Prepare a report on Nursing Diagnosis and Goals
The improvised patient care and the programs trying to incorporate the guidelines basis the setting in nursing arena hold a crucial role. The fundamentals as that are laid in medical surgical nursing encompasses the crucial components from the various interventions. The inclusion of neonatal, paediatrics, maternity along with mental health and community health care has gained popularity. With the nursing diagnostic identified, it is essential that the care plan being formed is well evaluated and monitored. The various nursing care plans does aid in the decision making skills enhancement basis the developed skills (Swift, M. C., & Stosberg, T., 2015; Ciemins, E. L., Brant, J., Kersten, D., Mullette, E., & Dickerson, D., 2015; Lewis, A. L., & Tavares, G., 2016). The older adult consideration in health promotion and patient teaching has been of crucial concern. The specific disorders that form part of patient care with the intervention of procedures provisions the basis of such nursing practices in the health care arena.
The ISOBAR model forming a crucial part well describes the identification along with situation comprehension, observations, background, agreed plan and read back. The format has been developed and practised as it provisions minimal concerns arising from the communication. The root cause analysis done basis the diagnostics in adults is necessary. The flexibility in the approach aids in the development of the program with the inclusion of various strategies to match the goals and objectives (Swift, M. C., & Stosberg, T., 2015; Ciemins, E. L., Brant, J., Kersten, D., Mullette, E., & Dickerson, D., 2015; Lewis, A. L., & Tavares, G., 2016). The implementation of the diagnostics basis the goals pertaining to diagnostics do need to bring about the crucial prioritization of the various processes and sub processes.
Identify - My abilities are associated as provisioning nursing intervention in the arena of physio orthopaedic and the ability to well provide care for patients suffering from CHF. The patient - Mr. Jones Daniel is 56 years old. The native of Brisbane, the family history of Mr. Jones is that his wife being 52 years old is not suffering from any ailment. Mr. Jones mother and father passed away at the ages of 72 and 74. His mother was suffering from acute diabetes His father had chronic heart disease and was operated twice. Mr. Jones smokes cigarettes - 12 cigarettes in a week. His alcohol consumption is 250 ml. /week. He works as a floor Supervisor at an MNC. He has been operated for a head injury 5 years back. Mr. Jones is currently on no medication.
Situation - The situation pertains to the 56 year old male having a condition of congestive heart failure. The admission of the patient with the diagnosis identified and the intervention needed for physio orthopaedic sessions too. The identification of nursing diagnosis is congestive heart failure which is considered to a health problem with the impact felt globally. The incidence along with the prevalence of CHF has been present in the society (Di Biase, L., Mohanty, P., Mohanty, S., Santangeli, P., Trivedi, C., Lakkireddy, D., ... & Casella, M., 2016; Crowley, M. J., Diamantidis, C. J., McDuffie, J. R., Cameron, C. B., Stanifer, J. W., Mock, C. K., ... & Williams, J. W., 2017). The identification of physio orthopaedic in clinical practice has been embraced with the greater enhancement in the prevention of complications amongst patients.
Observations - The observation of symptoms as that are associated to the patient encompass fatigue and the intervention as that would be required to monitor the changes in heart rate are significant. The rest and activity pattern has also to be observed as part of the nursing intervention. The management plan for the patient is also taken into consideration with the observation.
Background - The flexibility and the engagement of care needed for Mr. Jones is recommended due to the conditions. With the diagnosed CHF, it is critical that the lifestyle has to be improvised. The condition is caused due to the functional alteration. The patient has complications associated with both the cardiac chambers. The symptoms linked to the systemic congestion are prevalent for Mr. Jones. There is a risk of the progression of CHF in patient. With the conditions of feeling fatigue and the lesser mobility, the patient also has fatigue and pain in the joints.
Recommendation - In order that the relief is brought from the symptoms associated with the condition of Mr. Jones, it can be recommended that the essential treatment is provisioned for congestive heart failure. The reversing of progression is a challenge that is faced with respect to the medical condition of patient.
It is essential to know whether the planned outcomes have been met. The aspects of the disease have been increasing over the years and regulated prevention stand to be essential. The construction of nursing diagnosis and the management of plan are emphasized to a greater extent. The support programs as part of the symptoms as that are prevalent in the case, the need for monitored intervention with a care plan would need to be well adhered (Di i Biase, L., Mohanty, P., Mohanty, S., Santangeli, P., Trivedi, C., Lakkireddy, D., ... & Casella, M., 2016; Ghadery-Sefat, A., Abdeyazdan, Z., Badiee, Z., & Zargham-Boroujeni, A., 2016). In order to understand the ascertainment of planned outcomes having been met, there needs to be a checklist that would ascertain the tasks that would be listed as a check to understand if the appropriate care and treatment are being offered to the patient.
