Nursing Process Essay on Professional Experience Practice Analysis

Question

Task: The Nursing Process is a sequence of problem-solving steps used to identify and to manage the health problems of patients. The nursing process is commonly used by nurses to develop individualised plans of care for patients. The steps in the nursing process include Assessment, Diagnoses, Planning, Implementation, and Evaluation. Students are required to use the framework outlined below to assist with the formulation of their Professional Experience Practice Analysis (nursing process essay). Select a patient that you were directly involved in the nursing care of during your professional experience placement for this PEPA. Please ensure that you de-identify all personal information in relation to this patient in your nursing process essay.

Answer

Introduction
The current patient case covered in this nursing process essay involves Cara Webb, a 75 years old female, who has been taken to the emergency department (ED) from her feeling of unwellness. The current Professional Experience Practice (PEP) has been undertaken to develop safe and quality nursing practice through comprehensive assessment, developing a plan, implementation as well as evaluating outcomes. The patient had been diagnosed with type 2 diabetes during her menopause for which she takes oral hypoglycaemics, she weighs 60 kgs. Her father had type 1 diabetes mellitus, hypertension, and died of a stroke at the age of 65 years. She frequently is seen to experience non-compliance with glaucoma, hypertension, peripheral neuropathy, hypercholesterolemia, and osteoarthritis. She has been experiencing frequent episodes of fever for a few days post which she has a productive cough, which got worse with feeling short of breath. At the ED presented by her son, she was seen to have RR of 28 breaths/ minute, saturation on RA 90% with left lobe clear of auscultation, where her chest X-ray confirmed right-sided pneumonia. She was diagnosed with community-acquired pneumonia and was given oxygen therapy titrated for maintaining her SpO2 of 94% and above. She was also given management for her blood glucose levels where her recordings were 12 – 16.4 mmol/L. On her physical assessment, her GCS 15/15 was seen equal size 3mm and reacted to light. She felt pain on coughing in her anterior and lateral chest with pain scores being 5/10. Evaluation of her chest auscultation reveals coarse crackles right lower lobe and dullness on percussion. She is having difficulty to spit out her sputum, which is thick yellow and have been sent to the lab for microscopy, culture, and sensitivity. She has regular toileting and can mobilize inside the house without assistance and sometimes holding onto the furniture, outside her home she makes use of a single prone stick.

Nursing assessment
Post receiving consent from the patient, a comprehensive system-based assessment was conducted. The patient was seen alerted and oriented with GCS of 15 with equal size of pupils. The patient diagnosed with pneumonia had been assessed for risks from allergies and diagnosed with allergy from penicillin. The patient does not face risks associated with falls or swallowing. She was seen to have abnormal lung sounds with a productive cough. She does not have altered skin condition or any past histories of pressure injuries, however, she is at a risk from pressure injury with her Braden score being 19. Her speech reveals a lack of clarity and there is a need for an interpreter to understand what she is saying, this is potentially due to lack of her nutrition and poor management of her health. As back at home she was functioning without any help and her husband has dementia. Mismanagement of her blood glucose levels was apparent with irregularities in eating habits. She had erratic checking of BGL levels and since admission, her BGL levels had been fluctuating. Examination of her respiratory system revealed acute pneumonia with difficulty in breathing and continuous coughing, hence the risk of acute lung infection. However, her toileting was normal and also her movement which did not require insertion of catheter or bed assistance for toileting.

Nursing Diagnosis
The North American Nursing Diagnosis Association (NANDA) have set out principals for nursing diagnosis with three different concepts (Herdman, 2012). Three nursing diagnoses are focused here, the first two relating to actual health care problems which the nurse will be treated, and the third one relates to the potential health care problem. When Cara had been admitted to the hospital then the nursing diagnosis was seen related to the risk of future falls. With her fluctuating blood glucose levels and insufficient and nutritious diet plan, she is at tremendous risk from the potential health care problem, and nurses are responsible for creating and maintaining patient safety such that all such future falls can be prevented (Azzolin et al., 2013). Risk due to future falls can be of tremendous consequences for Cara and could lead to increase medical complications, prolonging her stay at the hospital, and needing treatment also assistance back at home for impeding recovery. Due to her fluctuating blood glucose levels and acute pneumonia, she needs to be assisted by nursing professionals for preventing potential falls and complications arising in her treatment. Also, as she is toileting regularly she needs assistance to prevent any complicacies arising from falls during toileting.

