Patient Assessment and Care Plan Development - Free Samples

Question: Discuss about the Patient Assessment and Care Plan Development. Answer: Introduction: The nursing process provides an orderly and logical way in problem-solving approaches for administers in the nursing care unit so that the customers needs are efficiently met (DOENGES MOORHOUSE, 2012, p.5). The nursing process comprises of five steps which are the assessment, diagnosis, planning, implementation, and evaluation. The environment in which the assessment of the patient gets done should be safe to minimize any risk that may occur to the nurse or the patient (Smith and Rushton, 2015, p.34). The patient's room can be assessed for any material or wire that may cause risk during the assessment. Another crucial factor to consider before the evaluation is the privacy and dignity of the patient remains confidential by drawing the curtains around the patient's bed. Moreover, the patient should be at rest and comfortable emotionally and physically before the assessment begins. According to Smith and Rushton (2015, p.34), the nurse should also ensure that all the equipment she needs are available in good working condition before the assessment begins. This equipment may include a watch, stethoscope, a pulse oximeter and score chart to fill the findings after making observations. The nurse can also check the hygiene of her hands before beginning the assessment of the patient. According to Banet et al. (2013), vital signs can be detailed research on established findings of the patient, and they provide more credible information on the treatment measures to be taken on a patient. It may involve the nurse understanding the adequacy of oxygenated tissues in the blood that will enable natural breathing for the patient. For instance, a patient can be suspected of hypoxia when the signs and symptoms indicate low-oxygen levels in the blood (SHELLEDY PETERS, 2016, P.188). Other significant signs and symptoms may include excitement, restlessness, headache, and overconfidence. When the nurse does a physical examination of the patient, he or she has an increased heart rate and respiratory rate which raised the blood pressure and respiratory distress signs. The nurse, therefore, measures the pressure pulse launched by the heart within a specified period. Another simple test that is made by the nurse is when she measures the saturation of oxygen by pulse oximetry which provides an estimate of the oxygen saturation that safe and convenient (SHELLEDY PETERS, 2016, p. 189). Either way, the nurse may decide to make a direct measure of the patient's arterial oxygen composition. Though it is a suitable method to be used by nurses, it quite expensive and time consuming compared to other ways. According to SHELLEDY PETERS (2016, p.189), the treatment of hypoxia depends on the rate at which it may have affected the patient because the signs and symptoms tend to differ depending on the degree of infection. For instance, a patient with mild hypoxia will tend to have an increase in the breathing rate and shortness of breath which increases the heart rate and mild hypertension. It causes a patient to be overconfident, excited, tired, restless and in some cases, the patient feels dizzy (SHELLEDY PETERS, 2016, p.190). The moderate hypoxia is said to be identified by intercostal retractions and tachypnea which causes hypertension among its patients. The moderate hypoxia may cause agitation, impaired judgment, decreased in night vision and confusion. The severe hypoxia is characterized by strict respiratory arrest and cyanosis which result in cardiac arrest, hypertension which is later followed by hypotension. Most of the patients in this stage experience severe headaches, comma and sometimes unconsciousness (SHELLEDY PETERS, 2016, p.190). Primary Assessment of the Respiratory patient The assessment of the breathing rate of the patient is essential to find comprehensive information about what may be ailing the patient. According to GEHRIG WILLMANN (2013, p.224), the nurse may assess a series of steps which may include her placing her hands on the patient to feel the chest rise which enables her to know that if the patient is breathing in and out at an average rate. Furthermore, she may count the number of times the chest rises for about 30 seconds and multiply by 2 to find the patient's respiratory rate. The nurse takes sufficient time doing this so that she may make the critical observation on the rate of breathing and characteristics of what happens when the patient is breathing in and out (GEHRIG WILLMANN, 2013, p. 224). Therefore, the nurse can note if the breathing of the patient is irregular and she may also further her observation when she listens for any unusual breathing sounds. She can know if the patient requires a lot of effort to breathe because an average person's breathing is usually quiet and effortless. Furthermore, the nurse can understand if the breathing is abnormal when the patient breaths rapidly or has a weak air intake into the lungs (GEHRIG WILLMANN, 2013, p.224). According to GEHRIG WILLMANN (2013, p. 225), during the respiration assessment, it should be best done immediately after taking the pulse of the patient and the patient should not know whether the nurse measures his or her respiration rate. It is essential because respiration rate is under voluntary control and therefore if the patient knows that the nurse is counting the breaths she or he is making, the patient may change the breathing pattern (GEHRIG WILLMANN, 2013, p.225). This will result in inaccurate information regarding the patient which is very dangerous as it may lead to wrong diagnosis. Hence, after determining the pulse rate of the patient, the nurse should keep her fingers in a resting position on the patients wrist and begin making assessment on the patients breathing rate. This will keep the patient at rest since she or he may assume that the nurse is still counting her pulse rate. Furthermore, the nurse may observe the patient's breathing rate through the use of peripheral vision which sees the rising and falling of the chest through the patient may control the breathing rate voluntarily (GEHRIG WILLMANN, 2013, p.225). During this period of observing the rise and fall of the patient's chest when breathing, the nurse can note whether there is an abnormal breathing pattern when she counts the number of respirations the patient has made in 1 minute. It will further the nurse's findings on the unusual breathing characteristics of the patient. After all the results, the nurse can record the observations and conclusions