INTRODUCTION
ACUTE ILLNESS
Acute illness that has severe symptoms but is of short duration. It also recovers in short time.
ACUTE INFLAMMATION
Acute inflammation is characterized by local vascular and exudative changes and usually lasts less than two weeks. The process of infection in any part of the body is called inflammation. Redness, swelling, pain, warmth are seen in the inflamed part of the body. Pathogenic micro-organisms are the main cause of inflammation in the body.
ASEPSIS
Asepsis means the condition of being free from disease-causing microorganisms. (free from disease producing microorganisms).
DIESEASE
DCS is a condition in which the health of the body deteriorates. A person’s health does not remain the same, there is a change in the physiological functions of the human body. A person cannot do some work and the vital function of his body also deteriorates. Diseases are mainly caused by pathogenic micro-organisms.
HEALTH
Health can be called complete physical, mental, social, spiritual well-being, not merely an absence of disease and infirmity. (not mere absence of disease or infirmity).
ILLNESS
Illness reduces people’s efficiency. People are unable to maintain any kind of physical and emotional balance and due to this the performance of the person is disturbed.
INFECTON (infection)
When any microorganism enters the human body and grows and multiplies and produces a disease, it is called an infection.
MODE OF TRANSMISSION
This is a type of transfer mechanism in which microorganisms are carried from one place to another. Generally, the mode of spread of DCs is called mode of transmission. Da. T. Direct contact, droplets etc.
PORTAL OF EXIT
This is a place in the body from which microbes in the body have a way to escape. Da. T. By urine and stool, by nose and oral CVT etc.
PORTAL OF ENTRY
This is the place in the body from which the microorganism enters the body of the host. Da. T. Microorganisms enter the body through the nose, oral cavity, broken skin and mucus membranes etc. and spread diseases.
Reservoir
This is the place where any microorganism can grow and multiply.
susceptible host
This is a person who cannot fight against microbes if they enter them.
So the micro-organisms develop and multiply and cause disease and these people cannot resist those micro-organisms.
Terminal illness
A terminal illness is a type of illness or disease that cannot be cured. It is fatal in which the person does not have a chance to live his life.
Trend
A trend means a change in a certain direction or an improvement in any rule. New developments in any field are called trends.
Wound
A wound occurs in the body in which there is a break down or cut in the continuity of the cells, tissues and structures of the body.
This breakdown is caused by any kind of physical injury, internal or external, it is called a wound.
The following topics are included in this unit.
a.BRIEF HISTORY OF EVOLUTION OF MODERN MEDICINE AND SURGERY.
b. THEORY OF ILLNESS AND ITS CAUSATION – ILLNESS AS HUMAN EXPERIENCE.
c. REVIEW OF NURSING PROCESS AND NURSING CARE PLAN.
A) BRIEF HISTORY OF EVOLUTION OF MORDEN MEDICINE 💊 AND SURGERY (History of development of medical and surgical).
Medical surgical nursing
When any patient comes to the hospital for the treatment of any kind of illness or inflammation or disease condition, it is cured by using medicines, it is called medicine branch and when the condition is not treated by medical treatment and those people are treated by surgical treatment (arm action). If required, it is called surgical branch. Thus any patient is cared for through the use of medicine and surgery.
In both these branches, the care of the patient through the use of different types of nursing care is called medical surgical nursing.
Evolution of modern medicine and surgery.
The history of medical science is regarded as part of the history of civilization. It logically began in Mesopotamia.
The first evidence of weapon action is the Stone Age trapid skull.
Some adults had skulls. Perhaps it was performed on people with head injuries to relieve pressure on the brain.
According to him, the treatment of injury and illness was a combination of common sense and magic.
People knew that falling caused bones to break and fire caused burns, animal bites and human scriptures caused wounds (injuries).
Primitive people believed that among the causes of diseases were evil spirits or magic performed by the enemy.
The cure seems to be exorcism.
ANCIENT EGYPT MEDICINE 💊:
About 3000 b.c. the curtain rose on Egyptian civilization.
