Wanda Scott. Norquest College NFDN Assignment 2. Nursing Process / Care Plan. Cindy Hoyme

Transcription

1 Running Head: ASSIGNMENT 2: NURSING PROCESS / CARE PLAN 1 Wanda Sco Norques College NFDN 1001 Assignmen 2 Nursing Process / Care Plan Cindy Hoyme

2 Inroducion This is a Nursing Care Plan o pracice criical hinking and follow nursing conceps and he nursing process. This will analyze crieria from he scenario and goals will follow he SMART forma. Raional will be suppored by acceped raionals, and summery provided oulining evaluaion and effeciveness of he nursing inervenions. Scenario Your roommae is a suden in he Pracical Nurse program. She confides in you he following: I is he middle of November and she has one monh lef o complee her course work, sudy for finals and finish buying her Chrismas presens for family and friends. She is having difficuly mainaining her par-ime job a Sporcheck since she is working hree 12-hr shifs in he clinical seing, plus she is aking an English course one evening a week. She has been up several nighs rying o complee a scholarly paper and is having difficuly wriing i. She has conemplaed seeking help from he college uor for his. She has been eaing ake-ou pizza and coffee o keep herself going bu has alked o one of her insrucors abou how bes o ea healhy on a suden budge. Two of her peers jus called in sick o clinical complaining of vomiing and diarrhea and she had spen he previous afernoon wih hem in sudy group. On op of all his, her boyfriend is pressuring her o spend more ime wih her. She is finding i difficul o juggle all of hese responsibiliies and is feeling very anxious. As she is your roommae, you are also aware of he following: She is 19 years old, has wo younger siblings and boh parens are living. She has moved from New Brunswick o Albera wih her boyfriend. Her family remains in New Brunswick. She is allergic o shell fish She has been diagnosed wih Ashma as a child and uses Venolin puffers occasionally when needed. She akes no oher regularly scheduled medicaions.

3 STEP 1 Clien Name: Susan Smar Medical Diagnosis: Ashma Clien Percepion of Healh Needs: Manage Anxiey, Improve nuriional inake Clien Goals for Healh: Decrease work load, ge assisance wih paper and improve knowledge for beer eaing. Allergies (food, medicaion, environmenal) Medicaions Dieary consideraions Shellfish Venolin MDI Avoid crusacea (shrimp, crab, lobser, clams) and mollusks (mussels, oysers and scallops). STEP 1: NURSING ASSESSMENT FORM HEALTH ASSESSMENT DATA Fill in daa from he scenario Clien Susan is experiencing anxiey from her work load from he Pracical Nurse Program and a evening English course, a paper ha is due, sudy for finals, par-ime job and a hree clinical shifs. Susan is also concerned abou he pressures of Chrismas and her limied ime o complee especially he need o purchase presens for family and friends. Time managemen difficulies due o her par-ime job and pressure from her boyfriend. She saes she is finding i difficul o juggle all of hese responsibiliies and is feeling very anxious. Healh 19 y/o. Unknown weigh and heigh. Admied o improper food inake - coffee and pizza. Recen exposure o flu like sympoms, or similar possible conagan. Ineffecive sleep - busy schedule; PN program, nigh course, 12/h clinical shifs (x3), and saying up rying o finish paper, par-ime job and limied/decreased social conac wih boyfriend. Spiriual Variable (Environmen) Unknown spiriual pracices / beliefs / riuals Unknown spiriual guidance Developmenal Variable (Environmen) Relaionship wih boyfriend Relaionship wih family Sociological Variable (Environmen) Assume primary language is English Unknown culure, recreaion, exercise, hobbies or social aciviies Paricipaes in a sudy group Psychological Variable (Environmen) Parens live in New Brunswick Suppor form College for paper wriing Feels anxious wih overload of responsibiliies Boyfriend - pressuring for more ime, increasing load

4 HEALTH ASSESSMENT DATA Deerminans of healh impacing clien s healh (Environmen) Pending due daes: paper, final exams, Chrismas gifs Time pressures: par-ime job, 3 clinic 12/h shifs Limied suppor sysems- boyfriend seems no o undersand, family no in he same ciy, unknown abou friend/oher suppor sysems Poor nuriion- coffee and pizza Faigue / lack of sleep Healh Prioriies as deermined by he Nurse and Clien Decrease anxiey Manage schedules / prioriize /increase sleep Ge assisance - uor for paper and nuriion on a budge from nursing insrucor Clien Srenghs as deermined by he Nurse and Clien Deermined o finish paper and sudy for finals so ha she obains good grades. Willing o seek help and learn, uor and nursing insrucor. She is quesioning why her boyfriend is causing exra sress by asking for more ime from her already busy schedule and sressed sae.

