Category: Writing

Nursing process

Order Instructions:

using APA format, the information from this course, and your assigned readings write a six (6) to ten (10) page paper (excludes cover and reference page) addressing the application of the nursing process to a patient care scenario. Use these directions and the scoring rubric as you develop the paper. Outlines and abstracts are NOT required with this paper. Do not include the scenario in the paper
A minimum of three (3) current professional references must be provided excluding a nursing diagnosis book. Current references include professional publications or valid and current websites dated within five (5) years. Additionally, a textbook that is no more than one (1) edition old may be used. Do not use abbreviations…write out everything.

The paper consists of three (3) parts:
1. The meaning and use of the nursing process in making good nursing judgments that effect patient care
2. The development of a plan of care using the nursing process for a specific patient situation
3. The preparation stage for a teaching plan to prevent a recurrence of a similar situation
The following sheet will assist you when composing the plan of care for the paper: Overview of the Nursing Process.

Part 1 (3-4 pages)
Review the required readings about the nursing process. In your own words, define each step of the process and provide an example for each step.
In the implementation step, what is meant by direct and indirect care as described by the Nursing Intervention Classification (NIC) project?
Discuss the three (3) types of nursing interventions (nurse-initiated, dependent, and interdependent) that applies to the patient care situation. Provide an example of each (refer to your textbook).
Explain how the nursing process provides the basis for the registered nurse to make a nursing judgment that results in safe patient care with good outcomes.
Discuss how the registered nurse evaluates the overall use of the nursing process. Identify three (3) variables that may influence the ability to achieve the desired outcomes for the patient.
How is the plan of care modified when the outcomes are not met?
How does the RN use the nursing process to make decisions about the priority of care?

Part 2 (3 pages)
Patient scenario
A 78-year-old man is living in an assisted living facility. He is able to walk very short distances and uses a wheelchair to transport himself to the communal dining room. He administers his own medications independently and bathes himself. Over the last year he prefers to remain in the wheelchair even when in his room. He has a history of CHF, hypertension, hyperlipidemia and lower extremity weakness. He is able to state his current medications include metoprolol (Lopressor) 50 mg once daily by mouth, furosemide (Lasix) 20 mg once daily by mouth, Quinapril (Acupril) 20 mg once daily by mouth, atorvastatin (Lipitor) 20 mg once daily by mouth. During a routine examination, his physician noted a pressure ulcer over the ischium on the right buttocks. The wound is oval about 10mm x 8 mm, with red and yellow areas in the middle and black areas on some surrounding tissue. It has a foul odor. The patient had been padding the area so “it doesn’t get my pants wet”. The physician arranged for him to be admitted to the hospital in order for intravenous antibiotic therapy and wound care to be initiated. After being admitted to the hospital his medications are: metoprolol (Lopressor )50 mg orally every 12 hours, furosemide (Lasix ) 40mg once daily by mouth, quinapril HCl (Accupril) 40 mg once daily by mouth, cefazolin (Ancef)1.5 Grams in 50 mL 0.9 % Normal Saline intravenously three times a day. The result of the wound culture identified Methicilin-resistant staphylococcus aureus. After a surgical debridement of the black tissue a SilvaSorb® (antimicrobial gel) dressing was ordered daily.
Develop a Plan of Nursing Care for this patient that includes all steps of the nursing process:
• One (1) actual NANDA-I nursing diagnosis statement addressing the priority problem the patient is experiencing. You need to provide the entire nursing diagnosis statement. For example: Acute pain, related to tissue trauma, as evidenced by patient rating pain at 7 on the 0-10 verbal pain scale. Provide a rationale, with evidence, why this nursing diagnosis is the priority for this patient.
• What is the assessment data that supports the use of this nursing diagnosis? These are the assessments you will collect to determine if the patient has this nursing diagnosis. For example: Will assess the patient’s pain using the 0-10 verbal pain scale.
• One (1) expected outcome (realistic, measureable and contains a time frame). that addresses the diagnosis and meets the criteria for an expected patient outcome. Discuss whether the outcome is a cognitive, psychomotor, affective or physiologic outcome. Discuss why the time frame selected for the evaluative criteria was selected. Use evidence as the basis for the time frame and criteria. You need to be specific to this particular patient. For example: Patient will rate pain at 3 on the 0-10 verbal pain scale. Of course, you would also need to answer the rest of the items in this section.
• Four (4) nursing interventions that includes at least one (1) nurse-initiated, one (1) dependent, one (1) interdependent intervention. Label your interventions as above. Provide a rationale for each intervention that is evidence-based. Lastly, your interventions must be able to move the patient toward the achievement of the outcome. Select interventions, you as the RN can perform, that could reduce the pain and provide the rationale as to why; be sure they are evidence-based. For example: Teach patient guided imagery to distract attention and reduce tension.