Another risk diagnosed which requires nursing intervention relating to actual health care problem is the diagnosis of her being at risks from pressure-related injuries. Though she has no histories of pressure-related injuries or any marks related to the same, yet due to her prevalent diabetes, and treatment needed for maintaining her blood glucose levels, she is at high risks of dehydration also due to impaired nutrition status, at risk of pressure-related injuries and ulcers (Lopes et al., 2016). Pressure related injuries and ulcers are highly common among patients suffering from type 2 diabetes and professional care of nursing need to ensure that appropriate management for reducing such risks is extended and to ensure the patient is at comfort. Pressure related injury is a high priority concern and can lead to further complications hence needs best to be managed.

Related to a potential health care problem, Cara is diagnosed with risks related to allergies and can lead to potential complications. Nursing diagnosis aligned with a previous medical diagnosis of the patient needs to administer pharmacological interventions along with other nursing strategies to reduce risks of aggravation from potential allergies through systematic care. She is diagnosed with pneumonia hence ineffective airway clearance need to be undertaken with avoidance of any allergic symptoms.

Nursing Objectives
Nursing objectives set for the patient case for all the above health problems identified will be as follows;

For ND1, the nursing objective will include preventing risks from falls (S) by measuring frequency regularly (M) during the hospital stay (A), within the period of hospital stay (R) and (T).

For ND2,the nursing objective will include preventing pressure-related injuries (S) by monitoring patient frequency (by Glamorgan Pressure Injury Risk Assessment Tool) regularly (M) during the hospital stay (A), within the period of hospital stay (R) and (T). For ND3, the nursing objective will include effective clearance of airways by preventing risks from allergies (S) by measuring any contradiction related to medications with frequency regularly (M) during the hospital stay (A), within the period of hospital stay (R) and (T).

Nursing Interventions
A nursing care plan implementation for fall risk is aimed at reducing any future falls for the patient. Hence the specific goal for the patient is to document the patient is at potential risk from falls by having a management plan to remind the same (Aranda-Gallardo et al., 2013). Cara need to be given pneumonia medication without any contradiction such that allergic conditions is not aggravated. This will assists in relieving her airways and easing her breath.With regards to the diagnosis of risks from pressure-related injuries, the patient's intended outcome is to have nil pressure-related injuries or ulcers and to document that the patient is at high risk from the same. This diagnosis will assist in reminding that the patient having no history or site of pressure-related injuries is highly susceptible to the same, hence nursing management needs to ensure that the patient does not receive it during the stay at the hospital. The patient will need regular monitoring and checking for any sites for pressure-related injuries or ulcers such that they can easily be prevented.

Nursing intervention adopted for Cara for reducing her elevated risks from falls will include a prolonged approach, as she is highly malnutrition and has fluctuating blood glucose levels. The nursing interventions will be extended during the period of hospital stay with the patient being educated to implement the same back at home such that the risks can be avoided (Milos et al., 2014). Firstly, Cara will require modification in her environment, where the hospital staff is alerted each time she tries to go to the toilet or stand up without assistance, which will significantly reduce the possible effects from another fall from arising. The second approach to reducing patient falls will include instructing the patient to use the nursing bell to communicate her needs.

Environmental modification in this case will include transferring the patient to a low-low bed with alarm installation on the bed and chairs, which immediately alerts when the patient will try to stand up. As per the Australian Commission on Safety and Quality in Health Care (ACSQHC) adjusting the environment for the patients according to their risk profile is a suitable strategy (Australian Commission on Safety and Quality in Health Care, 2012). With provisioning for low-low beds along with a combination of other mechanisms for prevention, if falls such as patient education, patient falls can effectively be prevented. Also, the implementation of bed and chair exit alarms can provide reliable as well as appropriate in the prevention of falls during a stay at the hospital (Ambrose et al., 2013).

Cara, who is seen to have effective cognitive functioning must be educated for her high risks of falls. Involving the nursing bell within her reach and ensuring when to press and ask for staff can help in avoiding fall risk alleviations. It is crucial that the nurse bell is positioned and nurses’ response to the same in regards to best practices in nursing care. Also educating the patient in regards to risks from falls can emerge as an effective strategy in reducing falls.