In a civilized society some people did specialized jobs.
The first known doctor in history was Shekhet Anach. He healed Pharaoh’s nostrils.
Another doctor we know of was Imhotep.
Who was Pharaoh’s Wazir or Prime Minister.
He was also a doctor and was so famous that he was worshiped as a god after his death.
Egyptian physicians used a wide range of medicines derived from herbs and minerals.
They mixed the father with wine or beer or sometimes with dough to make pills.
Egyptian doctors also used ointments for wounds.
The Egyptians believed that the human body was filled with action like irrigation canals carrying blood, urine and faeces, tears, and semen.
The Egyptians used laxatives and induced vomiting to open irrigation canals that sometimes become blocked (blocked) which can cause blocked passages in the human body.
The Egyptians used clamps, suture, and cauterization.
They had surgical instruments like probes, saws, forceps, scalpels and scissors.
They also knew that honey is a natural antiseptic that helps prevent wounds from becoming infected.
They also dressed the wounds with willow bark which had the same effect as honey.
Most Egyptians were clean, bathing and changing clothes regularly every day to help with their health.
Ancient Greek medicine
Modern medicine has its origins in ancient Greece.
Most of the Greeks believed in a god of healing called Asclepius.
People who were sick made sacrifices or offerings to God.
He would then spend the night in his temple.
They believed that God would visit them in their sleep i.e. dreams and when they woke up they would be healed.
At the same time Greek doctors developed a rational theory of disease and discovered cures.
The most famous Greek doctor is Hippocrates.
Hippocrates emphasized that doctors should carefully observe and record patients’ symptoms.
Hippocrates also rejected all magic and believed in herbal remedies.
A number of Greeks hypothesized that the human body was composed of elements. A person who had those elements properly balanced was healthy, but if they were out of balance, he became ill.
Finally, Aristotle thought that the body was composed of four humors. It contains phlegm, blood, yellow bile and black bile.
If a person has too much or too little of one humor, that person becomes ill.
Roman medicine 💊 (Roman medicines)
The Roman Empire was often Greek In Roman times Galen became a famous doctor.
Galen believed in the theory of the four senses and also believed in the treatment of illness.
So if a patient had a cold, Galen would give him something hot like pepper.
The Roman nomenclature suggested that small animals causing disease were carried through the air and entered the body through the nose and mouth.
Rome was a total engineer and created a system of public health.
Even the Romans knew that filth promoted disease. They appreciated the importance of cleanliness. They built aqueducts to produce clean water in the towns.
Medicine in middle age
Medicine developed in the Islamic world.
Known as Olrazi (Razez in the West) in the tenth century. A Western doctor of this name was the first to distinguish between smallpox and measles, writing about hemophilia.
Muslims established many hospitals, they also invented distillation and refinement. (Purification by changing substances directly from solid to vapor without passing through the liquid state).
In the Middle Ages only monasteries had sanitation. Streams provide clean water Waste water was used to clean toilets which were in separate rooms.
Medicine in 16 th century
Girolamo Fricastoro suggested that infectious diseases are caused by disease spores that are carried by the wind (droplets) or transmitted (spread) by touch (direct contact).
Leonardo da Vinci dissected the human body and made accurate drawings of what he saw, another great surgeon was Ambrose Pare.
In the 16th century, a surgeon applied oil to a wound. He made a mixture of egg white, rose oil, and turpentine and found that it worked better than oil.
Parr also designed prostheses. In 1513 Eucharius Rosali published Rosen Garden, a book about childbirth.
An English translation published in 1540, The Birth of Mankind, has become a standard text.
However, the mid wives were women. Syphilis was common in the 16th century.
The standard treatment was mercury administered through a urethral series.In the 16th century, syringes were also used to irrigate rice fields with wine.
17 th century Medicine
An Italian named Santorio invented the clinical thermometer.
In 1628 William Harvey discovered how blood circulates around the body Harvey realized that the heart is a pump that pumps blood out every time it contracts.
