Step I. Patient Assessment
Collecting information or data about the patient and identifying problems requires the following steps :
- Completing an admission interview
- Conducting physical examination
- Reading reports and the notes of others
- Referring to written resources as necessary
- Using one`s own nursing knowledge to analyze information
- Stating the patient`s problems or potential problems as nursing diagnoses
In-depth assessment will provide clues to recent stress the older patient may have experienced and has been reluctant to mention. For example, Mr. J is 72 years old and is admitted to the hospital by rescue squad with headaches and dizziness after he “blacked out for a while”. By asking questions about his family, and where they live, the nurse learns that his 17-years-old grandson was killed in a recent car accident. This will be a consideration in assessing his symptoms, his moods, and his interactions.
Misunderstandings about medications, past treatments, and medical advice often some to light in the course of an interview. In this way, the nurse learns about the elderly patient`s health education needs.
Step II. Nursing Diagnoses
The nurse analyzes information and develops nursing diagnoses. These diagnoses describe the problems that interfere with meeting the patient`s basic needs, along with possible contributing factors. Nursing diagnoses are recorded on the care plan and are the basis for establishing goals and planning care. A nursing diagnosis gives all of the team members a point of reference to explain why a specific plan is place, and it assists them in making observations.
For example, an older patient often has impaired physical mobility, and will either be unable to ambulate or will require assistance. When the nurse makes a decision about the reason for this limitation, and states this in a nursing diagnosis, nursing care can be more patient-directed.
Let us consider two different patients. One had heart disease and this diagnosis :
“Impaired physical mobility related to pain, fatigue, edema, and medication”.
The other patient has a neurological problem with this nursing diagnosis:
“Impaired physical mobility related to weakness, vertigo, and poor coordination”.
Although both patients will have a nursing order to be ambulated with assistance, the assistance will be different. The neurological patient will have a cane. The cardiac patient needs a nurse at his side and holding his arm. Other orders for care and observations will also vary in accordance with the factors that cause the limitations of these patients. For instance, after ambulating, the patient with heart disease may need to have his lower extrimities elevated to decrease edema.
Step III. Planning Care
Before the nurse can plan care, goals should be established. Goals are patient behaviors or expectations that indicate has been solved or prevented. Whenever possible, the patient should help set these goals. Goals must be specific and realistic, and they must relate to the nursing diagnoses :
- Short-term goals : to be met in the hospital, in a matter of hours or days. Example : the patient will independently drink six glasses of water every day.
- Long-term goals : what the patient hopes will eventually happen. Example, the patient will weigh 150 pounds by (date). (20 pounds weight loss in 4 months) The nurse decides what kind of nursing actions could be taken and then selects those she judges to be the most workable. These are written as nursing orders on the care plan. This is an example of a nursing order : Encourage the patient to drink a glass of water at 8 A.M.-10-12-2-4-6 P.M.
Step IV. Implementations
The nurse puts the care plan into action. Besides giving care, the nurse must observe how the patient is responding. Nursing actions and patient responses are accurately and clearly charted.
Step V. Evaluating Care
The nurse reviews the goals and checks patient progress as documented in the chart and by further patient assessment. The plan is updated with new nursing orders as necessary.
Reference :
Farrell J : Nursing Care of the Older Person, J.B. Lippincott Company, Philadelphia, 1990.
