The nature of nursing is complex and efforts to define it are still continuing. Virginia Henderson(1961) viewed nursing as assisting the individual sick or well in the performance of those activities contributing to health or its recovery (or to peaceful death) that hes/he would perform unaided if s/he had the necessary strength, will or knowledge. Nursing is concerned with the psychological social spiritual and physical aspects of the person rather than only the clients diagnosed medical condition. Focus of nursing is on the needs, patterns, responses, strengths or deficits of the whole person interacting with the environment. Nursing is assisting the client (individual person, family, groups or community) solve his/her health problems. Problems are the unmet basic needs, barriers in normal human responses, health status or self care deficits.These may be the actual or potential threats to enjoying sense of well being.
Tuesday, November 18, 2014
Format of Nursing Care Plan Based on Nursing Process
i)Identification data
Name : ...................................................................................................
Age : ...................................................................................................
Sex : ...................................................................................................
Religion : ...................................................................................................
Marital Status : ...................................................................................................
Educational Background : ...................................................................................................
Occupation : ...................................................................................................
Date of Admission : ...................................................................................................
M.R.D. No. : ...................................................................................................
Diagnosis : ...................................................................................................
Ward : ...................................................................................................
Bed No. : ...................................................................................................
Address : ...................................................................................................
...................................................................................................
Date of Discharge : ...................................................................................................
Date of Planning : ...................................................................................................
Name : ...................................................................................................
Age : ...................................................................................................
Sex : ...................................................................................................
Religion : ...................................................................................................
Marital Status : ...................................................................................................
Educational Background : ...................................................................................................
Occupation : ...................................................................................................
Date of Admission : ...................................................................................................
M.R.D. No. : ...................................................................................................
Diagnosis : ...................................................................................................
Ward : ...................................................................................................
Bed No. : ...................................................................................................
Address : ...................................................................................................
...................................................................................................
Date of Discharge : ...................................................................................................
Date of Planning : ...................................................................................................
ii) Brief Socio-Eeconomic History
1) Family history
2)Development of Nursing Care Plan Using
Nursing Process
a) Type of family ----- Nuclear/joint
b) Numbers of family members
c) Any specific disease in members
d) Health status of family members
e) Total Income
f) Dietary habits
g) Housing condition ---- Own/Rental/Water/Electricity Supply etc.
h) I.P.R. Among Family Members
Personal history
- - Hygine and grooming
- - Any H/O Allergy
- - H/O smoking, alcohol, tobacco, drinking etc.
- - Life style flabits--exercises-drugs etc.
3) Hisotry of fast illness
4) History of present illness ---- Present complaints
5) Examination by doctor (from casesheet)
6) Investigations:
1) Family history
2)Development of Nursing Care Plan Using
Nursing Process
a) Type of family ----- Nuclear/joint
b) Numbers of family members
c) Any specific disease in members
d) Health status of family members
e) Total Income
f) Dietary habits
g) Housing condition ---- Own/Rental/Water/Electricity Supply etc.
h) I.P.R. Among Family Members
Personal history
- - Hygine and grooming
- - Any H/O Allergy
- - H/O smoking, alcohol, tobacco, drinking etc.
- - Life style flabits--exercises-drugs etc.
3) Hisotry of fast illness
4) History of present illness ---- Present complaints
5) Examination by doctor (from casesheet)
6) Investigations:
7) Doctors Ordes:
8)Name of Investigation
Assessment:
a) Subjective Assessment:
b) Objective Assessment :
vital signs
Head to foot examination
9)Nursing Care Plan
10) Health Teachings
11) Progress Notes ---- (Day wise)
12) Activity
Assessment:
a) Subjective Assessment:
b) Objective Assessment :
vital signs
Head to foot examination
9)Nursing Care Plan
10) Health Teachings
11) Progress Notes ---- (Day wise)
12) Activity
a) Write three nursing care plans using nursing process.
Select patient from anyone of the following setting
Select patient from anyone of the following setting
- OPD
- Medical/surgical ward
- ICU, CCU, RR, Neuro ICU
b) Discuss nursing process with your supervisor?
c) Write five objective and subjective data?
c) Write five objective and subjective data?
