Activity 1: NCM 119 Unit 1

 The nursing process entails using problem-solving approaches that need technical and scientific knowledge, sound judgment, and decision-making abilities in order to analyze, develop, implement, and evaluate a plan of care. When assessing the patient, developing a nursing care plan, and executing therapies, critical thinking, clinical reasoning, and clinical judgment are employed. Frequent evaluation, with adjustments to the treatment plan as needed, is critical to assisting the patient in achieving the desired results. Throughout the nursing process, the patient is always the focal point of nursing care. Individualized, patient-centered care and assessing whether such care was successful in attaining patient outcomes are critical components of safe, professional nursing practice.

The nursing process consists of five major steps: 

Assessment is gathering and evaluating data in order to acquire a comprehensive picture of the patient's requirements and risk factors. 

Diagnosis is forming nursing diagnoses based on data, patient input, and clinical judgment. 

Outcomes/Planning is establishing short- and long-term objectives based on the nurse's examination and diagnosis, ideally with patient engagement. Choosing nursing interventions to achieve such objectives. 

Implementation entails carrying out nursing care in accordance with the care plan, which is based on the patient's health status and the nursing diagnosis. Documenting the care provided by the nurse. 

Monitoring (and documenting) the patient's state and progress toward goals, as well as changing the treatment plan as necessary.

A care plan is essential in health and social care to ensure that you receive the appropriate amount of care and that it is delivered in accordance with your wants and preferences. These are tailored to each individual's requirements and hence vary from person to person. Despite the fact that each care plan is unique, they all fulfill the same aims, which include: 

Making certain that the patient receives the same level of care regardless of which care professional is on duty.

Making certain that the care the patient get is documented

Assisting the patient in identifying and managing your care requirement

Thus, care plans are adaptable, which means that if your care needs change, the plan will be evaluated and updated to ensure it fits your needs and preferences. A good care plan can help the patient understand their illness better, live as independently as possible, and have more control over their life. In formulating the patient’s care plan, the following questions must be answered:

What your assessed care needs are

What type of support you should receive

Your desired outcomes

Who should provide care

When care and support should be provided

Records of care provided

Your wishes and personal preferences

The costs of the services

The nursing care plan is the official record of a procedure, and most care plans are divided into four columns that roughly reflect the nursing process's phases. Care plans include the following:

Identify the primary medical diagnosis of your client: This includes diagnoses such as diabetes mellitus, pneumonia or heart failure. This may also include the surgical procedure the client has had such as an abdominal surgery , hysterectomy or a total joint replacement. 

Identify the client’s risks: Situations, personal qualities, limitations, or medical disorders that might impair a person's capacity to recuperate, manage with stresses, and return to his or her original health prior to hospitalization, sickness, or surgery are examples of risk factors.

Identify Strengths: Strengths are characteristics or traits that enable a person to recover, manage with pressures, and return to his or her previous health (or as near to it as feasible) prior to hospitalization, sickness, or surgery.

Create Your Initial Care Plan: These general care plans reflect the typical, anticipated care that a client needs that is either medical or surgical.

Review the Collaborative Problems on the General Plan: Review the collaboration problems. These are the physiological issues that you must keep an eye on. Remove none because they are all related to the ailment or operation that your client has undergone. You'll need to include how frequently you should monitor vital signs, record intake and output, change dressings, and so forth.

Review the Nursing Diagnoses on the General Plan: Review each nursing diagnosis, interventions, the goals listed, and delete the goals that are inappropriate for the client.

Complete the initial care plan: This can be either written or printed. Identify which of the collaborative difficulties and nursing diagnoses are connected with the primary condition for which your client was hospitalized, now that you have a care plan?

Additional Risk Factors: If your client has risk factors, consider whether these risk factors make your assigned customer more likely to develop a problem.

Evaluate the Status of Your Client (After You Provide Care): Assess the client’s status. Compare the data to established norms (indicators). Judge if the data fall within acceptable ranges. Conclude if the client is stable, improved, unimproved, or worse.

Document the Care You Provided and the Client’s Responses on the Agency’s Forms, Flow Records, and Progress Notes

In conclusion, the written plan produced by the provider only for the specific services required by the individual to ensure optimal health and safety for the delivery of home and community-based care is referred to as the plan of care.