The set of actions put up to take care of a patient who is suffering from a certain type of disease can simply be described as the nursing process. The steps are meant to guide the nurse or whoever is managing the patient to administer the right medication as per the prescription. The patient should be tested first to determine what he/she is suffering from before being medicated. During the nursing process, one is required to have a plan to act as a guideline during the process. Building up a plan is an intermediary phase of the nursing course. A nursing plan also makes the evaluation of the nursing process easier. In case the wrong medication was administered it is easier to correct the mistake made by the nurse.
A good nursing plan should focus on minimizing or getting rid of the existing problem. The nurse or whoever giving the nursing services should do it deliberately, which is out of one’s own will. The nurse should have also undergone training in the nursing field for efficient knowledge so as to handle patients effectively. The nursing plan should be future related and should have a holistic center that meets the needs of the patient being served. The intervention of the nurse should be precise easily understood to help any other person who might administer the nursing services follow the plan in case of the nurse’s absence.
Accurate records about the patients should be kept to ensure careful monitoring of the patient’s progress. The records help the team taking care of the patient communicate effectively and are used in research institutions especially when some patients react differently during the medication process. Records are normally kept informed of charts that contain patients’ medication, progress in terms of infection control, and the name of attending medical officers. Charts and records are used as a communication device among the medical officers attending to the patient. The advantage of charts is that it helps the patients understand the causes of their illness thus undertake preventive measures since prevention is better than medication and cost-effective for both parties.
By use of the nursing process, nursing plans are created. Before a plan is created, a nurse first gathers both subjective and objective data. This organization helps the medic identify where the patient will require nursing services, and it is through this that the nurse makes a diagnosis. Diagnosis of a patient’s infection should be based on facts and evidence supporting the diagnosis.
After making a diagnosis the nurse should use a system known as Problem Etiology Signs and Symptoms (PES) to calculate the possible outcomes and the goals to be achieved during the nursing process. A date should be set on when to expect a change in the patient’s health. This would help the medical officer or nurses know whether the medication is working or not.
Steps of Making a Plan
During plan making by nurses, there are many things that the nurse should know before drafting a plan. He/she should collect useful information both objective and subjective. The patient’s diagnosis should be accurately determined. The patient’s medical history should also be acquired. Allergies and family medical history should also be known as some patients are known to react differently to some medications. The nurse should also list down expected results during the medication period. This would help monitor the patient’s progress. Finally, the nurse should also have the number of medical personnel attending to the patient thus helping solve medication problems in case one of the personnel went wrong at some point.
Development of various nursing processes has been done by different writers but the most modern coming from APIRE from Hull University in the United Kingdom. It contains an additional stage “Recheck” used to evaluate the nurse’s activities, hence monitoring the effectiveness of the patient care.
Case study (Carissa Smith)
Patient’s Chief health Complain
The main reason for her visit is due to her chest pain (C/P), SOB that she has been experiencing.
Patient’s background and history
Carissa Smith, a female pseudonym patient. She is married and currently fifty years of age. She has an account of having unrestrained HTN, and was diagnosed recently with CHF and dilated cardiomyopathy. Smith has not been on her heart failure medication for the past four days and this was due to her lack of funds to purchase her medication.
Carissa is a cocaine user and had used it twelve hours before her check-up. She complained of chest pains in the midclavicular region under her left chest. The pain was described as substantial. Her chest pains began the previous day and had been constant since then. As she was experiencing the pains she tried to medicate herself by use of Excedrin PM and Tylenol PM but they did not help her much. She also tried taking one hundred milligrams of Toprol XL but unfortunately, that too did not help ease the pain. She started coughing producing green/brown sputum about fifteen minutes after her C/P commenced, after which she came to the ED accompanied by her daughter. Here she was given nitroglycerin, aspirin together with Lasix 40 mg IV.
