Richardson, The main disadvantage of the pre printed care plans is that it can be used as a checklist, the nurse only asking closed questions simply ticking the relevant boxes, not utilising her experience and knowledge.
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On the other hand, the advantages are evident in that they are in line with the original model and create a systematic guide, incorporating all the steps necessary for patient care. If used correctly the assessment process helps the nurse obtain an all round holistic picture of the patient. During the initial interview here are two types of data to collect. Objective data, which is, observable and measurable, and subjective data which only the patient can describe and explain. Wilkinson, Both types of data are of equal importance, although it is probably easier to obtain objective data as the patient may feel awkward or embarrassed about discussing certain things and should be encouraged, by asking further open questions.
Confidentiality should be emphasised at this point, informing the patient of their right to confidentiality. NMC, The nurse, explaining to the patient why so much information is needed.
Both types of data can be from either a primary or secondary source. The medical notes, including, previous reports and test results. It should be mentioned that the NP although important for patient care, is not an interrogation. Perception and intuition as to the mood or condition of the patient should be observed. If the patient is in pain or unwell, the assessment process should be discontinued, then completed at a later stage.. Essential information can be obtained from the secondary sources mentioned.
Emerson, states that Critical thinking in nursing is an essential component of professional accountability and quality nursing care Tanner, cited in Emerson p states that many nurse educators are reported to recognize that critical thinking is closely related to the nursing process However the definition of Scheffer and Rubenfield cited in Emerson p sees critical thinking as more than just a cognitive activity, incorporating creativity and intuition It could be argued that both are right the nursing process incorporates both cognitive and affective aspects.
The cognitive approach allows the nurse to call to mind her experience and knowledge, at the same time using creativity to read between the lines and ask more open questions gaining more information. Planning is the second stage of the nursing process the phases are interdependent and over lapping therefore the effectiveness of this stage depends on the quality and comprehensiveness of the assessment.
Wilkinson, Establishing goals, interventions and outcomes is the aim of the planning stage. Kozier, et al Planning should begin soon after the initial assessment is carried out, usually by the nurse taking the assessment. All nurses who care for the patient should take part in the ongoing planning, amending if circumstances change.
Although accurate documentation is an essential part of the registered nurse and health care assistants role HCA RCN in many wards HCA provide much of the physical care and may not have not been taught the significance of a care plan and may not report changes, or document correctly.
It is important to remember the care plan is important in the continuity of care of the patient and may be referred to by members of the multi disciplinary team MDT. The planning stage determines the problems and establishes the risks and priorities Wilkinson, The patient should be involved as much as possible in this stage.
Nursing Practice and Decision Making Essay Example | Topics and Well Written Essays - words
The nurse not making assumptions about the patients problems, needs and abilities but should confer with the patient, giving the patient the opportunity to contribute to their care planning. Although in some cases the nurse may need to utilise her skills and knowledge advising the patient on certain aspects of their health, the patient not relishing the importance of a problem or need.
Again sensitivity and empathy are important at this step, not just simply treating interventions as a series of tasks but to treat the person holistically explaining why the planned interventions are important.
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For example if a person as pressure ulcers, it should be explained why mobility is important also emphasising the importance of good nutrition explaining that referral to a dietician may be necessary. Implementation is the next step involving putting the plan into action.
It is not necessarily the nurse who initiated the care plan who should be accountable; as all qualified nurses are accountable and must always be able to justify action and omissions NMC, for that reason the nurse caring for the patient, when the task is carried out is responsible. Kozier et al, Not only to protect herself but for the implications to the patients welfare and safety. However other professionals contributing to the care are also accountable. Before Implementation the patient must be reassessed, to make sure an intervention is still needed. It would be unfair and unethical to subject a person to unnecessary treatments, referring to other members of the MDT if there is any doubt.
Kozier et al Looking at the patient as a person not just their medical needs is also a fundamental skill in nursing. Respecting their beliefs and values, when considering interventions, adapting interventions to the patients needs if required. For example a person with pressure ulcers who needs to be turned regularly may ask if they can be left undisturbed when their relatives come to visit, this request must be adhered too if possible. Explaining to the patient that all efforts will be made to comply with their wishes, however it may not be possible. Going back on an agreement could damage the nurse patient relationship causing friction between them.
Evaluation is the fourth step of the NP and is used to determine the effectiveness of the Care plan establishing if outcomes have been met, whether they should be continued or changed Kozier et al Lynda Juall states that, evaluation may be the most difficult stage of the NP. Describing evaluation as a step may be incorrect, since evaluation should be a continues process, mentally taking notes and evaluating throughout the implementation stage. Although the nurse may be busy and have more than one patient to attend to, it is vital that all observations and actions are documented, so that other nurses and members of the MDT can judge the efficiency of an intervention.
Protecting the patient from procedures that may be ineffective or no longer needed.
decision making by a nurse
The purpose of this paper is to analyze my decision of administering ativan by advocating for the patient and anticipating her change prior to confirming signs; which provided a therapeutic response. Clinical Decision During my community placement of the cataract clinic at St. The model places major emphasis on the quality of relationships, salience and pattern recognition, healing initiatives, critical reflection to analyze a situation pre and post and to value different ways of knowing. The client along with the nurse is intertwined in the center of the framework highlighting the importance of their relationship.
In this situation, being directly involved with the patient provided an opportunity to create a relationship on the basis of providing health and healing measures CAEN, Coming to Know the Client The first stage of this framework is coming to know the client, which requires the nurse to understand that the personal meaning of health and healing is individualized and the context of this area is highly subjective. In the case of this patient, the decision was based off a cue; a change.