About nursing interventions for reducing risks from pressure injuries for Cara, there needs to be adopted interdependent as well as dependent intervention strategies. The most effective strategy in a reduction in pressure-related injury is educating Cara regarding the same. This involves making her more concise and making the healthcare professionals as well as nurses alert when they are undertaking any such interventions. Another approach is to apply appropriate nursing protocols as per the NMBA standards of nursing care in administering dosage or rendering care to patients (Ossenberg et al. 2020). Nurses along with other healthcare professionals rendering care to Cara need to be alerted for the increased risks that she faces from pressure-related injuries, hence proper care needs to be reminded when caring for the patient. Also, ointment and other medication need to be made available to relieve any pressure-related injuries suffered by the patient (Gelinas et al., 2013). The patient's skin needs to be kept clean and dry, which should not be vigorously massaged or rubbed. Barrier cream can be applied for healthier skin such as Calmoseptine ointment use of chlorhexidine wipes also need to be used regularly.

The evidence base for nursing intervention
Cream massage for avoiding pressure injuries can be administered by the patient or by the nursing staff. It involves massaging the cream without the application of any pressure and relieving any pain suffered by the patient. A similar patient group administered with cream massage was found to be highly effective in reducing pressure-related injuries, especially in aged care. The success of this intervention mechanism is dependent on several factors and massaging with cream can relieve some symptoms. It can also reduce the severity of the symptoms.

Nursing Evaluation
In case of interventions of nursing applied for the patient case by setting a reminder for falls during admission and documenting it with appropriate nursing management plans, the appropriate outcome is evident. The strategies implemented worked effectively to minimize the risk of falls by patient education and using bell for calling nursing staff. The success of this strategy depends upon the patient using the bell and her understanding of risks from falls.

The patient's goal of reducing risks related to pressure-induced injuries is also attained. The intervention included educating the patient monitoring and also applying appropriate cream for reliving the patient.

Conclusion
The nursing intervention plan is focused on rendering a management plan to Cara by assessing, diagnosing, planning, implementing, and evaluating interventions based on the health needs of the patient. Assessing findings of risks from falls and planning of evidence-based interventions with modification of the environment and patient education can significantly reduce risks from the patient. Both the patient goals were seen to have been met with a reduction in risks from falls and pressure-related injuries.

References
Ambrose, A. F., Paul, G., & Hausdorff, J. M. (2013). Risk factors for falls among older adults: a review of the literature. Maturitas, 75(1), 51-61.

Aranda-Gallardo, M., Morales-Asencio, J. M., Canca-Sanchez, J. C., Barrero-Sojo, S., Perez-Jimenez, C., Morales-Fernandez, A., ... & Mora-Banderas, A. M. (2013).

Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis. BMC health services research, 13(1), 122.

Australian Commission on Safety and Quality in Health Care. (2012). National safety and quality health service standards. Australian Commission on Safety and Quality in Health Care.

Azzolin, K., Mussi, C. M., Ruschel, K. B., De Souza, E. N., de Fátima Lucena, A., & Rabelo-Silva, E. R. (2013). Effectiveness of nursing interventions in heart failure patients in home care using NANDA-I, NIC, and NOC. Applied Nursing Research, 26(4), 239-244.

Gelinas, C., Arbour, C., Michaud, C., Robar, L., & Côté, J. (2013). Patients and ICU nurses' perspectives of non?pharmacological interventions for pain management. Nursing in critical care, 18(6), 307-318.

Herdman, T. H. (Ed.). (2012). Nursing Diagnoses 2012-14: Definitions and Classification. John Wiley & Sons.

Lopes, C. M. D. M., Haas, V. J., Dantas, R. A. S., Oliveira, C. G. D., & Galvão, C. M. (2016). Assessment scale of risk for surgical positioning injuries. Revista latino-americana de enfermagem, 24.

Milos, V., Bondesson, Å., Magnusson, M., Jakobsson, U., Westerlund, T., & Midlöv, P. (2014). Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care. BMC geriatrics, 14(1), 40.

Ossenberg, C., Mitchell, M., & Henderson, A. (2020). Adoption of new practice standards in nursing: revalidation of a tool to measure performance using the Australian registered nurse standards for practice. Collegian, 27(4), 352-360.