Saturday, January 5, 2019
MANAGE NURSING CARE AT HOME, "Nursing Care Plans"
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.