Part 3 (1-2 pages)
To assist the patient in preventing a recurrence of a similar incident once he returns to the assisted living environment, the RN needs to develop a teaching plan. Use the nursing process to consider the information the RN would need prior to development of the plan. Respond to the following and be able to support your answers. You will not be developing a teaching-learning plan but demonstrating using the teaching-learning process to prepare for an individualized plan.
• How does the RN decide the format of the teaching plan, i.e., written, verbal, or other?
• How does the RN know which information needs to be included?
• When does the RN determine how and when to evaluate the teaching-learning process?

Compose your work using a word processor (or other software as appropriate) and save it frequently to your computer. Use a 12 font size, double space your work and use APA format for citations, references, and overall format. Information on how to use the Excelsior College Library to help you research and write your paper is available through the Library Help for AD Nursing Courses page. Assistance with APA format, grammar, and avoiding plagiarism is available for free through theExcelsior College Online Writing Lab(OWL). Be sure to check your work and correct any spelling or grammatical errors before you submit your assignment.

You are required to submit your paper toTurnitin(a plagiarism prevention service) prior to submitting the paper in the course submission area for grading.Access is provided by email to the email address on record in your MyExcelsior account during week 2 of the term. Once you submit your paper to Turnitin check your inbox in Turnitin for the results. After viewing your originality report correct the areas of your paper that warrant attention. You can re-submit your paper to Turnitin after 24-hours and continue to re-submit until the results are acceptable. Acceptable ranges include a cumulative total of less than 15% for your entire paper, and no particular area greater than 2% (excluding direct quotes and/or references).
See the videos below for instructions on how to submit your paper to Turnitin and view your Originality Report.
Video – Submitting a Paper
Video – Viewing Your Originality Report
When you’re ready to submit your work for grading, click Browse My Computer and find your file. Once you’ve located your file click Open and, if successful, the file name will appear under the Attached files heading. Scroll to the bottom of the page, click Submit and you’re done.
This activity will be assessed according to the NUR104 M6A3: Application of the Nursing Process

Paper Rubric.
PART 1
The nursing process is a series of organized steps designed for nurses to provide excellent care. They areassessment, diagnosis, planning, implementing, and evaluation. It is a five-part systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health.The nursing process is a scientific method used by nurses to ensure the quality of patient care.

The first phase of the nursing process is assessment, which consists of data collection by such means as interviewing, physical examination, and observation. It requires collection of both objective and subjective data. During this phase, the nurse gathers information about a patient’s psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to gather assessment data. Patient interaction is generally the heaviest during this evaluative phase.

Nursing diagnosing is the second phase in the nursing process, a clinical judgment about individual, family, or community nursing responses to actual or potential health problems/life processes. Provides the basis for selection of nursing intervention to achieve outcomes for which the nurse is accountable (NANDA, 1990);the diagnosing phase involves a nurse making an educated judgment about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These assessments not only include an actual description of the problem (e.g. sleep deprivation) but also whether or not a patient is at risk of developing further problems. These diagnoses are also used to determine a patient’s readiness for health improvement and whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment. Nursing diagnoses are different from medical diagnoses because they address patient problems that result from the disease process while medical diagnoses focus on the disease process alone.
The third phase of the nursing process is planning, which requires establishment of outcome criteria for the client’s care.Once a patient and nurse agree on the diagnoses, a plan of action can be developed. If multiple diagnoses need to be addressed, the head nurse will prioritize each assessment and devote attention to severe symptoms and high risk factors. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. For this phase, nurses generally refer to the evidence-based Nursing Outcome Classification, which is a set of standardized terms and measurements for tracking patient wellness. The Nursing Interventions Classification may also be used as a resource for planning.

Implementing is the fourth phase of the nursing process). This phase involves demonstrating those activities that will be provided to and with the client to allow achievement of the expected outcomes of care.The implementing phase is where the nurse follows through on the decided plan of action. This plan is specific to each patient and focuses on achievable outcomes. Actions involved in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for follow-up. Implementation can take place over the course of hours, days, weeks, or even months.

Evaluating is the fifth and final phase of the nursing process. It requires comparison of client’s current state with the stated expected outcomes and results in revision of the plan of care to enhance progress toward the stated outcomes.Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine of the goals for patient wellness has been met. The possible patient outcomes are generally described under three terms; patient’s condition improved, patient’s condition stabilized, and patient’s condition deteriorated, died, or discharged. In the event the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step.

