in relationship with the patient.
In order to keep Sarah to be part of her care, goals were set up and agreed with her and it also gives Sarah a clear view of what with be expected of her during the period of her stay in the hospital.
- IMPLEMENTATION
Implementation is “the stage of the Nursing Process in which the patient care plan is utilized and executed in collaboration with the other team members of the health care.”
The daily shift report turned over at the end of every shift was a good source of information sharing that indicated whether Sarah care was being given as planned.
Most often nurses do not have enough time to read the charts and look up for common problems during the shift but can be identified within the turned over notes.
I was able to find out that a nurse could make a meaningful and valuable contribution to the care of the patient.
Sarah care plan and chart was kept at the Nursing station in the patient cabinet for reference purpose. I also observed that which care given overlaps the next steps in the Nursing Process.
- EVALUATION
The final stage in the Nursing Process, which occur continuously during the procession of the care.
Evaluation refers to the outcome of the goals, reassessment, and documentation relating to specific goals in the Nursing Process.
At the end of the treatment client feels confident in moving around, she was also observed with normal body temperature at the end of the treatment plan. This stage involved re-assessment of Sarah’s support system and activity of daily living.
Sarah recovered and the discharge plan was discussed with her along with her relative. Follow up details were given to her. The treatment plan was discontinued.
CONCLUSION:
The nursing process as a way of gathering information to help you know the patient as a whole person and not just to focus on their presenting illness is found within holistic care.
Holistic care is very important in the Nursing Process. Holistic care requires regular ongoing assessment and patient-centred involvement to highlight the essence of the care.
Cooperation and collaboration between the therapeutic team, which enhance the care properly and yield a good prognosis.
Maximum communication was maintained among the therapeutic team. Sarah appreciated the team members of the medical ward on how she was treated and enjoyed her stay during her hospitalization. A follow-up visit and health education on how to prevent malaria and clean her environment properly were done.
REFERNCES
- Taylor C.R, Lillis C. Lemone p. and lynn P. (2011). Fundamentals of Nursing: The art and science of Nursing care (7th Ed.)
- Jarvis, C. (2008) physical examination and health assessment (5th Ed).
- Potter Perry: Fundamentals of Nursing third edition
- Spark Ralph, S. AND Taylor, C M. (2011) Nursing Diagnosis Manuel (8th ED)
- Lemon, P. and BURKE, K. (2011) Medical-Surgical Nursing (5th ED)
- ALfero-Lefevre R ( 1998) Nursing Process; A step by step guide 4th ED.