Blood circulates around the body Harvey then estimated how much blood is pumped each time.
Finally in 1683 Antoine Leuven Hunck observed the micro-organisms.
Doctors discovered that the bark of the cinquefoil tree treated malaria because it contained quinine.
18 th century Medicine
June Hunter invented the tracheostomy.
A cure for scurvy was discovered by giving lemon juice.
Edward Zenner received the smallpox vaccine.
19 th century medicine
Renlen K invented the stethoscope.
Louis Pasteur developed a vaccine for rabies.
A vaccine for typhoid was also discovered.
Rubber gloves were first used in surgery in the 1890s.
The banner show was greatly improved by Florence Nine Tingle and Mary Seacole.
who took care of the soldiers during the Criminal War of 1854.
In the 19th century, including Great Ormond Street, a hospital was established.
In 1864 Jean-Henri Dunant founded the International Red Cross.
Women were allowed to become doctors in Britain from 1865.
20 th century medicine
Different blood types were identified.
Insulin and EEG were also explored.
Alexander Fleming discovered penicillin.
A polio vaccine was also invented.
The first heart and lung transplants were performed.
Who abolished the small box and CT scan and invented the MRI.
Gene therapy was introduced in the 1990s.
Evaluation of surgery
Sushruta attained the perfection of the great in weaponry.
400 Before Christ His famous text identified as Sushruta’s code is essentially devoted to the action of arms.
It contains the surgical text of Ayurveda and that too is clear.
Vesicle calculi, anal fistula (fisula, hernia), bone break (fracture), extraction of fetus in abnormal labor (fetal investigation), amputation, tumor removal, hernia repair, and cataract operation ( Cataract surgery), and Weger’s operations were performed.
Rhinoplasty and plastic surgery were also performed.
He mentioned knives (knife) and needles (needle) based on their use and related tissues.
Thus modern medicine and surgery came into being.
B) THEORY OF ILLNESS AND ITS CAUSATION – ILLNESS AS HUMAN EXPERIENCE.
concept of Illness.
Illness reduces the ability of people to work. A person cannot maintain a balance between any kind of physical and emotional status and due to this the performance of the person is disrupted.
Illness is a state of a person that reduces a person’s emotional, intellectual, logical, social, religious, ability to work.
Due to any illness, a person’s normal day-to-day functioning is also reduced and it affects the person a lot.
There are two types of illness.
1) acute illness
2) chronic illness.
Acute illness
This disease occurs immediately. Due to this disease, a person’s ability to work decreases. The speed of development of symptoms in this disease is very high and usually occurs in a short period of time. These diseases are reversible (curable).
2) chronic illness
These diseases occur in a long period of time. Due to this disease, a person’s ability to work gradually decreases. Which usually causes gradual changes in the body throughout life and results in major illnesses and these illnesses are usually irreversible (cannot be cured). Chronic diseases last for a long time and these diseases remain the same throughout a person’s life.
concept of disease.
Diseases cause any kind of disturbance in the normal functioning of the body.
These diseases have a specific cause and their symptoms are mainly recognisable.
according to Oxford English dictionary
According to the Oxford English Dictionary, disease is defined as a condition of an organ or organ in which its functions are altered and from an economic perspective disease is defined as a misalignment of the human life system with the environment. is
A disease is a condition in which the health of the body is weakened. Due to this health, the human body cannot do any kind of important work, i.e. it loses its efficiency.
From the perspective of sociology, DCs are considered as a social phenomenon. All of which occur in society and are defined in terms of specific cultural norms prevalent in society. The simplest definition is that disease is the opposite of health which is any change from normal functioning or a state of complete physical or mental well-being because health and disease are opposite conditions.
Who defined health but not diseases. This is because there are many sets of diseases ranging from subclinical cases to severe overt disease. Some diseases begin acutely. For example food poisoning and some occur suddenly eg mental illness, rheumatism etc.
A carrier state is seen in some DCs. In which a person remains outwardly healthy and can infect others eg typhoid fever.