An Example of the Nursing Process

Assessment

A patient visits his general physician on Monday because he was feeling sick over the weekend. When he is called back from the waiting room, the nurse on staff takes his temperature, heart rate, and blood pressure. She then asks the patient a series of questions about how he’s been feeling lately. The nurse notes his responses when he says he’s been having difficulty breathing and has been feeling very tired. She also sees on the patient medical history that he has had previous problems with his cholesterol levels and blood pressure. The patient also has a blood sample taken during his doctor’s visit.

Diagnosis

The nurse looks over patient’s symptoms and notes that his heart-rate is higher than average and his blood pressure is elevated. She also considers that he’s experienced fatigue and shortness of breath before when his cholesterol levels were very high. The nurse determines that the patient is experiencing Hyperlipidemia, also known as having high levels of fat within the blood. John’s blood tests confirm this hypothesis. The nurse is also concerned that the patient is at risk for heart disease.

Planning

The patient returns on Tuesday for a follow-up visit. The nurse sits down with him in a closed room and explains his cholesterol levels and high blood pressure. She suggests that the patient be put on medication to help lower these numbers and recommends he exercise at least twice a week. The nurse also tells the patient he should stay away from salty foods and eat less red meat. John agrees with the nurse, and they setup a follow-up appointment two weeks later. The nurse reminds the patient to call if there are any changes in his condition, or if he starts to feel worse.

Implementation

the patient is prescribed the medication and takes it as recommended. One week later, he has a day where he feels especially sick and calls the doctor’s office. The nurse explains that the medication could cause it, stomach. The patient continues taking the medication and goes to the gym four times during the two week period. Once the two weeks has passed, he returns to the doctor’s office for his follow-up appointment.

Evaluation

When the patientreturns, a series of questions about how he’s been feeling areasked.The patient replies that he has been having easier time breathing and feels significantly less tired since exercising and taking the medication. The nurse marks “Patient’s Condition Improved” on his official medical records and congratulates the patient on his wellbeing. She then advises him to remain on the medication for one more month and to continue his exercise.

In the implementation step, what is meant by direct and indirect care as described by the Nursing Intervention Classification (NIC) project?
According to the American Association of Critical-Care Nurses Delegation Handbook, direct patient care refers to activities that “assist the patient in meeting their basic needs.” Indirect patient care refers to activities that “focus on maintaining the environment in which nursing care is delivered and only incidentally involves direct patient care.” There is a fine line between these two care providers and it is important to note that each situation is different.With Direct Patient Care, the caretaker takes patient vital signs, including blood pressure, respiration, temperature, pulse rate,and patients’ daily weightare Measure and record, Patient’s intake and output are also taken. The care taker Help patients through daily living activities, such as bathing, shaving, and brushing teeth, Change patient bedding and clothing Feed patients and calculate daily calorie intake. Assess and assist patients with mobility… Indirect Patient Care involvescleaning any medical equipment used by the patient Clean the patient’s home environment Preparefood or deliver meal trays. Taking any patient specimens to clinical laboratories, making phone calls, assembling patient care orders and scheduling appointments. Stock patient supplies Stocking patient supplies can apply to room, utility, and other supplies since indirect care providers often work at assisted living homes.
Discuss the three (3) types of nursing interventions (nurse-initiated, dependent, and interdependent) that applies to the patient care situation. Provide an example of each (refer to your textbook).

Nursing interventions are the actual treatments and actions that are performed to help the patient to reach the goals that are set for them. The nurse uses his or her knowledge, experience and critical thinking skills to decide which interventions will help the patient the most. There are different classifications of nursing interventions that can involve care of the entire patient. This can be anything from promoting bowel functioning, educating the patient on new medication side effects or just keeping the patient safe. Interventions can be focused on basic physiological needs, complex physiological needs, behavioral functioning, promoting safety, caring for the family, using the health system and/or the overall health of the community. As nurses we are caring for the total patient, so there can be interventions concerning every area of the patient’s life.

Some of the nursing interventions will require a doctor’s order and some will not. There are different types of interventions: independent, dependent and interdependent. Let’s learn about each and go over a few examples. Independent are actions that the nurse is able to initiate independently. The following would be an example of a health promotion nursing intervention, which is an independent nursing action. Dependent interventions will require an order from another health care provider such as a physician. For example the patient’s blood pressure is consistently 180/100. The nurse reports this to the physician. The physician orders an antihypertensive medication for the patient. The nurse administers the oral medication to the patient as ordered.interdependent are actions that

Are going to require the participation of multiple members of the health care team. For example the patient reveals to the nurse that she consumes a diet very high in sodium. The nurse includes diet counseling in the patient care plan. To help the patient even more, the nurse enlists the help of the dietician that is available in their facility to spend time with the patient to educate her on the role that diet plays in the control of high blood pressure