Medical past History
In two thousand and six in the month of July, Ms. Carissa was diagnosed with both CHF and dilated cardiomyopathy. In March two thousand and five she was diagnosed with stage II breast CA in her left intraductal breast carcinoma metastatic to 1/14 left axillary lymph nodes. In the same year, she suffered from depression. Carissa has had a longstanding HTN and mastitis too. On top of all that she had a prolonged habit of abusing many substances and QT intervals.
Patient’s hospitalization and surgical history
In August eighth two thousand and six Carissa was checked in the chest pain unit after presenting to the ED with C/P and SOB. Cardiac enzymes WNL, no dynamic EKG changes concerning cardiac ischemia. POC BNP was 864. Went on to have a pharmacologic stress test without evidence of inducible myocardial ischemia there was evidence of LV global hypokinesis with a calculated EF felt to be about 32%.
In two thousand six from the eleventh of July to the sixteenth Cassia was hospitalized to award a five-day stay after presenting to the ED with C/P and SOB. Cardiac enzymes, electrolytes, Mg++ levels all WNL, EKG showed normal sinus rhythm with LA enlargement, LVH, and a prolonged QT interval (.514 sec) but no dynamic changes worrisome for cardiac ischemia. An ECHO was performed during this time revealing LA dilation (5.0 cm), LV size at the upper limit of normal, severe impairment of LY systolic function with a calculated biplane EF of 14%. The LV diastolic filling pattern was felt to be “pseudo normal.”.
In July two thousand and five- Left mastectomy and in nineteen eighty-nine she had a vasectomy.
Allergies: The patient has allergies with PCN which causes the swelling of her throat.
Social History: Ms. Smith is a smoker. A habit she started at the age of fifteen. Her average smoking rate is five to one ppd. She is also an alcohol consumer for the past thirty-five years given that she is fifty years old. She mostly consumes liquor and currently drinks and consumes about fifty-six drinks in one week. In her twenties, she drank at least five drinks in a day for two years. On the other hand, Carissa has done cocaine for the past twenty years but refuses IVDU. In the meantime, she has no job which was a result of her physical condition. She has no medical insurance due to her lack of employment.
Family History: Carissa’s father suffered from a stroke which later killed him at the age of forty. Her mother suffered from the same infection but died much later at the age of sixty, twenty years after her father’s death. Carissa’s family is made up of five children three females and four males. One of her sisters and a brother suffer from HTN and DM. according to her information, she is the only one in her family that has suffered from cancer.
According to Pearce (2006), a care plan of a patient requires a lot of the patient’s details. According to the named patient, she is experiencing chest pains. Given that they are chest pains as a nurse one first check if her breathing system is normal to diagnose what her infection is. According to her health history, she is suffering from stage two breasts CA which could be the source of her pains.
Given that she is a drug addict close monitoring will be required this is because the more she uses the more her health deteriorates.
The health care plan is very important in many curable and incurable diseases. Cancer requires very keen and close monitoring of patients. Carissa being a cancer patient who is in very heavy medication requires close, keen monitoring as per Lee (2006, p 1376-1382).
A simple care plan can be put as follows: the nurse identifies the patient’s problems which include informational needs, the patient’s disease problems which in this case is chest pains. The nurse should on the treatment process and ensure the drug therapy is followed accordingly.
Hughes (1981) and Corngold (1973) suggest that the change of patient’s level of functioning is also another requirement from the treatment that is being administered. The nurse is expected to ask relevant questions concerning the patient’s health. This would help assess the patient’s current situation and inform the doctor in charge of the patient’s conditions. Patients should be encouraged by the nurses assuring they of getting better. This helps the patient to relax and save him/her from depression. Appropriate referrals should also be made to the client. The patient’s mobility should also be checked regularly.
In a care plan, the vision of the patient should also be monitored. The visual activity of the clients should be it helps to monitor the nervous system to be working properly. On the other hand, all the sensory organs should also be monitored.