In how many cases can a single organism cause more than one disease? For example streptococcus bacteria and how long it lasts While some diseases can make many illnesses, it is easy to determine the illness but many diseases have a border between normal and abnormal like diseases like diabetes hypertension. The final outcome of DCS is variable.
Causes of disease
DCS is a rare condition. which affects the organism’s body. It has been interpreted many times. It may be caused by a clinical condition associated with specific symptoms and signs. It can also be caused by external factors such as an infectious disease or an internal disorder.
causes of disease
1) Mechanical causes (Mechanical causes).
2) Biological causes (biological causes).
3) Normative causes.
4) Nutritional causes.
5) Environmental Causes.
1) Mechanical causes
This causes damage to the structure of the body and disease occurs due to any kind of defect in the normal function of the body. E.g. Injuries, wounds, fractures etc.
2) Biological causes
Biological causes also affect body function and result in genetic defects, infectious agents, and infections, changes in the immune system, and changes in the secretion of normal organs.
3) Normative causes
Common causes are psychological, but involve mind-body reactions (body-mind relationship). So due to these reasons, physical and mental problems arise.
4) Nutritional Causes
In developing countries, the main cause of diseases is due to nutrient deficiency, insufficient consumption of fruits and vegetables.
5) Environmental causes
Environmental causes play a major role in the development of an individual. Diseases include the following substances. Such as chemicals, acid aldehyde in cigarettes, allergens such as pollen, dust, mites, moisture, cat hair, etc. and pollutants produced by human activities such as sulfur oxide, nitrogen dioxide, carbon monoxide, carbon or dioxide, organic compounds carbon monoxide radioactive pollutants etc. and many DCs are caused by infectious agents like viruses, bacteria etc.
Thus the causes of disease include mechanical causes, chemical causes, normative causes, nutritional causes, biological causes and environmental causes etc.
concepts of disease causation
Germ theory of Disease:
Disease agent …… Man ……. Disease.
In 1873 Pasture put forward the microorganism theory of disease This theory states that many diseases are caused by the presence and actions of specific microorganisms (microorganisms) within the body. It is a guiding principle.
The theory embodied in the germ theory of disease is the concept of causation, commonly referred to as a one-to-one relationship between the causative agent and the disease.
The germ theory of disease was a revolutionary concept.
Because of this, many epidemiologists adopted a one-sided view of the cause of the disease.
Before the germ theory, it was widely believed that disease was spread by noxious odors. Disease-spreading conditions included rotting pulp, open drains, and such things were often very foul-smelling. Odor and disease were associated.
Thus, the theory shows that micro-organisms are the main contributor to the causes of any disease.
Epidemiological trial
Agent
Host,
And environment.
Epidemiological triad: A traditional model of infectious disease causation known as the AP-demographic triad.
This tried includes external agents. A host and an environment are included. In which the host and the agent are brought together to cause disease in the host.
Agent, host and environment are the main factors involved in the spread of any disease.
This epidemiological model has been in use for many years. It helped epidemiologists focus on different classes of factors, especially in the context of infectious diseases.
A classic example of a vector is the Anopheles mosquito.
As the mosquito takes blood from the infected host. It infects the parasite Plasmodium. Harmful to Plasmodium. However, after being stored in the salivary gland and injected into the mosquito that feeds on it, Plasmodium can cause malaria in infected humans, acting as a vector for malaria.
Agent
Agent Factors The first link in the chain of spread of disease is the agent of disease. A disease agent is defined as a substance. Living or non-living or force or dead, excessive presence or relative lack of nectar can initiate the disease process to perpetuate it.
Host
Host factors include various characteristics.
Host factors are important to the extent that they affect
First:= risk of exposure to source of infection and
Second := Host’s resistance or susceptibility to infection and disease.
Host factors may include this.
Age, gender, ethnic group, nutritional status, socioeconomic status.
Expressed behavior: such as smoking, diet, drinking, sexual activity, exercise, immunization status, or no vaccine.