How is the plan of care modified when the outcomes are not met?
Ongoing assessment is the key of the plan of care modification. Evaluation, which isthe last phase of the nursing process, follows implementation of the plan of care;it’s the judgment of the effectiveness of nursing care to meet client goals based on the client’s behavioral responses. Evaluating is a planned, ongoing, purposeful activity in which clients and health care professionals determine the client’s progress toward achievement of goals/outcomes and the effectiveness of the nursing care plan. Evaluation is continuous; it isdone immediately after implementation to make on the spot modifications in an intervention. Evaluation is performed at specified intervals. Evaluation continues until the client achieves the health goals or discharged from nursing care. Evaluation includes goal achievement &self-careabilities. ThroughEvaluation, Nurses demonstrates responsibility and accountability for their actions indicate interest in the results of the nursing activities. Process of Evaluating Client Response, Collecting data related to the desired outcomescomparing the data with outcomes andrelating nursing activities to outcomes. Drawing conclusions about problem status Continuing, modifying, or terminating the nursing care plan. When determining whether a goal has beenachieved, the nurse can draw one of the possible conclusions; The goal was met, that is the client response isthe same as the desired outcomes; The goal was partially met, that is either a short-term goal was achieved but the long term was not, or the desired outcome was only partiallyattained.–The goal was not met. Relationship of Evaluation to Nursing Process. When goals have been partially met or when goals have not been met, two conclusions may be drawn: the care plan may need to be revised, since the problem is only partially resolved, OR the care plan does not need revision, because the client merely needs more time to achieve the previously established goals. So the nurse must reassess why the goals are not being partially achieve and thus modified the plan of care.

How does the RN use the nursing process to make decisions about the priority of care?
Prioritizing patient care is the key in health care field. Triage decision making is an essential skill for nurses. Through initial assessment, a nurse must be able to prioritize patient care on the basis of appropriate decision making. the Triage Decision-Making Inventory, measures the identification of critical thinking, cognitive characteristics, intuition, and experience when making triage decisions .decision making is an essential skill for nurses who provide direct patient care or supervise nurses in both acute care and community settings. Anticipating and immediately identifying potential problems are part of the assessment phase of the nursing process. Triage is prioritizing care and making decisions on the next best steps or interventions. The general assumption is that triage occurs in the emergency room setting, but in actuality prioritizing care is performed in all clinical or community care setting.
PART 2
Impaired tissue Integrity related immobility as evidence bythe presence of pressure ulcer over the ischium on the right buttocks.
Rationale: The patient sits most of the time on the wheelchair even when in his room. This put a lot of pressures on the ischium which may lead to poor perfusion of the skin at the site follow by maceration and skin break down.
Assessment: The nurse will assess the skin over the ischium at the buttocks.

Outcome: Patient will display no wound over the ischium of both buttocks after eight weeks of treatment.
Interventions:
Patient will be repositioned by self or by staff every two hours to relief pressure from the decubitus/interdependent
Dressing will be changed as ordered and as needed to promote healing and comfort/independent
Pain medication will be administered as ordered/independent
The nurse will inspect wound daily for changes (eg sign of infection, complications, or healing).
Provide or encourage optimum nutrition (including adequate protein ,lipids, calories) to promote tissue healing and adequate hydrate to reduce and replenish cellular water loss and enhance circulation
• How does the RN decide the format of the teaching plan, i.e., written, verbal, or other?
• How does the RN know which information needs to be included?
• When does the RN determine how and when to evaluate the teaching-learning process?

Patient teaching is a function of nursing and a legal requirement of nursing personnel. In some states teaching is included in the legal definition of nursing, making it a required function of nursing personnel by law.. The patient should trusts the nurse to have the required knowledge and skills to teach, and the nurse respects the patient’s ability to reach the goals. This relationship is enhanced by communication that is continuous and reciprocal, once mutual trust and respect have been established. The goal of patient teaching is the patient’s active participation in health care and his compliance with instructions. Once the nurse begins instructing a patient (or family/support persons), the teaching process should continue until the participants reach the goals, change the goals, or decide that the goals will not help meet the learning objectives. The nurse should Use all appropriate sources of information ,and Review the patient’s medical records. The nurse should Read the history of medical problems as well as diagnoses, physical examinations, documentation of the nursing assessment, and the nursing interventions that have been performed. The patient and the family or support persons are the best source of needs assessment information. Identify the knowledge, attitude, or skills needed by the patient or family/support persons. Learning can be divided into three domain, cognitive, affective, and psychomotor. Assess emotional and experiential readiness to learn. Assess the patient’s ability to learn. The teaching approach must be appropriate to the developmental stage of the learner. The nurse should assess the patient’s intellectual development, motor development, psychosocial development, and emotional maturity. Chronological age does not guarantee maturity. Identify the patient’s strengths. Learning strengths are the patient’s personal resources such as psychomotor skills, above-average comprehension, reasoning, memory, or successful learning in the past.. Use anticipatory guidance. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When patients know what to expect, anxiety is reduced and they are able to cope more effectively. . Diagnose the Learning Needs, and Be realistic.. Confirm your diagnosis with the family. In addition, assess your own knowledge base and teaching skills. Planning ensures the most efficient use of your time and increases the patient’s chances for learning. Create a teaching plan. One nurse or several nurses can prepare and use a teaching plan. There are standardized teaching plans available for major topics of health teaching (some for computer use). Individualize the standardized plans to the patient’s needs and abilities.

