Why Nursing Care Plan and Nursing Process is Important.
Nursing Process(ADPIE).
Nursing Process is systematic, rational method of planning and providing professional, quality nursing care.
Directs nursing activities for health promotion, health protection, and disease prevention.
The nursing process is used to identify, diagnose and treat human responses to health and illness.
Main goals of nursing process is :
1. To identify a client's health care stutus and actual or potential health problems.
2.To establish plans to meet the identified needs.
3.To deliver specific nursing interventions to address those needs.
Nursing process is based on Critical thinking,
For the successful application of Nursing Process, the nurse integrates elements of critical thinking to make
judgments and take actions based on reason.
Critical thinking as a process of objective reasoning and analyzing facts to reach a valid conclusion,
is the major core integral part of professional accountability and quality nursing care.
Role of critical thinking in nursing process.
Critical thinking help allow nurse to:
A. identify client's health problems
B. Enable nurses to determine which problems necessitate.
C. Collaboration with physician and which are independent to nursing.
d. select appropriate nursing intervention for achieving predictable outcome.
The Nursing Process includes the following five steps:
1. Assessing.
2. Diagnosing.
3. Planning.
4. Implementation or intervention
5. Evaluating.
“ A - D - P - I - E ”.
1. Assessment
During assessment nurse collect all subjective and objective data ,
This includes things like taking vital signs, completing the nursing head to toe assessment,
getting the patient's history, and gathering any other type of objective or subjective data.
Types of Data
Objective data: Thing that can you seen( such as blood pressure, Bruises, Cardiac Rhythms, Tremors).
Subjective Data: thing that can't see ( such as pain, emotions, Itching).
Ask yourself a few questions to help guide your critical thinking process:
1. Do these signs and symptoms seem to be pointing toward one cause? Or multiple causes?
2. If that one cause (or multiple causes) were the case, what do I need to assess for further to get more information?
3. Did the patient say anything, or do I see anything, that may require follow up questions or further assessment?
4. What am I missing or forgetting to ask or do?
2. Diagnosis
The nursing diagnosis is the patient's response to what is happening.
Nursing diagnoses are standardized by NANDA, Always choose appropriate nursing diagnoses for your specific patient.
This means that the nursing diagnoses you pick should always match you patient.
3. Outcome identification:
Some nursing programs have "Outcome Identification" as part of the nursing process that you'll learn.
Outcome identification simply means that you are identifying goals for your patient.
All patient goal should follow the "SMART" framework This means that each goal select should be,
S: Specific.
M: Measurable
A: Achievable
R: Relevant
T: Time bound
4. Planning.
The planning step of the nursing process is where you decide how you will help the patient reach their goals from the previous step.
this planning step is all about what you will do as the nursing student or nurse.
Where the outcome identification step is all about what goals the patient has.
5. Implementation.
The implementation step is about taking action
You'll follow through with what you had planned out in the previous step.
This could be doing things like an intervention, educating the patient, completing a skill, or reassessing.
Evaluation.
in this step nurse student or nurses evaluate whether or not the patient met their goal and what needs to change for the future .
this is basically a reassessment of you patient and their plan of care.
Characteristics of Nursing Process.
1. Based on knowledge-requiring critical thinking ,
2. planned, organized and systematic ,
3. client- centered.
4. Goal-directed,
5. Prioritized,
6. Dynamic.
Main purpose of nursing process are:
1. To identify a client’s health status and actual or Potential health problems or needs.
2. To establish plans to meet the identified needs and deliver specific nursing interventions to meet those needs,
3. To provide holistic - individualized care for the client.
NURSING CARE PLAN TEMPLATE
Case study:
JOHN is male of 32 years old he live in Rwanda, kicukiro district , Kigarama sector, Rwampara cell, Ubumwe village.
He is masonry assistant, still single and lives alone at home. He is sick since one week and is brought by his relatives to the Hospital.
He is admitted in medical ward in a District hospital and presents the following symptoms:
On physical examination and full assessment you notice the following:
- Vital signs (Body temperature:39ᵒc, BP:70/40mmHG,Pulse:104Beats/min, RR:48Breaths/min and spo2 : 80%,pain score 4/10
- Loss of both motor and sensory function of both lower limbs(Paraplegia)
- Crackles in the basis of both the lungs by auscultation
- Necrotic skin wounds around the scapula, heels and coccyx due to unchanged position that he developed at home
- Poor hygiene and foul smell from his dirty clothes.
