Nursing Process that contains Nursing Care Plan is needed.
Nursing Process: a scientific and systematic approach to healthcare.
It contains Assessment, Planning, Objectives, Implementation, Evaluation and the Nursing Care Plan.
Nursing Care Plan: helps nurses to drive care and to treat each patient individually i.e. give an individualistic approach to healthcare for each patient.
For example, when a patient has been admitted for malaria according to the doctor’s diagnosis, nurses then look at the symptoms the patient is presenting with and they document symptoms seen in the Nursing Care Plan.
Nursing Care Plan contains:
• Nurse’s Diagnosis: to document symptoms seen e.g. high fever which is diagnosed by nurses as hyperthermia
• Cause: hyperthermia related to disease process
• Evidence: evidence of thermometer reading of 38.5 degree Celsius
• Objective: to drop the patient’s temperature by 1.5 degree Celcius after 2hrs of nurse’s intervention using SMART (Specific, Measurable, Achievable, Realistic and Time bound).
• Nurses’ Orders/Action:
-Expose patient to air
-Remove tight clothing
-Tepid sponge or bathe patient with lukewarm water
-Give anti-pyretic e.g. paracetamol
-Recheck patient’s temperature.
• Allergies and Reactions: Check to see if the patient is reacting to any of the anti-pyretic or other drugs given.
• Scientific Rational:
Exposing patient to air helps the brain (hypothalamus) to balance patient’s body temperature
Removing tight clothing allows the body to be free, skin pores are open and air easily gets to the skin
Tepid sponge or bathing patient with lukewarm water allows water get into the skin pores and helps to reduce high body temperature
Anti-pyretic works in the body and through the hypothalamus to reduce body temperature
Rechecking patient’s temperature helps to periodically measure progress made.
• Evaluation/Outcome:
Patient’s temperature has been reduced by 1.5 degree Celsius after 1 to 2 hours, etc.
N.B: All the manifestations and symptoms exhibited by a patient have to be documented, hence there can be up to 3 Nurse’s Diagnosis for one patient depending on the patient’s condition.
The Nursing Care Plan is totally different from Nurse’s Note on HealthStack.
Nursing Documentation:
Documents saved as draft in medication chart were not seen when it was opened hours later for continuation. Other documents saved as draft in other menus still show what was typed when they are opened hours later.
Fluid intake and output chart:
There is no save button to save details entered in this chart and so there is no way to know which nurse entered in which details.
Nurses are not able to search for values they have chatted from weeks back, there is no search button. They can only see as far as the page allows them to see when they scroll down.
Vital Signs Document:
They need a drop-down button where they can be able to select what time they are entering the input for each of the parameters (temperature, respiratory rate, oxygen rate, etc). This is so that they can compare results to time the result was recorded and ascertain whether the patient's health is improving and if he or she is responding to treatment.
Total Input and Total output: Also they need this chart to calculate at every 24hours, the total volume for input and the total volume for output.
This is because they need to:
A. know the difference between input and output
B. be able to ascertain if the kidney is responding to treatment.
c. to make sure they are not overloading the lungs.
Nursing Process that contains Nursing Care Plan is needed. Nursing Process: a scientific and systematic approach to healthcare. It contains Assessment, Planning, Objectives, Implementation, Evaluation and the Nursing Care Plan. Nursing Care Plan: helps nurses to drive care and to treat each patient individually i.e. give an individualistic approach to healthcare for each patient. For example, when a patient has been admitted for malaria according to the doctor’s diagnosis, nurses then look at the symptoms the patient is presenting with and they document symptoms seen in the Nursing Care Plan. Nursing Care Plan contains: • Nurse’s Diagnosis: to document symptoms seen e.g. high fever which is diagnosed by nurses as hyperthermia • Cause: hyperthermia related to disease process • Evidence: evidence of thermometer reading of 38.5 degree Celsius • Objective: to drop the patient’s temperature by 1.5 degree Celcius after 2hrs of nurse’s intervention using SMART (Specific, Measurable, Achievable, Realistic and Time bound). • Nurses’ Orders/Action: -Expose patient to air -Remove tight clothing -Tepid sponge or bathe patient with lukewarm water -Give anti-pyretic e.g. paracetamol -Recheck patient’s temperature. • Allergies and Reactions: Check to see if the patient is reacting to any of the anti-pyretic or other drugs given. • Scientific Rational: Exposing patient to air helps the brain (hypothalamus) to balance patient’s body temperature Removing tight clothing allows the body to be free, skin pores are open and air easily gets to the skin Tepid sponge or bathing patient with lukewarm water allows water get into the skin pores and helps to reduce high body temperature Anti-pyretic works in the body and through the hypothalamus to reduce body temperature Rechecking patient’s temperature helps to periodically measure progress made. • Evaluation/Outcome: Patient’s temperature has been reduced by 1.5 degree Celsius after 1 to 2 hours, etc. N.B: All the manifestations and symptoms exhibited by a patient have to be documented, hence there can be up to 3 Nurse’s Diagnosis for one patient depending on the patient’s condition. The Nursing Care Plan is totally different from Nurse’s Note on HealthStack.
Nursing Documentation: Documents saved as draft in medication chart were not seen when it was opened hours later for continuation. Other documents saved as draft in other menus still show what was typed when they are opened hours later.
Fluid intake and output chart:
Vital Signs Document: They need a drop-down button where they can be able to select what time they are entering the input for each of the parameters (temperature, respiratory rate, oxygen rate, etc). This is so that they can compare results to time the result was recorded and ascertain whether the patient's health is improving and if he or she is responding to treatment.
Total Input and Total output: Also they need this chart to calculate at every 24hours, the total volume for input and the total volume for output. This is because they need to: A. know the difference between input and output B. be able to ascertain if the kidney is responding to treatment. c. to make sure they are not overloading the lungs.