5 STEP 2 Acual Nursing Diagnosis Anxiey - mild/moderae As Evidenced by: saemen she is feeling anxious, also her demanding schedule- PN classes and nigh classes, clinic hours, par ime job, slighed boyfriend, final exams and Chrismas preparedness. May be relaed o: Real or perceived hrea o self-concep, goals of life, unme needs, persisen feelings of apprehension and uneasiness, a general anxious feeling ha a clien has difficuly alleviaing. Level of anxiey being experienced by he clien, personal vulnerabiliy, inadequae coping mehods and/or suppor sysems, possible evidenced by verbalizaion of inabiliy o cope or problem solve. Risk for Insomnia may be relaed o psychological sress, repeiive houghs. Risk for compromised family Coping: risk facors may include inadequae or incorrec informaion of undersanding by a primary person, emporary family disorganizaion and role changes. Risk for Impaired Social Ineacion/Social Isolaion: Low self concep, inadequae personal resources, or wihdrawal or repored change in paern of ineracions. (Doenges e al., 2010, p ) Poenial Nursing Diagnosis Sleep Paern Disurbance Faigue As Evidenced by: been up several nighs o complee her paper, hree 12/h shifs in he clinic, PN program, nigh classes and a par-ime job. May be relaed o: Inadequae sleep, possible evidenced by verbalizaion of unremiing and overwhelming lack of energy and compromised concenraion. Risk for Role Performance: risk facors may include healh aleraions, sress. Chronic pain evidenced by verbal repors of headache, sore hroa, arhralgia, abdominal pain, muscle aches, alered abiliy o coninue precious aciviies, changes in sleep paerns. (Doenges e al., 2010, p. 983)

6 Wellness Nursing Diagnosis Nuriion alered, less han body requiremens Infecion, risk for As Evidenced by: eaing pizza and coffee o keep herself going, recen close conac wih possible conagious people (now exhibiing diarrhea and vomiing). May be relaed o: Nuriion herapy o decrease risk of infecion or infecion proecion. (Bulecheck e al.,2013, p.509) Food inake, possible by weigh loss, poor skin urgor, decreased muscle one. (Doenges e al., 2010, p. 939) Choice of daily rouine lacking physical exercise. (Doenges e al, p. 1020)

7 PRIORITY NURSING DIAGNOSIS Anxiey - mild/moderae CLIENT GOAL Wrie one specific and measurable clien behavioural response. CLIENT-CENTRED OUTCOME Wrie saemens in measurable erms ha suppor he goal by using he SMART crieria: Specific Measurable Aainable Realisic Time-based Clien involvemen and response o inervenions, eaching, and acions performed Appear relaxed and repor anxiey is reduced o a manageable level. Anxiey will be measured on a 1-10 scale. Assis clien o idenify precipiaion facors and new mehods of coping wih disabling anxiey. Inervenions ha fi ino her schedule and aid in reducing he cliens load (paper, final exams and compleion of clinic shifs) Reassessed in weekly inervals Exercise: For every wo hours of sedenary work, en minues of moderae aciviy (yoga, walking or variey of ses), documened in daily journal. Daily conversaion (scheduled) o evaluae sress, exercise and o provide posiive feedback and increase self-eseem. IDENTIFY 3 NURSING INTERVENTIONS Selec nursing inervenions o mee he goals se, and o change or mainain healh saus 1) Esablish a herapeuic relaionship, conveying empahy and uncondiional posiive regard. (Doenges e al., 2010, p. 66) 2) Encourage clien o develop an exercise/ aciviy program, which may serve o reduce level of anxiey by relieving ension. (Doenges e al., 2010, p. 68) 3) Idenify acions and aciviies he cliens previous used o cope successfully when feeling nervous/ anxious. (Doenges e al., p. 68)

8 RATIONALE FOR INTERVENTIONS Provide raionale for selecion of nursing inervenions and use appropriae lieraure such as ex, aricles, and inerne sies o suppor inerne sies o suppor choices Esablishes clien o become comforable and o begin looking a feeling and dealing wih siuaion. (Doenges e al., p. 66) Open exploraion can make he siuaion less hreaening and encourages behaviours ha expand selfawareness. You encourage he clien s self exploraion by acceping he clien s houghs and feelings, by helping he clien clarify ineracions wih ohers, and feelings, by helping he clien clarify ineracions wih ohers, and by being empaheic. (Poer e al., p. 411) i is beneficial o reinforce ha exercise can be incorporaed in small amouns - as lile as 10 minues a a ime. (Poer e al., p. 783) May be helpful in reducion level of anxiey by relieving ension and has been shown o raise endorphin levels o enhance sense of wellbeing. (Doenges e al p. 68) Knowledge of how a clien has handled pas sressors can enable insigh ino he cliens syle of coping. Exploring resources and srenghs, such as he availabiliy of significan oher or communiy resources and be imporan when developing a realisic and effecive plan. (Poer e al., p. 407) Realizing ha individual already has coping skills ha can be applied in curren and fuure siuaions can empower clien. (Doengers e al., p. 68)