On the case we have different nursing diagnosis but when you are going to prepare nursing plan of care you have to use priority
the nursing diagnosis may be you can choose according to priority based on different approach that are available in nursing professional
such as Virginia Henderson, ABCD approach or other.
| DATE | NURSING ASSESSMENT | NURSING Diagnosis | NURSING PLANNING | IMPLANTATION | RATIONAL | EVALUATION | name of health care provider |
24/10/ 2024 | subjective data Physical weakness, fever, involuntary loss of urine, productive cough, difficulty in breathing pain score 4/10 objective data Vital signs Body temperature:39ᵒc, BP:70/40mmHG, Pulse:104Beats/min, RR:48Breaths/min Spo2: 80% Loss of both motor and sensory function of both lower limbs(Paraplegia) Crackles in the basis of both the lungs by auscultation Necrotic skin wounds around the scapula, heels and coccyx due to unchanged position that he developed at home Poor hygiene and foul smell from dirty clothes | ineffective breathing pattern related to lung crackles as evidenced by the RR of 48 B/minutes | restoration of respiratory rate from 48 beat/ minutes to 18 beat per minute with in 40 minutes. | place patient in semi-flowery position apply the oxygen therapy therapy
| we place the client in semi-sitting position with purpose of facilitating the lung or ventilation we apply the oxygen therapy with the purpose of facilitating the lung function | After 40 minutes the respiration rate has restored in the normal range of\ 18 beat/ minutes after 40 minutes the spo2 is 96%. | RN/ student nurse name of care provider signature |
24/10/ 2024 | subjective data Physical weakness, fever, involuntary loss of urine, productive cough, difficulty in breathing pain score 4/10 objective data Vital signs Body temperature:39ᵒc, BP:70/40mmHG, Pulse:104Beats/min, RR:48Breaths/min Spo2: 80% Loss of both motor and sensory function of both lower limbs(Paraplegia) Crackles in the basis of both the lungs by auscultation Necrotic skin wounds around the scapula, heels and coccyx due to unchanged position that he developed at home Poor hygiene and foul smell from dirty clothes | Acute Pain related to pressure ulcers
as manifested by pain score of 4/10 | relieve pain from 4/10 to 0/10 within 30 minutes | Administer prescribed medication | I give him that medication
in order to relive pain | after 30 minutes the client john has no pain | RN/ student nurse name of care provider signature |
24/10/ 2024 | subjective data Physical weakness, fever, involuntary loss of urine, productive cough, difficulty in breathing pain score 4/10 objective data Vital signs Body temperature:39ᵒc, BP:70/40mmHG, Pulse:104Beats/min, RR:48Breaths/min Spo2: 80% Loss of both motor and sensory function of both lower limbs(Paraplegia) Crackles in the basis of both the lungs by auscultation Necrotic skin wounds around the scapula, heels and coccyx due to unchanged position that he developed at home Poor hygiene and foul smell from dirty clothes | Risk for Infection
related to necrotic skin wounds, poor hygiene, and foul smell from dirty clothes. | prevention of infection within 2 week | improving personal hygiene and wound hygiene | i will increase personal hygiene with the purpose of preventing self contamination and increase wound hygiene and also the apply wound dressing by promoting
prevention of infection | in progress | RN/ student nurse name of care provider signature |
subjective data Physical weakness, fever, involuntary loss of urine, productive cough, difficulty in breathing pain score 4/10 objective data Vital signs Body temperature:39ᵒc, BP:70/40mmHG, Pulse:104Beats/min, RR:48Breaths/min Spo2: 80% Loss of both motor and sensory function of both lower limbs(Paraplegia) Crackles in the basis of both the lungs by auscultation Necrotic skin wounds around the scapula, heels and coccyx due to unchanged position that he developed at home Poor hygiene and foul smell from dirty clothes | Impaired Skin Integrity related to prolonged bed rest as evidenced by necrotic skin wound around scapula | promote wound healing with in 2 week | apply wound dressing and promote of nutrition and wound hygiene | apply wound dressing in order to prevent infection and bleeding of wound by facilitating wound healing | Reaassessment after 2 week ( in progress ) | RN/ student nurse name of care provider signature |
This case study contain different nursing diagnosis , i was choosing this and now
you can test your self to the remaining diagnosis and you can formulate nursing care plan.
visit our quiz page and test your self.