Physiological Conditions: Pregnancy, Puberty, Fatigue, Immunity, Pre-Existing Diseases etc.
Environment
The study of disease is really the study of man and his environment.
External or macro environment is “external to the individual human host, animate and inanimate and everything with which he is constantly acting and reacting”. Defined as, which includes air, water, food, soil etc.
Agent factor
Nutritional agent, mechanical agent, chemical agent, physical agent, social agent, absence or insufficiency or excess, biological agents.
Other causes for disease producing
Other causes include diseases like heart disease, cancer etc.
A disease is when any microorganism enters the host’s body and the microorganism multiplies and multiplies. It produces Bodima disease of the host. Thus the agent, the host and the epidemiological agent act as a model for causing the disease.
C) review of nursing process and nursing care plan.
Nursing process:
A nursing process is a set of actions used to determine, plan, implement, and evaluate nursing care.
Nursing process can be defined as a systematic method of assessing health conditions, diagnosing appropriate care needs, formulating care planning, initiating planning and evaluating the effectiveness of planning.
The nursing process is a systematic and organized method of planning and providing quality and individualized nursing care. It is synonymous with problem solving approach. which directs the nurse and client to determine nursing care needs, plan and implement care, and evaluate outcomes. It is a gosh approach to efficient and effective provision of nursing care.
The goal of the nursing process is to reduce and prevent actual or potential health problems. The nursing process can be applied to any action reaction. Which includes vein and client.
Objectives of Nursing Process.
The primary objective of the nursing process is to assist the nurse in managing the nursing care of each patient intelligently, scientifically, and judiciously.
It helps in maintaining the health of the patient.
Useful to protect the client from illness.
To identify the client’s clinical condition.
To identify the client’s actual and potential health problems.
To prioritize the nursing procedures provided to the client.
To meet the identified (need based) needs of the client.
To provide adequate health care facility to clients.
To evaluate the nursing procedure given to the client.
To assist in the peaceful death of clients during terminal illness.
steps of nursing process:
Assessment.
Information is collected about the patient’s condition.
Diagnosis.
This involves identification of the patient’s problems.
Planning.
This involves setting goals for the patient and planning nursing interventions for care.
Implementation.
This involves the implementation of the planned nursing intervention.
Evaluation.
This involves checking whether the set goals and expected outcomes have been achieved.
Nursing assessment:
Nursing assessment is the process of gathering or verifying data or information about a client.
It helps establish a baseline about the client’s level of health, health habits (health habits), past illnesses, related experiences, and goals for health care.
It begins during the nurse’s first encounter with a new patient and continues into the future. This assessment includes asking about vital signs and doing a head to toe assessment. Asking questions about his signs and symptoms and listening carefully to the answers.
Diagnosis
Nursing diagnosis is the assessment of potential or actual problems of the client’s health condition.
For the treatment of which a nurse should be licensed and competent.
It involves identifying these problems with the client, family, and significant others.
Based on the nursing assessment, the nurse formulates a nursing diagnosis.
Planning
Planning is the process of thinking about any nursing task before doing it.
In it, nursing activities (Action) are planned to achieve any specific goal.
And planning is done according to which care the client needs first.
Implementation
Implementation of the planned processes is carried out in A.
Plan of Action or nursing planning is implemented according to the patient’s needs. Actual care is provided to these patients.
Evaluation
It evaluates the implemented nursing processes.
In this, according to the goal that we have set, the achievement of the goal is evaluated or not.
Nursing assessment
Nursing assessment refers to the collection and interpretation of clinical data.
It focuses on collecting data about the client’s health status, functional capacity, physical condition, and responses to actual and potential health problems. is coming.
In nursing assessment, the nurse assesses the patient.
Nursing assessment includes client’s health related problems, related experiences, health practices, values and lifestyle, health history.
It includes observing the patient, interviewing the patient, his family, and other persons, examining the patient, examining the patient’s records, and collecting information.
purposes of nursing assessment
To collect client health information,
To determine the client’s normal function.
