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Nursing is a famous profession at this time. Nurses are one of the main pillars of the medical industry. For a nurse, the primary duty is to ensure patients receive safe delivery of care as outlined by the plan of care created by the medical staff. A nurse’s shift will be constantly collecting and analyzing information on a patient’s health. A nurse will be charged with what to do with this information. If you are in the nursing profession you will take a systematic approach to manage the needs of your patients by following the nursing process. The nursing process gives an outline of practice for the nurse to follow the needs of patients. Through this blog, I will explain the nursing process and the necessary steps in this universal nursing tool. Also if you are searching for programming help UK then choose GotoAssignmentHelp agency.
The Five Steps of the Nursing Process:
The nursing process is a five steps and evidence based process that is used to help nurses for guidance. The nurses think holistically about their patient’s health and overall picture of care. Nurses learn the nursing process during their training process in nursing school. In professional life, they use this process when taking care of patients. When a nurse plan how a shift will play out with the patient the nurse must use clinical judgment to create a general plan for the day. The nursing process keeps the chance for the nurse to gather information, prioritize problems, and set goals for every patient. Nurses gain more experience in the nursing process when deciding on patient care. The five steps are as follows –
1) Assessment Phase – In the assessment phase a nurse will look at any subjective and objective data collection in the history of the patient’s health. An example of objective data could be the oxygen saturation rate from the chart, or it may be documentation, demonstrating the oxygen filter flow of a patient. They note the increase several times in oxygen saturation overnight. Subjective data is information collected during a nursing hand. It may be the overnight nurse mentioned that the patient is looking “ar-hungry”. The nurses use this type of information to analyze the health of a patient. We know that nurses use various accessories for treatment. During the assessment phase, a nurse gathers all this type of information and assesses what is going on. Nursing assignment writers Chicago starts before watching a patient but it continues throughout the shift if a doctor asks a nurse to see, if the patient is looking worse than before or not. A nurse provides the details he/ she gathers during nursing assessment.
2) Diagnosis Process – In the diagnosis phase nurses take those assessment findings and formulate some nursing diagnoses that will guide them to care for the shift. Nursing diagnosis is a separate medical diagnosis and will be subjective based on nursing judgment. A medical diagnosis can be determined by a physician but a nursing diagnosis should be more focused on addressing the problems that the patient will face during their shifts. As an example, we can say medical diagnosis and nursing diagnosis respectively “acute respiratory failure” and “impaired gas exchange”. A nurse gives priority to the needs of the patient by creating a nursing diagnosis because the patient often has various problems. It may be patients’ oxygen requirements are more important than their ability to go for a walk. A nursing diagnosis creates based on the information about a patient that will help anticipate any challenges that need to address in a shift.
3) Planning Phase – The planning phase is also referred to as the outcomes phase. This stage helps a nurse to start formulating a plan of action. During this phase, the nurse creates some goals for the shift. He/ she decides what he/ she will do during his shifts. A nurse always keeps in mind that safety is the top priority and wants to plan goals that prioritize airway, breathing, and circulation first. For every medical issue, a nurse must assign a simple, achievable, measurable goal for a positive outcome for the patient. Normally these are short term goals and evaluate on a shift by shift basis.
4) Implementing Phase – In the implementation phase a nurse creates some nursing interventions that help to achieve the patient’s goal. Once a nurse addresses an airway and breathing can create additional action items that help to meet the goals from the planning phase. We must say the patient’s oxygen level stays up sometimes. So the next goal could be something like what will encourage the patient to use incentive spirometry 10 times in an hour.
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5) Evaluation Phase – The final and last phase of the nursing process is the evaluation phase. It takes place some interventions to see if the goals have been made. During this phase, a nurse will determine how to measure the success of goals and interventions. For a patient who has respiratory issues, one evaluation tool would be trending the patient’s oxygen saturation level in the shift. A nurse has to ask own self, am I able to wean the oxygen?
Some Possible Outcomes that a Nurse Used to Classify the Invention are as follows:
- Patient’s Condition Improved – A patient who maintains oxygen saturation above 92% in a shift does not need to use accessory muscles. The patient is now off oxygen.
- The Patient’s Condition Stabilizes – A nurse can wean the oxygen level this shift.
- Condition of the Patient Deteriorated – Oxygen liter flow increases twice in this shift and continues to monitor.
How to Create an Effective Nursing Care Plan:
- A nursing care plan serves as the basis for administrating, maintaining, evaluating, and effectiveness of positive outcomes for a patient.
- It is also known as a plan of care. A nursing care plan compresses a five step process and I have explained them before. This system ensures continuity of care. It is because the various staff working in various shifts can gauge progress and continue where the last shift left off.
- This system can be a lot easier with electronic documentation but it must be reviewed and customized when appropriate.
A nursing care plan works as an integral part of each patient’s care. It should be adjusted and evaluated continuingly from the start of the patient’s care until the time of discharge beyond. Many nurses struggle with the proper way to create an effective nursing care plan and make an adjustment that shows how goals are being managed effectively.
Importance of a Nursing Care Plan:
A nursing care plan ensures consistency and continuity of care among patients. If a robust nursing care plan is present, staff from different shifts, facilities, and various medical providers can use the information to give the same quality of care and support if needed. On the other hand, this process allows people to get a high standard of safe, effective, responsive care in a service that is well managed and followed consistently. The care plans should serve as a guideline to ensure that total and effective care is being granted to each patient. Continuity of care is achieved when all team members are serious about the plan of care and the revisions are made as care needs change.
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Reviewing a Care Plan:
A nursing care plan needs to be reviewed regularly. It is typically once a month or more often to ensure that any changes have been recorded in the care plan. Care plans are not reviewed regularly. It can become messy and very difficult to navigate when there is a lack of accurate and up to date information. The status of a patient can be changed and diagnosis can vary based on conditions that improve, worsen or present themselves as a different concern. A care plan is never reviewed routinely and it can update ultimately leading to poor patient outcomes. It also leads to the quality of medical care that is not being maintained consistently. The goal of a nurse should be improved patient care and not regress these important areas.
Sample of Nursing Care Plan:
A sample nursing care plan is divided into four columns and those columns are – nursing diagnosis, goals, outcomes, interventions, and evaluations. For each of patient might have a different number of nursing diagnoses based on their needs. But each of these columns must be included. Consistency and accuracy are included and ensured continuity of care by using this format. Every nurse has to think about these four areas when assessing their patients to formulate nursing care plan. A nursing care plan ensures that the plan is not only created for the sake of completion but rather to be used to achieve positive patient outcomes. The idea of a nursing care plan can be difficult to formulate. In that case, the nurse must keep in mind the importance they served and how the goals are set in the plans. The care plan acts as a guideline for other team members to follow. Verifying with shifts and staff nurses must strive to complete nursing care plan effectively for patient’s health progression. Nursing care needs critical thinking skills but the most important thing is the entire team work together cohesively and the results are favorable for the patient.
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