Match content with the appropriate teaching strategies and learner activities. For example, content explaining why certain treatments and medications are needed may be matched with printed or audiovisual materials. Children respond well to teaching strategies that permit them to participate actively. Schedule teaching within the limits of time constraints.Shorter, more frequent sessions allow the patient to digest the new information and prevents him from becoming tired or uncomfortable due to his illness. Decide on group or individual teaching and formal or informal teaching. Some learner objectives are met more readily in a one-to-one encounter (i.e., colostomy care) while others are met more easily in a group discussion with other patients that have similar problems. Formal teaching is the planned teaching done to fulfill learner objectives. Informal teaching occurs during nursing interactions with the patient and his family. Informal teaching often leads to planned, formal sessions. Formulate a verbal or written contract with the patient. The contract is informal and is not legally binding; however, such an agreement serves to motivate both the patient and the nurse to attain the learning objectives. It points out the responsibilities of both the nurse (teacher) and the patient (learner). Whether verbal or written, the contract should not be intimidating, but viewed as an aid to learning. Failure to meet contracted objectives should be redirected into new learning and decision-making situations. Implement the Teaching Plan. The implementation phase may be only a few minutes or the sessions may extend over a period of days, or perhaps months. Use interpersonal skills as well as effective communication techniques. Do not use technical and medical terms unless the patient has a medical background, but avoid a condescending attitude. Your attitude has a greater effect on the patient than any other factor. If the patient must learn special techniques or procedures, tell him or her that it takes time and practice to perform these new skills confidently. Review the contractual agreement before implementing the teaching plan
With chronic disease management being very complex, we often skim over the values of patient teaching in our nursing education. This is despite the fact that patient teaching and education are essential components of the nursing process (Jones, 2002). Data indicates that when patients are provided with a solid knowledge base about their disease process and treatment, the outcome is more favorable (Boswell, 2007).
In order to teach, the nurse must first have an understanding of the patient education process. The following are part of this process:
Assessment. The nurse must first identify the patient’s needs. In this initial process, she must identify the needs and the problems of an individual patient and his/her family.

Planning and diagnosing. Based on this assessment of the patients needs, the nurse then formulates a diagnosis and treatment plan. It should be tailored to the patient’s needs and educational level. The end product of this assessment is a diagnosis which will serve as a guide for treatment. This diagnosis is a sound judgment based on data and information (Rankin, 2001).
In the hospital, it is especially important for nurses to begin patient teaching at the time of admission. It is equally important to document this teaching for evaluation and reimbursement purposes. However, in the acute care setting, nurses often report feeling that they do not have enough time for it.
The following is a list of strategies that promote the incorporation of teaching into daily nursing practice:
Emphasize what is necessary. In the inpatient setting, many patients fear losing their independence (Jones, 2002). Patients will be motivated to learn what is necessary for them to care for themselves; therefore nurses should emphasize these strategies.
Choose the right time. Remember that when teaching, timing is crucial. For instance, if the patient has just been informed of a diagnosis, he or she will need time to cope with this information. There might be associated feelings of grief, powerlessness, fear, and vulnerability (Jones, 2002). These will cloud the ability to learn.
Look for teaching moments. Like choosing the right time for teaching, it is equally important to look for teaching moments. Imagine caring for a patient with end-stage renal disease. A teaching moment would be when the patient receives his tray and there is only a small amount of fluid. In this situation the nurse could ask, why is it important for you to monitor your fluid intake? Plan teaching during an uninterrupted time. When teaching the patient, timing is crucial. It is not appropriate to fit everything into the day of discharge. Similarly, it would not be appropriate to provide complex lessons during meal time or visiting hours.Use basic principles. It is important to consider the educational level of the patient when teaching. After all, not everyone has had a nursing education. Some patients might not be able to understand complex medical jargon. They may even be illiterate and are unable to read handouts.
Evaluate the senses. Nurses must evaluate the patient’s ability to see and to hear. For example, if a patient has difficulty seeing, it might not be practical to give her a handout on disease management. If the patient has difficulty hearing, it might not be appropriate to guide her with verbal instructions.Keep expenses in mind. Many patients, especially elders, live on a fixed income. Therefore, it might not be practical to recommend that they join a fitness center as a means of weight reduction. When recommending a glucometer for the diabetic patient or a scale for the dialysis patient, it is important to consider the cost of each one. Clearly define goals and objectives. Before beginning, it is important to have a list of goals and objectives that are formulated by the patient and the nurse. The significance of these should be understood by each person, and they should be evaluated on a continuous basis. Remember to document. When teaching a new skill, documentation is important. This allows the incoming nurse or a nursing assistant to see what has been done and where she should start. Likewise, if the patient has difficulty with a certain skill or needs certain assistance, this should be recorded so that accommodations or further instruction can be provided.