To organize the collected information,
To create a possible hypothesis for the patient.
To make a thorough investigation of passion.
To make nursing diagnoses.
To improve patient management skills and to handle patient problems.
To assess the patient’s health problem.
To assess client’s strength.
To assess the client’s health needs.
Type of assessment
1.Initial assessment (Initial assessment),
3.Emergency assessment (Emergency assessment),
4) time lapsed assessment,
Initial assessment
This assessment is done within a certain time limit as soon as the patient is admitted.
problem focused assessment:
This assessment is done early to identify any specific problems.
For example intake output is assessed to know the status of urination problem.
Emergency Assessment
This assessment is done immediately.
This assessment is done to accompany any physiological or psychology assessment.
This assessment is done when the patient has a life threatening condition.
Ex:=clients Airway, Breathing status, Circulation after cardiac arrest.
Time lapsed assessment:
This assessment is given to the client at a specific point in time. During that time the assessment of the client is done.
components of assessment
1) collecting data,
2) organized data,
3) validating data,
4) recording data,
1) Collecting data.
Collecting data is the process by which information about a client’s health status is gathered. In which client’s health history, physical assessment, physical examination, laboratory test are done, past history and present complaint of the patient are also collected in the data.
Collection of data should be systematic and continuous, no information should be missed.
Collection of data is done keeping in mind the problem of the patient.
While collecting data, it should be descriptive and complete and accurate.
type of data
2 types of data
1) subjective data,
2) objective data.
1) Subjective data: Subjective data includes symptoms.
Subjective data is what Kalans says in his own words.
This information includes things such as a client’s experience and emotions that can only be expressed in their own words.
This information is also provided by family members and acquaintances of the client.
2) Objective data: Objective data includes sign.
Objective data is obtained through observation, physical examination, laboratory tests, and measurement by the health team.
sources of data:
1) Primary source:
The primary source includes the client itself.
Which includes the subjective data of the client which the client can say in his own words. This information is accurate as it is provided by the client himself.
Client provides accurate information.
In which client’s health need, his life style pattern, his past, and his present symptoms etc are told by the client in his own words.
2) secondary source
This information is collected from the client’s family members and significant others, the client’s medical records, charts, other members of the health care team, and related caregivers.
Family and Relatives: These individuals know the client well.
It can supplement the information provided by the client.
They are the primary source of information for infants (infant or children), seriously ill, mentally retarded, and unconscious clients.
Health Care Team: Every member of the health care team is a potential source of information. They can identify and communicate data as well as verify information from other sources.
Such as may collect client information from records, reports, laboratory investigations, etc.
Thus objective data can be obtained from family members of the client, known people of the client, friends, records, reports etc.
method of data collection:
1)Observation:
In this the information is collected by observing any patient.
2) interview
Interviewing involves interviewing clients to obtain information, identify problems, evaluate change, teach, or provide support or advice.
3) Examination:
Systematic data collection is done to detect health problems using units of measurement (measurement), physical examination, techniques (technique), interpretation of laboratory results (laboratory investigation).
E.g. cephalocodel:= head to toe assessment,
Body system approach: Examining all the systems of the body.
Review of system approach:= In this only specific affected area has to be examined.
2) Organisation:
In this case, the nurse organizes the information gathered from the client into a specific order.
3) Validating data:
In simple word:=validating means cross checking the collected information
(Validating means cross checking the collected data).
To ensure that the collected information is fact and true or not, cross checking of the data can be done in any of the following ways.
By rechecking the client’s data eg rechecking pulse, blood pressure etc.
Conforming subjective data with objective data.
Asking for rechecking of collected data by experts eg asking for rechecking of checked blood pressure.
Re-checking the information collected.
Verification of client’s statement.
Verification with family members and friends of the client.
Verification of wrong information also.
Also take help of some kind of reference book including tax book, journal, research study.
4) Recording data:
It is very important to record and report the information received from the client.
Records should be accurate, complete, and in plain language, in an organized manner.
Proper record reporting of all information is very important so that no information is omitted.