Documentation of Nursing Care Plan
Documenting the plan of nursing care or writing the nursing care plan, is the final product planning process. If you fail to document your plan of nursing care, you waste all the effort that you have done in determining an individualized care plan for your patient. No one will know the work that has been done. Nursing care plan serves five purposes:
1) To validate that there has been a thorough plan of care formulated for each patient.
2) To serve as a record that can later be studied to evaluate patient care.
3) To communicate to other nurses the specific problems, goals and interventions that have been identified for the patient.
4) To same; time and avoid duplication of work.
5) To help in legal purposes.
1) To validate that there has been a thorough plan of care formulated for each patient.
2) To serve as a record that can later be studied to evaluate patient care.
3) To communicate to other nurses the specific problems, goals and interventions that have been identified for the patient.
4) To same; time and avoid duplication of work.
5) To help in legal purposes.
Development of Nursing Care Plan
Assessment
Assessment is the foundation step of nursing process. It consists of systematic and orderly collection of information pertaining to and about the health status of the client. The information obtained helps to make nursing diagnosis and to develop a plan of care. Informations are obtained by data collection.
Data Collection
Data collection includes accumulation of comprehensive information about the client on initial assessment. The initial assessment provides baseline data. The data involves information about clients health problem, specific factors that contribute to the problem. The client has health problem (s) with which hes/he gets admitted and may also develop additional problem during his stay in the hospital, because of this course of illness, and the treatment modalities.
The data collected by the nurse during assessment are:
Assessment is the foundation step of nursing process. It consists of systematic and orderly collection of information pertaining to and about the health status of the client. The information obtained helps to make nursing diagnosis and to develop a plan of care. Informations are obtained by data collection.
Data Collection
Data collection includes accumulation of comprehensive information about the client on initial assessment. The initial assessment provides baseline data. The data involves information about clients health problem, specific factors that contribute to the problem. The client has health problem (s) with which hes/he gets admitted and may also develop additional problem during his stay in the hospital, because of this course of illness, and the treatment modalities.
The data collected by the nurse during assessment are:
- Subjective Data
- Objective Data
Subjective Data
Subjective data includes client’s description of his personal health status, problem e.g. feeling,description pain, weakness, nausea. This data also include information supplied by client’s family members. The data are not observable and are difficult to measure objectively.
Objective Data
Objective data are usually the one that is obtained through senses --sight, smell, hearing, touch and during physical examination of the client. Objective data are observable and measurable.For example: rate of pulse, weight, presence of oedema. The data collected by the nurse can be historical data and current data.Historical data has information related to the events that have occurred prior to the present.The event might be previous hospitalization, presence of chronic disease, pattern of bowel movement in the past, childhood illness in an adult patient. Current data refer to the events that are occurring at present e.g. pain, vomiting, inability to pass urine and present illness.
It is always necessary to validate subjective with objective data, historical with current data. For example, subjective data of feeling of pain is validated by objective findings of pallor, increasednsweating and hypotension. Similarly, historical data e.g. passing stool once every day and bowels not moved for two days (current) may initiate a strategy to help patient move his bowels. But when substantiated with historical data the client may inform that movement of bowel on every alternate day is his routine at home. Thus the information obtained earlier becomes valid. Therefore, validation of the data is necessary before planning care.
Nursing Diagnosis
The diagnostic process involves processing the data by classification interpretation and validation. Writing nursing diagnostic statement is the basis of identifying client’s problems and strengths. The health problem and the etiological factor are reflected in the formulation of diagnostic statement. The diagnosis is verified with the client and documented. Planning
Planning includes setting priorities and writing outcomes. The different problems of the client identified in the nursing diagnosis needs to be prioritized. The nurse can determine priority problems related to needs of client. Outcomes/goals are written from the diagnostic statement in terms of client’s behaviour that are desired to be achieved by the nurse in the limited time. The characteristic features of outcomes are:
client centered
observable and measurable
time limited and realistic.
The areas in which outcomes are written include:
appearance and functioning of the body,
specific symptoms,
knowledge,
psychomotor skills and emotional status.
Implementation
Implementation involves preparation for executing the plan and carrying the interventions to resolve client’s problem. The interventions include all those independent, dependent and interdependent nursing actions carried out by the nurse to restore health, prevent illness,promote wellness and facilitate copying with altered functioning. The implementation of nursing action is followed by complete and accurate documentation of events.