Patient education requires that the nurse think critically. No longer are we simply responsible for administering medications and communicating with physicians. We also play a dynamic role in assuring that the patient is able to be independent in managing his disease.
In essence, we are nurse educators. After all, teaching is a vital component of the nursing process. However, the process is not uniform in nature. In order to promote learning, it is valuable to keep these proposed strategies in mind. And as part of our nursing education about the values of patient teaching, we have to remember that the patient population is indeed heterogeneous.

Evaluation, the last phase of the teaching process, is the ongoing appraisal of the patient’s learning progress during and after teaching. The goal of evaluation is to find out if the patient has learned what you taught.
Here are some ways you can evaluate learning:Observe return demonstrations to see whether the patient has learned the necessary psychomotor skills for a taskAsk the patient to restate instructions in his or her own wordsAsk the patient questions to see whether there are areas of instruction that need reinforcing or re-teaching,Give simple written tests or questionnaires before, during, and after teaching to measure cognitive learning Talk with the patient’s family and other health care team members to get their opinions on how well the patient is performing tasks he or she has been taughtAssess physiological measurements, such as weight and blood pressure, to see whether the patient has been able to follow a modified diet plan, participate in prescribed exercise, or take antihypertensive medication Review the patient’s own record of self-monitored blood glucose levels, blood pressure, or daily weights Ask the patient to problem solve in a hypothetical situation.Your documentation of patient teaching should take place throughout the entire teaching process. Documentation is done for several purposes. Documentation promotes communication about the patient’s progress in learning among all health care team members. Good documentation helps maintain continuity of care and avoids duplication of teaching. Documentation also serves as evidence of the fulfillment of teaching requirements for regulatory and accrediting organizations such as the JCAHO, provides a legal record of teaching, and is mandatory for obtaining reimbursement from third party payers. Documentation of patient teaching can be done via flow-charts, checklists, care plans, traditional progress notes, or computerized documentation. Whatever the method, the information must become a part of the patient’s permanent medical record. Table 6 shows suggestions on what to document and how.

References

http://www.briarcliffe.edu/student-life/briarcliffe-blog/october-2013/healthcare-fields-direct-indirect-patient-care

http://www.nursingprocess.org/Nursing-Process-Example.html

http://study.com/academy/lesson/what-is-nursing-intervention-definition-examples.html

http://www.brooksidepress.org/Products/Nursing_Fundamentals_II/lesson_7_Section_2.htm

http://www.nursetogether.com/guide-patient-teaching-and-education-nursing#sthash.ZCuuWZqb.dpuf

SAMPLE ANSWER

 Nursing process

Part 1

Nursing process

The nursing processes are series of nursing steps designed to help the nurses provide quality care. The nursing processes are five part system used to make decisions that pertains with the identification of health complication and treatment process. These systems include diagnosis, planning, implementation, as well as evaluation. These processes are scientific and are evidenced based practice. The first step is the assessment step (Bruylands et al., 2014). This consist collection of patient’s information relevant to diagnosis, carried out using various approaches such as physical assessment, interviews, as well as observations. This involves the assessment of patient’s psychological, sociological, spiritual, and physiological status. For instance, when a patient visits a physician due to abnormal body functioning (Flemming, 2014). The registered nurse checks the patient’s heart rate, blood pressure and the body temperature. The patient is health assessment is done to identify the patient cultural and traditional values; nutritional process and lifestyles are investigated. During this stage, the blood samples are taken to the laboratory for further analysis of the patient health condition (Gratti, 2013).