Nursing diagnosis:
Nursing diagnosis is the second step in the nursing process followed by nursing assessment.
In this phase, the data collected is analyzed and a nursing diagnosis is made based on the problem.
Nursing diagnoses are made according to the North American Nursing diagnosis association (Nanda) method.
A nursing diagnosis is made by gathering potential and actual information about the client.
Nursing diagnosis a
PES P:=PROBLEM,
E:=ETIOLOGY,
S:= SIGN AND SYMPTOMS /DEFINING CHARACTERISTIC. )
PURPOSE OF NURSING DIAGNOSIS:
To analyze the collected data.
To assess the normal functional status of the client.
To identify the strength of light and its weakness.
To make a diagnosis for the patient.
characteristic of nursing diagnosis.
1) Nursing diagnosis should be clear and concise.
2) Nursing diagnoses should be made according to lion’s evidence.
3) This should be on the basis of planning.
4) Nursing care should be provided in a proper manner.
Type of nursing diagnosis:
1) Actual diagnosis,
2) High risk diagnosis,
3) wellness diagnosis (wellness diagnosis),
4) syndrome diagnosis (syndrome diagnosis).
1)Actual nursing diagnosis:=
This diagnosis is made when the nurse is assessing the client. The diagnosis is based on the actual need of the client.
2) High risk diagnosis:
This problem describes a possible problem. It means that the client is more likely to develop the problem than other problems in the same situation.
Risk factors indicate a problem that is only likely to develop unless you intervene or do something about it.
For example, an obese class undergoing hip replacement surgery so the patient is on continuous bed rest may create a risk nursing diagnosis as follows.
3) Wellness diagnosis:
In this a diagnosis is made about any particular wellness.
4) Syndrome diagnosis:
This involves making nursing diagnoses about symptom syndromes.
Ex:= rape, Trauma, Syndrome.
statement of nursing diagnosis:
There are three parts to a nursing diagnosis statement.
1) problem,
2) Etiology,
3) definite characteristic.
1) problem:
The problem involves stating the client’s problems and formulating a nursing diagnosis based on them.
Ex: knowledge deficit, Acute, Chronic, Ineffective, Altered, Decrease.
2) Etiology:
The etiology component of a nursing diagnosis identifies one or more causes of health problems.
Provides direction in the administration of nursing intervention.
It helps the nurse to individualize patient care because two patients may have the same problem but with different etiology.
3) Definite characteristic:
Any signs and symptoms of this problem are involved. This includes subjective and objective data.
Ex:=fluid volume deficit related to decrease oral intake manifested by dry skin and mucus membrane.
2) Risk for impaired skin integrity related to immobility manifested by redness on skin.
planning:
Planning is an important third step in the nursing process.
It is an important activity that involves the nurse’s thinking about what to do, when to do it, where to do it, and who will do it.
Planning involves interaction with the client with family and health care with their members.
In planning, nursing care is planned by the nurse according to the patient’s need and care is provided to the patient according to the patient’s need.
Planning is a deliberate systematic phase of the nursing process that involves decision making and problem solving.
Planning is a nursing behavior that keeps the client at the center and plans interventions according to his needs to achieve a specific goal.
Planning is a series of events carried out to achieve a specific goal and is carried out by the nurse.
purposes of planning:
To provide specific direction in the client’s activity.
To maintain continuity of care for the client.
To provide nursing care to the client as per his requirement.
Types of planning:
1) Initial planning
2) Ongoing planning
3) Discharge planning
1) Initial planning:
This planning is done immediately after patient admission.
This planning has to be done very quickly and in short duration as it has less hospital stay.
2) Ongoing planning:
On going planning is all done by the nurse.
And client care is provided.
This planning has to be done every day and planning has to be done after the ongoing assessment.
3) Discharge planning:
This planning involves planning what kind of care the patient will need at home when he or she is discharged from the hospital.
And what kind of environment the client has to provide at home and any special care at home is planned.
