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Nursing Process

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Leanne Battersby 17024576 BA Hons Adult Nursing Faculty of Health and Wellbeing Sheffield Hallam University 20th June 2008 Principles and Practice of Nursing 1 Word Count 3,838 Principles and Practice of Nursing 1 Assignment This assignment will show the writers understanding and knowledge of the nursing process. In order to do this a specific patient has been chosen, focussing on one goal of care highlighted through the use of the assessment of a nursing model. To maintain confidentiality and protect autonomy, the patients name has been changed and any details through which a reader could identify the patient or the care location have also been changed. This complies with the NMC professional code of conduct (2002). Furthermore for legal issues, the writer has gained consent from the selected patient. The writer explained to the patient clearly what information would be needed in the report and that confidentiality would always be maintained. With this information the writer was able to gain informed consent. The information provided was gathered from a number of sources. Primarily the patient and their medical notes, but also from medical and nursing staff. The specific patient is Joyce, 66 years of age. Joyce visited her GP complaining of abdominal and back pain along with indigestion. After being referred for an ultra sound scan and having several blood tests, she was diagnosed with gallstones. Halton (1994) verifies that gallstones are hard pieces of stone-like material that are made from cholesterol, calcium carbonate, calcium bilirubinate, or a mixture of these. They are normally caused when the chemical balance of your bile has too much cholesterol in it. This causes the bile to form into small particles which may then grow into gallstones. Joyce was prone to getting gallstones as Sanford (1982) explains that in more than 80% of cases, gallstones occur when your liver produces bile with high cholesterol content. An excess of cholesterol in your bile may be due to factors such as a high cholesterol diet and advancing age. ...read more.


Sleeping. Joyce takes no medication to aid her sleeping and explains that she has a 'good night's kip' most nights. She has not suffered any sleep deprivation before coming into hospital. Dying. Joyce did not feel comfortable discussing death. Kindlen (2003) reports that gallstones can sometimes cause flu like symptoms such as a high temperature. Joyce's baseline temperature on admission is 37.6�C. This is slightly above the normal range. The writer has chosen the goal of care is to control Joyce's body temperature. The cause of the temperature could be for several reasons; disturbance of body tissues, malignancy or surgery but in relation to Joyce it could be a sign that gallstones are causing an infection to develop in her gallbladder. It is therefore highlighted that Joyce already has a slightly raised temperature has the potential problems of developing pyrexia. Planning Planning is the second phase of the nursing process. In this phase, the nurse develops a plan to assist the patient to meet needs identified in the assessment process. Excellent communication skills are needed here to educate the patient regarding treatment they need, to enable them to make informed decisions regarding their care. Walsh etal states that 'it is the nurse's responsibility to communicate effectively with the patient to bring about optimum nursing care' (2002). Mutual priority setting with the patient serves two purposes. Firstly it involves the patients in the planning of their own care. Secondly, it enhances the relationship between nurse and patient. After this has been achieved, the nurse needs to establish Joyce's care goals. A nursing goal can be defined as 'a statement of what the nursing intervention is intended to achieve' (Yura and Walsh 1978). Alfaro (2002) clarifies that goals should be simple, measurable, achievable, realistic and time scaled. To meet these goals it is essential that the nursing interventions are also planned. The writer would like Joyce's temperature to return within normal range within 12 hours. ...read more.


I thought that as I had been observed carrying out this standard procedure on many other occasions then my practice must have been seen to be correct. I was also concerned that the practice of the qualified nurses was so inconsistent, which led me to evaluate the whole process. The Royal Marsden (Richardson 2008) advocates the guidelines of nursing action in compliance with pyrexia as discussed in my plan of care for Joyce. Therefore my practice was within the trust protocol. This experience made me think about my attitude towards literature and how it is applied in practice. Through evaluation of the event in question I have become more aware of different practices concerning reducing body temperature. I am aware that many practices are used within my placement are, but as I develop professionally I am developing my own skills and will plan care as appropriate to the patient using the protocol rather than consulting the protocol immediately. There is no clear evidence in controlling body temperature which intervention should be implemented first within this area but I will use the literature which is available to justify my actions, and therefore give evidence based care. In conclusion, Joyce's temperature was back within normal limits in a short period of time, safely and effectively. I am aware that all nurses do not use evidence in the same way and may use different methods but as long as my practice is safe and evidence based then I can practice safely. My future practice will depend on the area in which I am working and I aim to find out the trust protocol concerning clinical procedures before I commence any procedure. Furthermore, if possible the patient should ask which type of intervention they would prefer first and their opinions and views should be respected. Within my action plan my aim is to research further into the controlling of body temperature, not only raised temperature but lowered temperature too. I am also planning to have a discussion with the qualified nurses on the subject of fever management in children and the elderly. ...read more.

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