Evaluation is used to judge each component of nursing process. It measures the effectiveness of nursing interventions. It consists of comparing and judging the data about client’s progress.The client’s response to the nursing interventions will guide the nurse to continue with the plan care, modify it or terminate. In case the plan of care needs modification the nurse will reassess and carryout the remaining steps of nursing process. When the care is continued the ongoing process of assessment and evaluation is continued.
Subjective data includes client’s description of his personal health status, problem e.g. feeling,description pain, weakness, nausea. This data also include information supplied by client’s family members. The data are not observable and are difficult to measure objectively.
Objective Data
Objective data are usually the one that is obtained through senses --sight, smell, hearing, touch and during physical examination of the client. Objective data are observable and measurable.For example: rate of pulse, weight, presence of oedema. The data collected by the nurse can be historical data and current data.Historical data has information related to the events that have occurred prior to the present.The event might be previous hospitalization, presence of chronic disease, pattern of bowel movement in the past, childhood illness in an adult patient. Current data refer to the events that are occurring at present e.g. pain, vomiting, inability to pass urine and present illness.
It is always necessary to validate subjective with objective data, historical with current data. For example, subjective data of feeling of pain is validated by objective findings of pallor, increasednsweating and hypotension. Similarly, historical data e.g. passing stool once every day and bowels not moved for two days (current) may initiate a strategy to help patient move his bowels. But when substantiated with historical data the client may inform that movement of bowel on every alternate day is his routine at home. Thus the information obtained earlier becomes valid. Therefore, validation of the data is necessary before planning care.
Nursing Diagnosis
The diagnostic process involves processing the data by classification interpretation and validation. Writing nursing diagnostic statement is the basis of identifying client’s problems and strengths. The health problem and the etiological factor are reflected in the formulation of diagnostic statement. The diagnosis is verified with the client and documented. Planning
Planning includes setting priorities and writing outcomes. The different problems of the client identified in the nursing diagnosis needs to be prioritized. The nurse can determine priority problems related to needs of client. Outcomes/goals are written from the diagnostic statement in terms of client’s behaviour that are desired to be achieved by the nurse in the limited time. The characteristic features of outcomes are:
client centered
observable and measurable
time limited and realistic.
The areas in which outcomes are written include:
appearance and functioning of the body,
specific symptoms,
knowledge,
psychomotor skills and emotional status.
Implementation
Implementation involves preparation for executing the plan and carrying the interventions to resolve client’s problem. The interventions include all those independent, dependent and interdependent nursing actions carried out by the nurse to restore health, prevent illness,promote wellness and facilitate copying with altered functioning. The implementation of nursing action is followed by complete and accurate documentation of events.
Evaluation is used to judge each component of nursing process. It measures the effectiveness of nursing interventions. It consists of comparing and judging the data about client’s progress.The client’s response to the nursing interventions will guide the nurse to continue with the plan care, modify it or terminate. In case the plan of care needs modification the nurse will reassess and carryout the remaining steps of nursing process. When the care is continued the ongoing process of assessment and evaluation is continued.
Review of Steps of Nursing Process
Definition
Nursing process is a framework that enables the nurse and the client together to resolve health related problems of the client in a systematic, organized and logical way.
Purposes
1) It provides a framework within which nurses can identify client’s health status and provide quality care and checks its outcomes through evaluation.
2) It helps in rendering individualized care.
3) It avoids unnecessary (duplication of) nursing actions thus saves time.
4) It helps in providing organized priority based care.
5) It encourages clients and family participation in care.
Steps
Nursing process consists of the following steps:
1) Assessment
2) Nursing Diagnosis
3) Planning
4) Implementation
5) Evaluation
Nursing process is a framework that enables the nurse and the client together to resolve health related problems of the client in a systematic, organized and logical way.
Purposes
1) It provides a framework within which nurses can identify client’s health status and provide quality care and checks its outcomes through evaluation.
2) It helps in rendering individualized care.
3) It avoids unnecessary (duplication of) nursing actions thus saves time.
4) It helps in providing organized priority based care.
5) It encourages clients and family participation in care.