The second phase in nursing process is the nursing diagnosis. This involves clinical judgment about the patient, about the potential health complication that the patient could be suffering. This is done using the health assessment, and is the basis that guides selection of nursing intervention. In this phase, the nurses are expected to make ethical judgment regarding the potential health complication. In some cases, the nurse can make multiple diagnoses in one patient. The stage is important because it helps the identification of the issue at concern, thus preventing risk of further complication. The diagnosis is also done to assess patient readiness for treatment. For instance, the registered nurse looks into the patient’s signs and symptoms. The nurse evaluates the alteration of the patho-physiology and risks of developing associated diseases.

The next nursing process phase is the planning stage. This stage involves the establishment of the care strategies and the outcome criteria for the patient care. The development of the plan action involves the prioritization the care plans and more attention and efforts are devoted to high-risk diseases and factors. Each healthcare problem is assigned a clear as well as measureable goal for the expected beneficial outcome. In this phase, the nurses are required to apply the evidence based nursing outcome classification (set of standards as well as measurements for tracking disease wellness of the patient) (Fee and Bu, 2010). Nursing intervention classification can be applied during the action phase. The Maslow’s hierarchy of needs is often used during the action planning of care. For instance, the patient pharmacological and non-pharmacological therapeutic processes are identified, the criteria of the administration is established as outlined by the evidence-based practice.

Implementation phase is the fourth stage of nursing process. The stage involves demonstration of activities that will be given to the patient, with the aim of improving their health. This includes actions such as monitoring of patients to check for indicators of improvement, providing direct care to the patient, medical tasks, education, and health management of the patient such as follow up clinics. This could take days, weeks, and months (Mori 2014).

The last nursing process phase is the evaluation phase. This involves comparison of patient’s current state of health in comparison with the expected outcomes. The findings indicate whether the patient care plan will be revised or not (Dailly, 2011). For instance, the patient can be asked to answer a series of questions, have the symptoms been relieved, and have the patient condition improved from the last time. If the care plan is successful, the patient is advised to continue with care, as the registered nurse advices the patient on self-management strategies (Bernard, Hunter, & Moore, 2012).

Direct patient care as described by the American Association of critical care nurse’s delegation handbook includes activities that help the patient their immediate needs. On the other hand, indirect care refers to the activities that that focus in the maintenance of the environment where nursing care is delivered. Literature indicates that there is a thin line between the care providers, but the registered nurse should not the differences (Kee et al., 2009). For instance, with direct patient care, the healthcare provider will take the patient   vital signs such as blood pressure, temperature, and patient’s daily weights. Direct care also involves taking daily activities such as brushing teeth and bathing. Changing patient beddings, feeding patients, and the calculation of weight are among the direct care. Indirect patient care will involve activities of cleaning equipments, taking patient specimens to the laboratories, phone calls, and communication, and the scheduling of appointments. Additionally, patients supplies stock, utility, supplies and other indirect care that is used to assist living homes (Olson-Sitki, Kirkbride, & Forbes, 2015).

Types of nursing interventions

Nursing interventions refers to the actual actions and treatments conducted to facilitate the patient achieve the goals set for them. The registered nurses use their experience, critical thinking skills and knowledge, which aids the registered nurse deliver quality care. There are various types of nursing interventions classified in to three broad categories, dependent, interdependent, and independent intervention (Kehrel, 2015). The interdependent intervention is nurse action plan that are implemented through teamwork. This includes consultations between healthcare providers during the decision making process. Dependent interventions   are the strategies which as directed by the healthcare providers with higher authorities than the registered nurses. These include activities termination patients or referral process. Independent interventions are all activities implemented by registered nurses, and do not require consents from the physician or other practitioners (Nazarko et al., 2010).

Modification of care plan where outcomes have not been met

Continuous assessment should be conducted to ensure that the outcomes are met. This process is known as evaluation and is the last stage of the nursing process. This is done to ensure that the implementation plan of care, nursing diagnosis and assessment process meet the nursing care goals. Evaluating care is an ongoing purposeful practice the healthcare professionals determine the effectiveness of action plan (Doenges et al., 2013).This is done to evaluate the intervention effectiveness. It is the only to evaluate the responsibility and accountability of the nurse’s actions. The nursing process helps the nurses identify the main challenge in the patient’s body. The process helps the identification of etiology and facilitates the identification of risk factors. Through the nursing process, the outcomes are expected are often goal oriented and focuses in the provision of care (Gracia et al., 2014).

Using nursing process by RN to deliver care

Through the process, it is important to document and communicate effectively. The interventions should be evaluated to examine whether they meet the patient expected outcome. This includes working together to ensure that the outcomes have been achieved. If the interventions are not effective, then the registered nurses will brainstorm to identify the research gap and identify the variables that could cause the intervention not work effectively (Blodgett, 2009).