9 EVALUATION Describe how you plan o evaluae if he goal was me or no me. Daily communicaion o assess anxiey signs and sympoms. Verbal cues and saemens regarding well being or self-concep or accepance would provide a feedback mehod. (Poer e al., p. 405). I is imporan o share observaions for validaion and allow Susan o provide inpu and verify percepions. This allows for greaer insigh and clariy. (p. 407) Level of anxiey and precipiaion or aggravaing facors, verbal descripion of feeling (expressed and displayed, awareness or abiliy o recognize and express feeling and relaed subsance abuse (if any). (p.68) Signs ha Susan has reduced some of he sressors (exams, paper, Chrismas shopping), ogeher wih coping suppor will lesson daily sress. Eiher daily or weekly sress evaluaions (scale 1-10). Monioring coping behaviours: (Poer e al., p. 406, 412) Daily exercise log for racking, monioring and re-evaluaion. Correlaion wih sress scale indicaes a posiive response, elevaion of sress would indicae a modificaion is needed. (Poer e al., p. 77)

10 Summary The nursing process is a valuable ool for nurses, a comprehensive process ha forifies he professionalism wih evidence based and researched bes pracice guidelines. This is a foundaion on which we gaher informaion, provide a nursing diagnosis, provide planning, implemen and finally evaluae he oucome. This is a circular process, wih a diligence for change, reassessmen and openness o expand our nursing plan, all for he very bes possible care and o promoe wellness. For he assessmen phase of he nursing process here was only he wrien scenario for informaion. There was no objecive informaion available, vials, weigh, heigh, visual observaion of body language, demeanour, affec, shaking/remor, eariness, eye conac o coun jus a few. Subjecive daa from he scenario included: her course load in he Pracical Nurse program including her 3 clinic shifs, oher demands from a nigh English class, and impending final exams. Susan also has many oher ime consrains, her par ime job, Chrismas shopping for her friends and family and o furher compound her sress her boyfriend is pressuring her for more of her ime. Susan is admiing o no handling he sress well and rying o cope wih saying up nighs o ge her paper done, and relying on pizza and coffee o keep her going. In he diagnosis phase, he firs prioriy of he Nursing Diagnosis is mild/moderae Anxiey. The clien s srengh is ha she is willing o seek assisance for her problems. Susan can and should seek her nursing insrucors experience wih beer nuriion and her budge. She is also

11 eneraining geing help from he uor for her paper ha is due, bu she also could ge some sudy ips for her finals ha migh help her o sudy beer and faser herefore freeing up some much needed ime. Willingness o help yourself is he very firs sep o improving her qualiy of life and helping her hrough his sressful ime. These coping skills will help build self eseem, forify her characer and provide sraegies for furher sressful evens in her life. She is young and living wih her boyfriend quie a disance from her parens. No relaionship hisory is given, so his sressor is only a possibiliy. There are many more nursing diagnosis ha could apply o his scenario; Coping, defensive and ineffecive, Relocaion sress syndrome, Adjusmen impaired, Role performance alered, Social ineracion, impaired, Risk for infecion, Risk for Powerlessness, Fear, Risk for compromised resilience,self-eseem siuaional low, Nuriion, less han body requiremens, imbalanced, Faigue,Insomnia, Knowledge (need o learn coping, nuriion and exercise sraegies) deficien, and readiness for enhanced. In he Planning phase i has been deermined ha here are many differen ways o increase Susan s wellness, decrease her sress and aid in some copying sraegies. If she received help from a uor, she could possibly decrease her sudy ime and finish her paper. his would free up ime for oher aciviies (such as exercise, fulfilling her need for some down ime or ime for socializing wih friends or her boyfriend), and possibly increase her ime for sleep. Finishing her paper would help decrease her sress and decrease her o do lis. Exercise would help alleviae her sress by providing endorphins and providing a healhy sudy break (improving circulaion during sedenary periods - siing he new smoking).