in the patient's charts. It mostly relies on knowledge taught and it's a bit complex because it revolves around nursing theories and practices. Therefore, nurses may find it hard to understand how some aspects relate to care planning. According to Moura et al. (2015), the Roper-Logan nursing model aims at providing theoretical knowledge about nursing care based on daily living activities. The model is used by a nurse to assess the independence of the patient depending on their actions on a regular basis. It helps the nurse in determining which interventions may lead to increase independence as well as what are the ongoing support that is needed to terminate any dependency that may still exist (Moura et al., 2015). Hence, the nursing care plan comprises of what needs to be done to solve the actual problem that is ailing the patient. It also helps the patient to have a positive mindset on issues that they may experience and cannot get cured. Therefore, the activities done on a daily basis should not be in a checklist, but instead, Roper says that the nurse should view them as a cognitive approach on the care and assessment of the patient. The model states that the patient on admission undergoes evaluation and her or his independence and dependence should undergo review throughout the evaluation and care plan. Hence, the nurse is able to check if a patient is improving or not through observation of the patients change in the independence and dependence continuum. The model also includes activities of living such as eating and drinking, breathing, elimination, mobilization and maintaining a safe environment (Moura et al., 2015). For the assessment made, hypoxia affects the rate of breathing as one of its vital signs. The disease further results in hypertension and loss of consciousness. About breathing, Roper states that the mechanism of respiration is the expansion of the lungs to inhale oxygen which is followed by the relaxation of the lungs when exhaling carbon dioxide. The module further states that oxygen is transferred from the lungs to the tissues of the body through the blood and carbon dioxide is removed from the tissues through the blood when the lungs exhale and relax. According to Roper et al. (2012), he states that many activities affect the activity of breathing. For instance, diseases that affect the lower and upper respiratory duct which can lead chronic bronchitis, cancer of the lungs, asthma and acute conditions. Furthermore, Roper states that sniffing of toxic components may lead to adverse health effects and may lead to other diseases such as coronary heart disease and cardiac arrest. Hence, the nurse is required to make observations and note problems relating to the changes in the rate, rhythm, and manner of breathing. From the assessment made, hypoxia can be handled by the nurse through determining the pace and rhythm of the heartbeat which enables her to provide the appropriate medication for the illness and prescribe it accordingly. According to the Ropers module, this is the third stage of the nursing process, and it provides evidence of how the nurse intervenes to solve the problem that the patient may be experiencing. It made possible due to the range of knowledge and skill that the nurse has and being an expert in her field of work. The nurse advice the patient on the importance of having more oxygen in the body to get rid of the illness. The nurse may issue the patient with an inhaler so that it can make breathing more comfortable for the patient. Inhalers fall under the category of primary treatments for hypoxia because they deliver high oxygen levels that a patient may need (Stern and AESRX LLC, 2013). If the patient does not respond to this medication the in the nurse would try to give medicine through the veins in the arms and the use of a little of the steroid drugs for purpose within a limited time to shrink the inflammation in the lungs of the patient. For the treatment of a moderate and severe hypox ia patient, medications administered to the patient in prescribed dosage at the intervals of 1-2 hours. The use of best dosage levels provides the patient with better chances of recovering faster. The other step the nurse may undertake for the welfare of the patient is giving the patient dosage that can handle the adverse effects of the illness such as heart rate, respiratory rate and pressure of the blood (Stern and AESRX LLC, 2013).According to the Roper's module, any nursing care plan implemented will have numerous benefits to the patient. This also provides the base for providing the care that a patient may need as his or her situation continues to change. At this stage is where the nurse evaluates whether the care and medication they gave the patient has efficiently worked on making the patient feel better (DOENGES MOORHOUSE, 2012, p. 130). For instance, the patient who was suffering from hypoxia has resolved the breathing problem he had by doing deep-breathing exercises which have helped in oxygen restoration in the blood and tissues of the patient. Furthermore, the use of the inhaler has contributed to the oxygen restoration in the blood of the patient, and this has made his breathing rate to be normal since he is no longer trying to gasp for air. At this stage, the nurse can readjust to priorities she had made earlier if by the end of the evaluation it will not have accomplished them. References Banet, M.J., Zhou, Z., Kopotic, R.J., Dhillon, M.S., Terry, A.S. and Henk, V.I., Sotera Wireless Inc 2013,Device for determining respiratory rate and other vital signs. U.S. Patent 8,506,480. DOENGES, M. E., MOORHOUSE, MF 2012,Application of nursing process and nursing diagnosis: an interactive text for diagnostic reasoning. Philadelphia, PA, F.A. Davis Company. https://public.eblib.com/choice/publicfullrecord.aspx?p=1109625. GEHRIG, J. S., WILLMANN, DE 2013,Patient assessment tutorials: a step-by-step procedures guide for the dental hygienist. Philadelphia, Wolters Kluwer Health/Lippincott Williams Wilkins. Moura, G.N.D., Nascimento, J.C.D., Lima, M.A.D., Frota, N.M., Cristino, V.M. and Caetano, JA 2015, Activities of living of disabled people according to the Roper-Logan-Tierney model of nursing.Northeast Network Nursing Journal,16(3). Roper, N., Logan, W.W. and Tierney, AJ 2012, Model of nursing: explanatory booklet. SHELLEDY, D. C., PETERS, JI 2016,Respiratory care: patient assessment and care plan development. Smith, J. and Rushton, M 2015, How to perform respiratory assessment.Nursing Standard (2014+),30(7), p.34. Stern, W., AESRX LLC 2013,Treatment for hypoxia. U.S. Patent Application 13/547,462.