Some of the variables that could cause   failure of the intervention include data collection, assessment, diagnosis processes, and the healthcare medical devices. In other cases, etiology can be poorly explored causing misdiagnosis. In other cases, the outcomes could be unmanageable, or unrealistic (Lu, 2013). The outcomes should result with reduced infections risks, reduced readmission rates, and improved quality of life. If the interventions is not effective, the nurses should begin planning for care overall. The nurses should conduct evidenced based research will help the nurses identify the appropriate strategy that will help address the relevant matter as necessary (Fjetland and Søreide, 2010).

Part 2; Nursing care plan

Impaired tissue integrity is the NANDA-I nursing, which associated immobility is caused by pressure causing ulcer on the ischium on the buttocks of the right side (Savage and Kub, 2009).

Rationale: The patient sits in one position for a long period in the wheelchair, in the home care facility. This puts more pressure on the ischium, causing the poor perfusion of the patient skin at that site, resulting to maceration of the skin, making the skin to break down (Nazarko et al., 2010).

Assessment: Assess skin above the ischium on the right side of the buttocks. Patient weight and height, patient temperature, pulse rates, respiration, pupils dilated, gastrointestinal system, neurovascular system, muscular system and blood pressure will be assessed.

Nursing diagnosis: Patient education, ulcer management, and pain relieve strategies.

Outcome: Patient will verbalize no pain, and wound recovers within eight weeks of the treatment

Patient will learn to reposition by themselves or with the aid of staff every two hours to relief pressure

The patient dressing will be changes as needed to promote healing and independent

Pain medication will be administered to the patient independent.

The wound will be inspected daily to monitor complications, signs of infections and if the wound is healing

The patient will be educated optimum nutrition including lipids, calories, and adequate protein to aid the tissue healing. The patient will be advised to adequate hydrate to ensure that replenish cellular loss of water, and improve circulation.

Interventions:

1. Establish the reason behind the preferred usage of movement aid. This will help identify strategies that will help the patient prefer mobility, yet avoid sitting so much on the mobility aid.
2. Patient agility will be recorded to monitor  the patient movement pattern to  identify the patients  walking aids  that will reduce pressure ulcer
3. Nurse will conduct  research to identify evidence based practice to reduce  disease progression to relieve  pressure ulcer
4. Patient will be educated on  behavioral modification , such as movements every two hours to ensure that the patient does not remain seated in one position
5. Assess barriers that will reduce effective medical diagnosis and medication errors.

Rationale and evaluation

1. Patient verbalizes pain reduction and that there is little discomfort. The pressure ulcer is caused by sitting in one position.
2. Routine monitoring and strategies to reduce patient pressure ulcer. Patient was advised to use roho cushion seats, rotation every two years and use of padded wear to reduce pressure wound.
3. To ensure that the teaching program is objective and very realistic. This will help the patient become empowered.

Part 3:  patient education

Patient teaching is a core function of registered nurses as indicated by the nursing professional bodies. In some states, teaching is one of the legal requirements by the nursing standards. The patient should trust the nurse to be empowered through training (Baillie et al., 2014). The nurses should understand the patient ability to learn. The relationship is enhanced through communication that is reciprocal and continuous. The main objective is teaching the patient is to ensure that the patient is empowered. The nurse should instruct the patient, describe the disease physiology, and importance of medication (Olson-Sitki, Kirkbride, & Forbes, 2015).The nursed should use the relevant sources information, review patients medical history, physical examination, and documentation of nursing assessment, diagnosis, and intervention. The caregiver and patient support is very important. It is also important to evaluate the patient health literacy, skills, and attitudes to facilitate the learning process (Gotelli et al., 2008).

Learning process can be categorized into affective, cognitive, and psychomotor. The patient emotional as well as experiential readiness to learn. The teaching approach chosen must be used must be developmental. The nurse should assess patient’s intellectual development, psychosocial development, motor development as well as the emotional maturity. It is important to identify the patient’s strengths and weaknesses including reasoning ability, memory, and comprehension (Vaillant-Roussel  et al., 2014). The nurse should use anticipatory guidance that will facilitate psychologically preparation of the person for the unfamiliar or unexpected events. The teaching plan should be created; there are standardized plans for major topics of the health teaching which can be used. The match content should be used appropriately. The teaching plan should allow active practice and should be scheduled based on time constraints. The teaching plans have shorter to enable to digest the healthcare information and ensure that the objectives are met (Svavarsdottir et al., 2014).

References

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