Steps
Nursing process consists of the following steps:
1) Assessment
2) Nursing Diagnosis
3) Planning
4) Implementation
5) Evaluation
 |
| Steps of nursing process |
Development of Nursing Care Plan Using Nursing Process
All health care professionals are striving to upgrade client care. Nurses are concerned to provide health care to both well and ill clients in different settings. In 1950s the term ‘‘Nursing Process’’ was first used and ‘‘nursing diagnosis’’ was considered as ‘‘the weak link’’. In 1972 both the terms emerged as having ‘‘the strong link’’ in nursing practice. Today in the era of cost containment the value of one’s contribution to the health care delivery system must be measurable and demonstrable. The combinations of nursing care plan based on nursing diagnosis gives nurse a concrete instrument to quantify nursing. Nursing care plans are the keys to professional nursing care and must be written for specific nursing diagnosis to document the care needed the care given and the clients responses.
Sample Proforma for Health Assessment of an Individual including Psychosocial Development
The sample proforma will provide you the guidelines to do comprehensive assessment of physical and psychosocial development of an individual.
1)Identification Data
Name : ..........................................................................................................
Age : ..........................................................................................................
Sex : ..........................................................................................................
Religion : ..........................................................................................................
Education : ..........................................................................................................
Occupation : ..........................................................................................................
Income : ..........................................................................................................
Marital Status : ..........................................................................................................
Address : ..........................................................................................................
..........................................................................................................
2)Physical Examination
Vital Signs: Temp..................... Pulse ..................... Resp ..................... B.P......................
Height..................... Weight .....................
Body built: Ectomorphic
Mesomorphic
Endomorphic
3)Head to Foot Assessment
Hair and Scalp ---- clean/dirty
shiny/dull/dry firm/brittle
Alopecia ---- yes/no
Pediculosis/dandruff/boils
Face : Pleasant/cheerful/serious/frowning/fearful/Moon face/
swollen face Skin colour: uniform/pigmented
Eyes : Appearance: Bright/sulk/clean/dirty
Conjunctiva: Pink/moist/dry/pale/discharge/Bitto’s spot
Cornea : glossy appearance/moist/dry/ulcer
Vision : normal/short/long sightedness
Ear : Clean /dirty/discharge/infection/boil/dizziness/pain/polyps/hearing/problem
Nose : clean/dirty/discharge/infection/boil/deviated septum /
epistaxisMouth : 1ips----pink/dry/moist/pale/cyanosed/cracks/angular stomatitis/cleft lip
Teeth : Clean/dirty/straight/malpositioned/white/yellow/stained/
cavities/decay/number
Gums : Pink/black/patches/clean/dirty
Tongue : Pink/pale/clean/moist/dry/coated
Throat and neck : Normal/congested
Lymph nodes : palpable/not palpable
Skin: colour: : pink/pale/pigmented/ clean/ dirty/ smooth/rough/ dry/ oily/elastic/ Non elastic
Nails : clean/dirty/brittle/pink/pale/cyanose/white patches/ spoon shaped nails
Feet : clean/dirty/cracked heels
Toe nails : short/long/clean
Respiratory system : rate/pattern/abnormal sounds/dyspnea/haemoptysis
Cardiovascular system: pulse: tachycardia/bradycardia/palpitation
GIT system: appetite : good/fair/poor/abdominal pain/indigestion /vomiting/Polydypsia/dyspepsia
Bowel habits : regular/constipation/diarrohea
Urinary System : normal/polyuria/oliguria/incontinent
Colour : straw/yellow
Muscular system : extremities: normal/any deformity/odema/pain
Bones and joints : normal/congenital anomalies/stiffness/swelling/limited movement/backache
Central Nervous System : oriented to time, place and person/confused/disoriented/nervousness/mood changes/memory loss
4)Habits
Sleep: 8-10 hrs/less than 8 hrs
Personal Hygiene: good/fair/poor
5)Sociological Health
Relationship with Family members/peers/significant others.............................
Relationship with neighbours: good/frequent fights
Occupational history: satisfaction with employment
Economic status perception of adequacy or inadequacy of income - Pattern of health
care: preventive/promotive/curative
6)Cognitive abilities
- - - - Intellect comprehension
- - - - Learning pattern
- - - - Memory
- - - - Concentration
- - - - Judgement
7)Spiritual Health
- - - - Faith in god: yes/no
- - - - Goes to temple/church: yes/no
1)Identification Data
Name : ..........................................................................................................
