Nursing assignment - Diagnosis using Five Sequential Steps

Requirement

1- Write a report on "Nursing assignment" with references to APA within 2000 words.

Solution

Introduction

The various procedures of nursing could use as an organized system for the purpose of establishing a patient oriented care plan, taking into consideration five steps in an orderly manner. 
The serious characteristic of the various kind of illness from which an old age person suffers requires them to take part in their caring process in the hospital and also allow the members of their family as well as their care takers to take part in the process of their care taking as much as it is suitable in the process of their discharge planning. Moreover the biological as well as the emotional need of a patient also communicates with the environment in which he is living. 
However the case study is about an 83 year old man named Harold, who has a very serious medical history in the past of angina as well as cerebral vascular incident on his left side. But in the current scenario he has been admitted to the hospital because of his attack of angina. 
The first part of the assignment will discuss about the five orderly steps in the nursing procedure and also determine two nursing diagnosis in relation to the patient in concern. The second part of the assignment will discuss about a multidisciplinary action team would be referred to the team as per his diagnosis and a justification would also be provided to include such team members. In the final part of the assignment some important legislation as well as the ethical guidelines would be provided for the care need of the patient. 

Diagnosis using Five Sequential Steps

Diagnosis 1: Impaired mobility

However Mr. Harold has also been diagnosed with impaired mobility which means that the patient is incapable of moving on his own and the overall physical movement of his body is also restricted because of one or more critical conditions. The old age of Mr. Harold could be one of the reasons for his impaired immobility which reduces the functional ability of his muscles, reduces the weight and power of the muscles and also creates an impact on the balance of the patient along with the problem associated with the movement of the muscles. Such a problem occurs due to the occurrence of stroke, fracture of the leg and also due to the problem of excessive obesity. 

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Diagnosis 2: Dehydration

Mr. Harold has also been diagnosed with the problem of dehydration which means that he was losing liquid from his body and his body also does not have sufficient amount water or any other form of liquid to enable his body to function in a normal manner. However such a condition could be very much dangerous for the old age patients and also in the case of children.  Because of the old age of the patient he already has low water level in his body and he is also taking certain kind of medicines which is also increasing the risk of dehydration in him. Such patients usually suffers from low blood pressure, mostly when shifting from one place to another, increase in the heart beat and also low flow of blood in the body. 

Five Sequential Steps of the Nursing Process

1.    Assessment: 

The process of examination requires the need of certain serious thinking competencies as well as the potential to collect information appropriately. The process of examination should be very much related to the subject and also very much precise. The information collected on the basis of the subject should be an oral statement made by the patient itself or by his care taker (Toney-Butler, & Thayer, 2019). There are certain specific information which can be calculated and there are some adjustable data like the weight and height of the patient, the put in and put out of the patient as well as a range of vital signs of the patient. 
Such important information are usually gathered from the patients themselves or from their main care taker, who may not necessary be his family member. However even the friends of the patient can also provide such important information. The storage of such information electronically might result in overloading the information which will also help to a great extent in the examination of the patient. In this phase the potential to think in an analytical manner overtakes the need of subject based thinking. 
It is clear from the symptoms mentioned in the case study that the patient was having low blood pressure, he was 83 years old and hence he was more prone to dehydration. 

2.     Diagnosis: 

The process of establishing a diagnosis by the nurses makes use of the judgemental skills of the nurses medically and also helps the process of making appropriate strategies and then applying the same in relation to the caring process of the patient. Moreover the North American Nursing Diagnosis Association provides all the nurses with upgraded lists of various kinds of diagnosis which could be made by them. Hence as per the NANDA, the nursing diagnosis is known as the process of making a medical diagnosis in relation to the various health problems faced by the patients. 
The nursing diagnosis is framed based on the Hierarchy of Needs by Maslow, which enables the nurses to plan the care of their patient on the basis of its significance in relation to every different patient(Toney-Butler, & Thayer, 2019). 
As per the hierarchy of needs, it is very much important to first fulfil the simplest need of the concerned patient which is their psychological need and then work towards fulfilling their need of self respect and also the need to develop one selves. In this case the most basic needs includes the need of a proper nutrition, breathing needs, suction needs, the need to exercise, sleep and sex(Toney-Butler, & Thayer, 2019).  
The nursing procedure should also include the need to protect the patients from any kind of injuries such as by the use of helmet and also educating the patients on various risk factors of having a stroke or a heart attack. 
Hence it is very much important to first meet the various emotional as well as the safety needs of a patient before the application of any nursing care plan as well as any procedure on the patient. Then gradually the need of self respect and self development could be fulfilled. 
However Mr. Harold was diagnosed with an impaired mobility and dehydration. 

