Nursing care is much
more than administering physician-ordered medications and completing assessment
sheets. A professional registered nurse
also develops care plans for patients.
These are guides that identify a patient’s medical or emotional condition
and difficulty and details scientifically based nursing actions to improve the
condition. Knowing the basis of nursing plans may help in understanding the clinical
reasoning, logic, and information that follows in our chapters concerning
patient illnesses, treatments, and care considerations for your patient
If you have skilled
nursing services providing care for your family member, you may come across Nursing
Care Plans. While you will not be
responsible for formulating plans, implementing the protocols, or generally
being involved with them, you should have a basic understanding of what they
are and how they are used in nursing.
A nursing care plan
begins with a diagnosis. A nursing
diagnosis differs from a medical diagnosis. A medical diagnosis is formulated using
scientific and clinical data to determine a disease process, illness, or
injury. A physician uses this diagnosis
to plan courses of treatment to minimize or eliminate the medical disorder,
such as by prescribing medications and ordering tests.
In nursing, the
diagnosis is also determined using assessment and clinical data, and quite
similar in the end-product, which is to benefit the patient’s health. However, the results of what the patient
is experiencing is diagnosed, not the medical ailment. For example, a medical diagnosis could be
“mesothelioma, lung cancer, and surgical removal of a lung lobe.” A nursing diagnosis, which depicts the
condition or problem the patients exhibits, could be “impaired gas exchange,”
which is related to the removal of pulmonary tissue and decreased functioning
of lung tissue due to the disease process.
These directly relate to the patient’s inability to oxygenate blood, yet
don’t specifically relate to the lack of lung tissue or specify a disease. All nursing diagnoses directly correspond
to the patient needs and/or conditions. Nursing
diagnoses begin the care plan after assessment of the patient and diagnosis
from those approved by the North American Nursing Diagnosis Association
(NANDA).
The nursing diagnosis
is determined by defining characteristics which validate the
diagnosis. They may be both subjective and
objective. Subjective characteristics,
again using the example noted above, would be difficulty breathing (dyspnea) as
in “I can’t catch my breath;” chest pain, because the lungs aren’t sufficiently
expanding; or describing periods of lightheadedness. These are reportable by the patient or family
members. Objective characteristics
are measurable or perceptible by the nurse, such as: abnormal breath sounds
heard with or without a stethoscope, thick and tenacious sputum, decreased
blood oxygen saturation of less than 92% with supplemental oxygen, heart
rate above normal, and confusion and restlessness due to decreased
oxygenation of the brain.
Outcomes can then be
proposed. Outcomes are the positive,
measurable benefits and goals expected to be achieved in a specified amount of
time by implementing the nursing care plan.
Positive outcomes are evidenced by presenting data
and are measurable. For example, the
patient is to have “increased gas exchange within 4 days as evidenced by
decreased dyspnea at rest or exertion, increased sputum production to relieve
congestion, increased of level of consciousness, decreased respiratory and
heart rate, decreased adventitious breath sounds.”
Once the nursing
diagnosis is determined and supported by defining characteristics (the first
part) and the outcome is hypothesized (the result), the actions to get there
are proposed and eventually tested by the evidence that the goal was or was not
achieved. The path to achieve those goals, stated as
outcomes, is then detailed by listing interventions and rationales. Interventions, very simply stated, are
actions: “What I am going to do for the patient.” Rationales are the reasons why the
interventions will benefit the patient: “This will help because….”
Examples of
interventions and rationales for the patient included elevating the head
of the bed (the intervention) because it provides increased oxygenation and
decreases pressure on the diaphragm, thereby promoting ease of breathing
(the rationale). Auscultating
(listening to) lung sounds and assessment of breathing and respiratory values
include noting rate and quality of the respirations every 2 hours; these checks
provide positive or negative changes in the patient’s condition. Signs of further decrease in function
would be shallow respirations, nasal flaring, increases in heart rate, and
decreases in level of consciousness.
These are all further evidence of lack of oxygen due to decreased gas
exchange and would indicate further decline.
Giving the patient more fluids (an intervention) would help to
loosen tenacious secretions and noting input amounts provides indication
whether enough quantities are being consumed.
Teaching and assisting
the patient with frequent deep breathing exercises and use of incentive
spirometer maximizes
expansion of lung tissue including smaller airways. Teaching and assisting patients with
splinting their chest and effective coughing when sitting up aids to relieve
chest discomfort and maximizes production.
These are all examples of nursing interventions based upon a diagnosis
of impaired gas exchange. They are
intended to treat the condition of the patient – not the disease the patient
has.
The nursing process and
nursing care plans are adjustable. They
change and are amended as the patient’s condition improves or worsens. Additionally, nursing care plans do not
solely involve the nursing profession.
They are collaborative and involve all aspects of the patient’s
care-giving team, such as respiratory therapists, physical therapists,
physicians, and numerous other professionals involved in the patient’s path to
well-being.
A
detailed example of such a nursing care plan is given in Appendix 5.
In the following chapters we turn our
attention to managing the nursing care at home for some conditions with which
we lack first-hand at-home experience, thus having to rely on the medical
literature, our training and our experience in other venues.
While not all medical
conditions, situations, or disease processes can be addressed in depth in this
book, the authors felt it was important not to ignore other events and
illnesses that your patient may be experiencing. There are so many illnesses that can occur,
that we needed to take a different approach from an illness-specific one. To do so, we decided to use the
classification system often used in medical settings for assessments. Within
the eleven principal categories will be highlighted some of the more common
illnesses. In some cases, as with cancer, several categories are involved. In
addition, this section will also speak to the method of assessment and the
systemic approach which typically dictates medical practice. As much as possible, this section will follow
that system-based approach. Familiarity with these assessment categories
will assist in the understanding and management of nursing care.
The Nursing Assessment
form used in our home situation is separated according to various systems. This is a standard approach to all nursing
documentation. Assessments are not haphazard comments about
the patient. Rather, assessments are a
standard method of examining the patient and recording data in a precise manner
based upon the function of a system.
Some overlap of
findings may occur between systems. This
should not be considered unusual. The body uses individual systems that
interact with each other to maintain the body as a unit.
When one system is
failing,
or having difficulty, the body reacts to try to achieve a functioning that
is as normal and balanced as possible (homeostasis). Perhaps the best way to illustrate this is by
a simple analogy: When the mother has
the flu, the father steps in and cooks dinner for the family. He doesn’t cook as well as mom, usually, but
the kids are fed, mom can rest, and he isn’t overworked, so he can go to his
job in the morning and perform well.
When the body has a
dysfunctional system, the other systems step in and help. They might not do as well as the ailing
system, but, at least temporarily, positive functioning continues. For example: when respiratory function is
decreased, the heart rate and therefore the cardiac output (blood flow)
increases to deliver oxygenated blood to tissues.
This cannot continue
indefinitely.
The other systems help, but eventually cannot maintain homeostasis. As in the example above, the increased heart
rate tires the heart; it may increase in size, eventually causing cardiac
dysfunction, be less able to pump, and/or eventually cease working altogether.
Monitoring individual
systems provides an insight to the operation of the whole body. Adverse changes to more than one system can
then alert to multiple system problems and indicate the need for intervention.
Contact information:
###
Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549
Our book is available from amazon.com, bn.com, and OutskirtsPress.com: How to Manage Nursing Care at Home
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