Age : ..........................................................................................................
Sex : ..........................................................................................................
Religion : ..........................................................................................................
Education : ..........................................................................................................
Occupation : ..........................................................................................................
Income : ..........................................................................................................
Marital Status : ..........................................................................................................
Address : ..........................................................................................................
..........................................................................................................
2)Physical Examination
Vital Signs: Temp..................... Pulse ..................... Resp ..................... B.P......................
Height..................... Weight .....................
Body built: Ectomorphic
Mesomorphic
Endomorphic
3)Head to Foot Assessment
Hair and Scalp ---- clean/dirty
shiny/dull/dry firm/brittle
Alopecia ---- yes/no
Pediculosis/dandruff/boils
Face : Pleasant/cheerful/serious/frowning/fearful/Moon face/
swollen face Skin colour: uniform/pigmented
Eyes : Appearance: Bright/sulk/clean/dirty
Conjunctiva: Pink/moist/dry/pale/discharge/Bitto’s spot
Cornea : glossy appearance/moist/dry/ulcer
Vision : normal/short/long sightedness
Ear : Clean /dirty/discharge/infection/boil/dizziness/pain/polyps/hearing/problem
Nose : clean/dirty/discharge/infection/boil/deviated septum /
epistaxisMouth : 1ips----pink/dry/moist/pale/cyanosed/cracks/angular stomatitis/cleft lip
Teeth : Clean/dirty/straight/malpositioned/white/yellow/stained/
cavities/decay/number
Gums : Pink/black/patches/clean/dirty
Tongue : Pink/pale/clean/moist/dry/coated
Throat and neck : Normal/congested
Lymph nodes : palpable/not palpable
Skin: colour: : pink/pale/pigmented/ clean/ dirty/ smooth/rough/ dry/ oily/elastic/ Non elastic
Nails : clean/dirty/brittle/pink/pale/cyanose/white patches/ spoon shaped nails
Feet : clean/dirty/cracked heels
Toe nails : short/long/clean
Respiratory system : rate/pattern/abnormal sounds/dyspnea/haemoptysis
Cardiovascular system: pulse: tachycardia/bradycardia/palpitation
GIT system: appetite : good/fair/poor/abdominal pain/indigestion /vomiting/Polydypsia/dyspepsia
Bowel habits : regular/constipation/diarrohea
Urinary System : normal/polyuria/oliguria/incontinent
Colour : straw/yellow
Muscular system : extremities: normal/any deformity/odema/pain
Bones and joints : normal/congenital anomalies/stiffness/swelling/limited movement/backache
Central Nervous System : oriented to time, place and person/confused/disoriented/nervousness/mood changes/memory loss
4)Habits
Sleep: 8-10 hrs/less than 8 hrs
Personal Hygiene: good/fair/poor
5)Sociological Health
Relationship with Family members/peers/significant others.............................
Relationship with neighbours: good/frequent fights
Occupational history: satisfaction with employment
Economic status perception of adequacy or inadequacy of income - Pattern of health
care: preventive/promotive/curative
6)Cognitive abilities
- - - - Intellect comprehension
- - - - Learning pattern
- - - - Memory
- - - - Concentration
- - - - Judgement
7)Spiritual Health
- - - - Faith in god: yes/no
- - - - Goes to temple/church: yes/no
- - - - Attitude towards health/disease: religious/neutral/fatalistic –
- - - - Respect towards other religions
8)Psychological Health
- - - - Behaviour
- - - - General appearance/facial expression
- - - - body posture
- - - - mannerisms
- - - - motor activity
- - - - Speech pattern
- - - - General mood and manner
- - - - Abnormal eating patterns
- - - - Memory
- - - - Orientation to time, play, person
- - - - Thought process
- - - - Thought context.
- - - - Respect towards other religions
8)Psychological Health
- - - - Behaviour
- - - - General appearance/facial expression
- - - - body posture
- - - - mannerisms
- - - - motor activity
- - - - Speech pattern
- - - - General mood and manner
- - - - Abnormal eating patterns
- - - - Memory
- - - - Orientation to time, play, person
- - - - Thought process
- - - - Thought context.
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