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Nursing Diagnostic I
The first nursing diagnosis pertains to the congestive heart failure. The public health prevalence with the global occurrence has the probability associated with cardiovascular risk factors. The essential type of risk factors is associated with arterial hypertension along with dyslipidaemia and diabetes mellitus. The sedentary lifestyle along with obesity and stress are the associated risk factors that are linked to the diagnosis.
The goals are linked to being patient centric and measurable. The goals can be summarized with respect to the below considerations -
• The use of systematic and dynamic approach in the collection and analysis of data based on nursing delivery.
• Assessment of patient pain done accordingly and appropriate pain management coordinated
• Meeting potential care needs for the patient
The implementation of the nursing intervention based on the goals has to consider the potential complication that the patient along with the nurse has to be aware of. With the regulated monitoring of the care plan and the intervention matching the goals, it is essential that the post-operative education to the patient is being provisioned. (Herold-Majumdar, A., Schaller, M., Fleischer, S., & Behrens, J. , 2016) With reference to the needs of the patient basis the post-operative procedure, there are need of the assessment done and appropriate physio orthopaedic care is being provided to the patient. The balanced routine with changes to the lifestyle to reduce stress and well management of patient care stands to be essential.
The evaluation of intervention needs to be well documented. The evaluation of the clinical setting is significant. The criterion referenced scale which has an appropriate rating methodology has to be well incorporated. The feedback basis the evaluation done also needs to be documented. The documentation as part of the medical records has to be saved as a soft copy in the database of the patient. The statistical approach with the success of adherence of fundamental skills and the conceptual framework well exhibited through the intervention is essential (Schneider, M. A., & Ruth-Sahd, L. A., 2015).
Nursing Diagnostic II
The physio orthopaedic diagnostic as that would be needed post-operative sessions due to the lack of immediate regulated mobility. The orthopaedic condition with the pain in the joints and feet brings about the essential consideration of the needed intervention with respect to the diagnosis.
The goals linked to the nursing diagnosis are related to -
• Adherence to the diagnosis with the monitoring done in an effective manner
• Promoting advanced evaluation techniques (Schneider, M. A., & Ruth-Sahd, L. A., 2015).
• Identifying the essential intervention and adhering well to the care needs of the patient
The implementation of the nursing intervention with the diagnosis identified pertains to the regulated care needs of the patient met with the well managed patient care plan adhered. There is a need well recognized to ensure that the goals of the program are well met ad the education is provisioned to the patient along with the members of family of patient. The implementation for the intervention has to take place in a smooth manner with the essential considerations maintained.
The evaluation will be based on the ability to identify the nursing intervention well and documenting the facts. The evaluation of the clinical performance would be judged with the expected change in behaviour and essential considerations well kept under control. The evaluation has to be computerized with the available software in order to maintain greater adaptability.
Patient care along with the linked programs trying to incorporate the various guidelines basis the setting in nursing arena is significant. The ISOBAR model analysed gives a fair analysis of the identified patient and self-abilities. The situation too is crucial that encompasses the identification of nursing diagnosis is congestive heart failure which is considered to a health problem. It is important that the observation techniques are well monitored. The condition of congestive heart failure is caused due to the functional alteration. The patient has complications associated with both the cardiac chambers. In order that the relief is brought from the symptoms associated with the condition of Mr. Jones, it can be recommended that the essential treatment is provisioned for congestive heart failure. The other nursing diagnostic is physio orthopaedic. The goals are related to being patient centric and measurable. With regards to the needs of the patient, there is need pertaining to the assessment done and appropriate physio orthopaedic care is being provided to the patient. The feedback basis the evaluation done also needs to be documented.
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Ghadery-Sefat, A., Abdeyazdan, Z., Badiee, Z., & Zargham-Boroujeni, A. (2016). Relationship between parent–infant attachment and parental satisfaction with supportive nursing care. Iranian journal of nursing and midwifery research, 21(1), 71.
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Schneider, M. A., & Ruth-Sahd, L. A. (2015). Fundamentals: Still the building blocks of safe patient care. Nursing2017, 45(6), 60-63.
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