An argument by Linda (1982 p. 1076-1079) is that diet should be observed and maintained according to dietary standards. Fatty foods should be avoided in all capacities because they are likely to cause a rise in cell count. To keep it simple, there should be a total cut of fat intake. This should be replaced by more eating more fiber foods, raw fruits, and vegetables as recommended by Weir (1989) and Reynolds (2003). Cereals should also be included I the diet as much as possible. Carissa should be given foods that are rich in vitamin A and C in almost every day’s diet. This will include cruciferous vegetables like the famous cabbage and cauliflower. A good diet leads to a healthy living being. Poor diet may worsen the patient’s condition. The patients should have a well-balanced diet containing all the minerals and food nutrients required by the body. The nurse should ensure that all the meals are provided at the right time of the day with the right medication as some drugs require someone to be full before being taken otherwise it will lead to further complications.
Some patients are entitled to surgeries. In this case, Carissa is the patient. She might need surgery in case the pains she is experiencing are being caused by something that needs to be removed. The nurse in charge should ensure proper preparation of the patient is done. He/she should also inform the patient of the expected outcome of the surgery and any possible complications that might in the operation. The dangers implicated in the procedure. Medical preparations such preparations of the operating room, that is by collecting everything the doctor will need for the operation for instance operating instruments, antiseptic gloves, masks, and many others.
In the care plan, the patient’s hygiene should also be included. In case one is handling a patient whose movement is impaired, assistance is required during the cleaning of the patient. This will include bathing and excretion. This process requires an understanding nurse who is very patient otherwise some might not be willing to go through with the process.
Family members should also be contacted to provide the necessary information and moral support needed for the patient.
When writing a plan one can choose a convenient format that will suit anyone that may want to administer the medication. One can draft a questionnaire that he/she will use to gather information from the patient. It will act as a guideline during the collection of both subjective and objective data. A table can be used to fill in the gathered information. The data collected can be easily analyzed and a diagnosis made. According to Beth (2007) and Pearse (2003), a simple working care plan can be as the one below it is a general plan that can be used to administer effective nursing.
Nursing Care Plan
- Client Initials Age Gender Date(s) of Care
- Allergies Date of Admission Code Status
- Height Weight on Admission Admission VS
- Admitting Dx
- Current Surgery with date
- Pertinent Hx
- VS this shift
- Activity Level Diet
- Current Weight
- Location of IV Site(s) IV Solution(s) and Rates
- PCA/Epidural (drug, concentration, dosage)
- Support Tube(s) and Location(s)
- Intake this Shift (differentiate route(s)) Intake last 24 hours (differentiate route(s))
- Output this Shift (differentiate route(s)) Output last 24 hours (differentiate route(s))
Client Health History
(From agency admission form)
- Nursing Assessment_____________
- Subjective Data__________________
- Musculoskeletal (include Functional Status)___________________________
- Integument (include condition of any invasive site(s), incisions)_______________________________
The above is a cancer patient. Depending on the degree of infection her life could go either way. She can survive or die. Given that she is a heavy drugs user consuming alcohol, tobacco, and even hard drugs like cocaine she will need close monitoring by the nurse to achieve her goal. The patient has also been diagnosed with other health issues like depression which would accelerate cancer if it is not taken care of, that is as per Komec (1996), Jaishy (1981), and Cheng (2010). Being a drug addict and broke at the same time might require a lot of patience and understanding from the nurse who will be taking care of the patient. The patient should also look for funds to receive a good medical service.
Generally, nursing services are essential services towards the well-being of the patient. A nurse determines a lot in the recovery of a patient. Good nursing services will encourage the patient; hence helping in building up the patient’s hope of a quick recovery. To administer good and effective treatment as per the prescription, the medical personnel in charge require a guideline that is informed of a care plan. This ensures organizations of work good time management. Good evaluation and good planning are both essentials in the success nurse’s services to the patient.
A plan is an essential need in nursing services. If one has no plan he/she can get credible plans from the internet and if books from the library
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Cheng, S. Your Mother Is in Your Bones. In Belles Lettres.2010 Web.
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Weir, E.K. (1989). Anorexic Agents Aminorex, Fenfluramine, and Dexfluramine Inhibit Potassium Current. New york. Oxford University Press.
William S. & Vincent B. (2009) Cancer care plan. 5th edn. New York. Oxford University Press.