Phases of planning:
Planning is the process by which a nurse plans the type of care to provide for a patient.
1) Setting priority.
2) determine goal and expected outcome. (Determining the target and expected results).
3) selecting the using strategies. (Selecting Nursing Approach Structures).
4) Developing nursing care plan. (Making Nursing Care Plan).
1) Setting priority:
Prioritization is a decision-making process in which the nurse inquires about the patient’s problems and sets them in order. Prioritizes which nursing care needs to be provided first.
A) High priority:
High priority includes problems in which the patient’s problem, if not solved, would cause great harm and could cause serious harm to the patient.
Ex: = ineffective airway clearance after surgery related to abdominal incision.
In this it is very important to clear the patient’s airway.
Airway clearance is therefore a high priority in creating a nursing care plan to improve the patient’s breathing pattern.
B) Intermediate priority:
Even if there is a little delay in providing nursing care in this priority, this does not indicate any kind of emergency but care is provided as soon as possible.
Ex: = pain related to surgical process.
Although this may take some time to relieve the client’s pain, it does not require immediate intervention.
C) low interventions:
Low priority includes nursing care that does not cause much harm to the patient, even if it takes time, and does not constitute an emergency.
Example:=definitely knowledge related to smoking cessation program.
2) determine goal and expected outcome:
The next step is to determine the goals or expected out come.
The nurse determines her goals and expected outcomes for each nursing diagnosis.
Goals are defined during the nursing intervention according to which care is provided to the client.
Purpose of goal:
To evaluate the client’s progress.
To see how effective the nursing intervention is.
Type of goals:
A) short term goal.
B) Long term goal.
A) Short term goal: This short time goal is to achieve the task within a short period of time. It is to be achieved within a week which requires immediate nursing care.
2) Long term goal: This long term goal is to achieve a long term task. This goal is usually achieved over weeks and months and can be achieved even after the patient’s discharge.
Expected outcome:
In this the behavior of the patient that we have to achieve through nursing care is the expected outcome.
3) selecting a nursing interventions:
Nursing interventions are designed to achieve client outcomes and have specific approaches.
Components of Nursing Intervention:
Each outcome should have a set of nursing interventions to accomplish.
To be an effective nursing intervention, the nursing intervention should be clear and concise.
Nursing intervention should be made in consultation with client family members consultant etc.
Nursing interventions should clearly state where and when they will be completed.
4) Development of nursing care plan:
Writing a nursing care plan is the first step in planning.
After assessing and diagnosing the patient, the nurse prioritizes each nursing diagnosis and formulates a nursing care plan.
How to write a nursing care plan.
column:1
Includes the using assessment according to the priority.
column 2:=
Nursing diagnosis,
Expected outcome,
column 3:=includes nursing planning,
column:=4
Nursing interventions,
column:=5 contains evaluation.
Implementation
In simple words, implementation is the process of putting planning into action.
This is the fourth step of the nursing process.
Nursing planning is the implementation of the care plan for the client.
Purpose of implementation:
To provide technical nursing care.
To provide nursing care to prevent diseases.
To achieve the best level of health of the client.
To provide proper nursing care to the client.
Evaluation
Evaluation is the fifth step in the nursing process.
This involves evaluating whether the nursing intervention implemented to the client has achieved the goals we have set.
In the evaluation phase, the nurse determines whether the goal of the nursing care provided to the patient has been achieved.
In simple words, the nursing care we provide to the client is done to see whether the client’s health has improved or not.
Purposes of evaluation:
To see whether the nursing provided by us is properly implemented or not.
To observe the client’s behavior regarding nursing care.
To see if the goal set by the nurse has been achieved.
To see if the client and family members are involved in the care provided by the nurse.
To see how much the patient cooperates with the nurse.
A nursing intervention is performed to see if there is anything wrong.
To see the quality of nursing care provided.
Thus in the nursing care plan
assessment,
Diagnosis,
planning,
implementation,
evaluation (evaluation).
In this step, if care is provided to any patient by the nurse, the first care plan is formed.