3.    Planning: 

In the third stage of the nursing procedure it is very much important to develop an objective and an expected result which has an influence on the patient in concern. The objective should be established as per the need of the patient, which in turn will also help in generating a positive result. However the objective established should be a “SMART” one.  It also plays an important role in improving the interaction, collection of documents, the process of pay back as well as the continuity in the health care process(Toney-Butler, & Thayer, 2019). 

4.    Implementation: 

In this stage of nursing procedure the ultimate action is taken to carry out the treatment procedure on the patient which was determined in the nursing care plan. In this phase there is a requirement of certain medical applications such as the implementation of oxygen, certain medications or the heart monitor(Toney-Butler, & Thayer, 2019). 

5.    Evaluation: 

In the last stage of the nursing procedure it is important to determine a positive result in the health of the patient, It is also very much important for any healthcare professional to ensure that the care procedure they are using, as well as the diagnosis they have determined generates a positive result on the health of the patient(Toney-Butler, & Thayer, 2019). 
Mr. Harold was diagnosed with an impaired immobility as well as dehydration because of his old age. 

Multidisciplinary team members

There is a requirement for some general physician, cardiologists, a medical specialist for internal disease as well as the experts in health care for the treatment of old age people. 
A general physician would be required to check up the overall health of Mr. Harold and keep all his vital functions under control. A cardiologist would be required for the treatment of his left vascular accident and for which the angina is just a warning sign but might also be life threatening in some instances, hence it requires the consultation of some experts. There is also a chance that his veins or arteries have been damaged internally so the help of an internist might also be required (Gomes, Almeida &Braile, 2010). Moreover Mr. Harold is a 83 year old man, hence he also needs the help of an expert who deals with the life of old age population. As the patient was also suffering from dehydration he required the help of a supervision team which consists of well educated nurses who could efficiently monitor the patient and regulate the fluid intake accordingly. 
In the case of an impaired mobility the multi disciplinary team should consist of a doctor, three nurses and six other professionals for conducting the therapy of the patient. Moreover the group of therapist includes a physiotherapist, a professional therapist, a therapist for conducting speech exercises, a physician for treating stroke as well as helpers of the healthcare system. 

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A great amount of consideration should be taken by the healthcare professionals for the treatment of the patients who are suffering from angina as well as vascular diseases. The general physician should first discuss the whole treatment plan with his patient and it is up to the patient to be ready for the treatment or to decline the treatment. No treatment should be forced upon a patient without discussing about it with him and his decision should also be respected but it should not be hazardous to his health. 
Firstly the right of the patient to accept or decline his treatment should be respected to a great extent, as it is considered to be the first sign of ethics in the field of healthcare. Moreover any decision taken by the physician which is advantageous for the patient should also consider the respect of the patient as well. Any physician should never make the mistake of neglecting the priority of his patient which can have a negative impact on the patient(Gomes, Almeida &Braile, 2010). Any patient should have the complete right to accept or decline any suggestions given to him by the physician. However even the physician has the complete right to decide which treatment would be the most beneficial for the patient and also not accept the decision of the patient if it is good for the health and life of the patient. 
It should also be the duty of the healthcare professionals to inform his patient about the kind of treatment they would be going through and they should also be true in communication of the treatment to the patient(Gomes, Almeida &Braile, 2010). 
The healthcare professionals should also take due amount of consideration that the cultural and religious sentiments of their patient is not hurt by any of their treatment procedures as well as by their communication with the patient. 
A healthcare professional has the full capacity to take any decision which is good for the patient and which does not hurts the respect of the patient. 
A healthcare professional has no right to refuse the treatment of any of his patient. 

Conclusion

The main purpose of this assignment was to develop a care plan for a 83 years old man Harold who has been diagnosed with impaired mobility and dehydration
In the first part of the assignment the discussion has been about the nursing procedures in five important steps. This part has also taken into consideration the discussion about the two diagnoses made in the case of Mr. Harold. In the second part of the assignment due amount of consideration has been given to the multidisciplinary team for the treatment of dehydration and the impaired mobility diseases and also the purpose of each member of the team has also been mentioned in the assignment. In the final part of the assignment due amount of consideration has been given to the different legal and ethical requirement in relation to the treatment of the two diagnosis made in the case of Mr. Harold. 

Reference:

  • Benjamin Wedro, F. (2019). What Does Angina Feel Like? Symptoms, Causes & Treatment. Retrieved from https://www.medicinenet.com/angina_symptoms/article.htm

  • Gomes, W., Almeida, R., &Braile, D. (2010). Multidisciplinary approach to heart disease. The patient as a priority in medical decision. Brazilian Journal Of Cardiovascular Surgery, 25(4). doi: http://dx.doi.org/10.1590/S0102-76382010000400003

  • Toney-Butler, T., & Thayer, J. (2019). Nursing Process. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/

  • Vascular Disease Information | Causes & Risks of Vascular Disease. Circulationfoundation.org.uk (2019). Retrieved from http://www.circulationfoundation.org.uk/help-advice

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