12 Providing addiional knowledge abou nuriion will add in basic body needs including abiliy o focus, sleep and performance. This would figh faigue and fulfill basic body funcion. Nuriion will boos immuniy and assis naural defences when in conac wih conagion. A herapeuic relaionship will provide a oule for feedback, serve o monior and evaluae and provide some valuable reinforcemen which will boos self eseem. Implemening pus he plan in acion. As saed in he planning phase he uor plays a vial role decreasing sress, reducing load and possibly increasing free ime. Exercise breaks could be planned and documened for racking and o serve as a reminder. For every wo hours of sudy a en minue break of moderae aerobic aciviy could be planned. Depending on resources, Susan could do si-ups ses puncuaed wih ses of jumping jacks/ burpies, walking/running, sreching or a video of yoga. Nuriion on a budge, weekly shopping guide will increase ime wih preparaion and meal planning. I will increase srengh, vialiy and wellness. Scheduled daily conversaions serve o monior an mainain relaionship. This would increase self-eseem, and monior sress. Evaluaion phase provides a basis for change and modificaion. Exercise could be increased as ime consrains change and load decreases. Daily conversaions could decrease o wice a week once a week, or could increase o wice daily depending on circumsances. his plan is fluid

13 and will depend on he measurable deerminans - he scale 1-10, saemens made by Susan and especially he decreasing commimens and ime consrains. The SMART forma ensures ha his planning phase has concree and measurable deerminans. This plan helps boh he nurse and he clien remained focused o a plan ha has realisic goals and oucomes.

14 References Doenges, M., Moorhouse, M. F., Moorhouse, M. F., Murr, A. C., (2010). Nursing Diagnosis Manual. Philadelphia: F. A. Davis Company. Poer, P. A., Perry A. G., Socker, P. A., Hall, A.H., Canadian Ediors: Ross-Kerr, G. C., Wood, M. J., Asle, B. J., Duggleby, W., ( 2014). Canadian Fundamenals of Nursing. Torono: Elesevier Canada.

15 KEY CONTENT MARKING GUIDE POINTS: NURSING ASSESSMENT Enered assessmen of clien findings (clien name, medical diagnosis, percepion of healh needs, clien goals for healh, allergies, medicaions, dieary consideraions, clien assessmen, healh assessmen). Enered assessmen of environmen findings (Spiriual, Developmenal, Sociological, Psychological, and Deerminans of Healh) Enered healh prioriies and clien srenghs Commens: /15 NURSING CARE PLAN: NURSING DIAGNOSIS Wroe a nursing diagnosis saemen ha focused on an acual problem in reference o a clien srengh or healh need, relaed facors, and evidence presened Wroe a nursing diagnosis saemen ha focused on a poenial problem in reference o a clien srengh or healh need, relaed facors, and evidence presened Wroe a nursing diagnosis saemen ha focused on a wellness diagnosis in reference o a clien wellness need, relaed facors, and evidence presened /15

16 KEY CONTENT MARKING GUIDE POINTS: Commens: GOALS/EXPECTED OUTCOMES Chose a prioriy diagnosis wih raionale Wroe one general goal saemen for he prioriy diagnosis Wroe one expeced oucome ha included measurable crieria by using he SMART crieria Commens: /15 INTERVENTIONS Nursing inervenion 1. Provided suppor for each inervenion wih evidence from he lieraure Nursing inervenion 2. Provided suppor for each inervenion wih evidence from he lieraure Nursing inervenion3. Provided suppor for each inervenion wih evidence from he lieraure /15

17 KEY CONTENT MARKING GUIDE POINTS: Commens: EVALUATION Idenify how you plan o evaluae if goal/ expeced oucomes were me or no me wih raionale Commens: /5 SUMMARY Described he benefis of using he nursing process and he nursing conceps (meaparadigm conceps and SMART crieria) in assessmen and nursing care planning Commens: /5 TOTAL /70

18 APA and Grammer Marking Guide KEY CONTENT MARKING GUIDE POINTS: TITLE PAGE Included: header and page number; running head; dae. Remaining iems cenred: ile of paper, suden name, college name, course and secion number, assignmen name and number, insrucor name BODY OF PAPER Paper organized header and page number; inroducion, body and conclusion; appropriae margins, double-spaced hroughou, inden 5 spaces or 1 ab for new paragraphs, correc fon Times New Roman, 12-p. fon. REFERENCES Ciaions in body of paper follow APA forma References, on separae page, follow APA forma GRAMMAR AND SPELLING Grammar appropriae and words spelled correcly (< 5 errors) TOTAL /5 Commens: GRAND TOTAL (ALL MARKING GUIDES) /75

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