Application of the Nursing Process to a Patient Care Scenario

Nursing Process, Care Planning and Teaching Plans

Part 1: Nursing Process

Nursing Process Steps

The nursing process (NP) comprises of five steps, or phases. First, the assessment step is the phase that entails the appraisal of patient statuses. It entails the interaction with and gathering of patients’ spiritual, physiological, psychological, and sociological condition data. Nurses gather the data via patient interviews, patient history examinations, observation, physical reviews, or reviews of the histories of patients’ families (Hagos, Alemseged, Balcha, Berhe & Aregay, 2014). Second, the diagnosing step involves the formulation of informed judgments as regards the actual, as well as potential, health problems that given patients have. The phase involves diagnoses, description of the problems, and determination of the possibility of the patients to develop other problems. Notably, the diagnoses as well assist in establishing whether the patients are ready for health enhancement and particular treatment courses (Grossman, 2013).

Third, the planning step occurs following the concurrence of a nurse and his or her client on a given diagnosis. The phase involves the development of appropriate action plans and prioritization of assessments where there is a need to address multifaceted diagnoses. Each of the problems diagnosed in the patient is matched with measurable and clear goals or aims for the anticipated advantageous outcomes. The fourth phase is the implementing step, which involves the following through of the action plans particular to the patient. The phase zeroes in on attainable outcomes. Some of the activities that define the step are the monitoring of particular patients for improvement signs or change signs, offering patients appropriate care, and performing the requisite medical tasks. The last phase is the evaluation step (Grossman, 2013).  It is an appraisal to establish if set aims for client, or patient, wellness are attained over given time. The aims may relate to the improvement or stabilization if patients’ conditions, or patients’ discharge, death or deterioration.

Indirect and Direct Care in the Implementation Phase

The NIC (Nursing Intervention Classification) characterizes direct care as the interaction of a patient with a nurse as the latter provides services to the former. The care includes patient assessment, execution of particular diagnostic procedures, teaching as well as action plan implementation. The NIC characterizes indirect care as the offering of given services to patients by nurses devoid of interacting. The care includes scheduling and charting. Notably, although the care is not provided directly to the patient, it is all aimed at ensuring his or her wellness.

Nursing Interventions

Nursing interventions take diverse forms. The interventions are deemed independent when nurses initiate them autonomously, for example, educating patients on given medications’ purposes. The interventions are deemed dependent if nurses require orders from other authorities like physicians in order to offer them. Such interventions include the administration of given medications by patients as ordered by physicians. Collaborative, or interdependent, interventions are offered by teams (Grossman, 2013).  For instance, a nurse and a dietician can counsel a diabetic patient on the foods to take jointly.

How NP Offers RNs Basis for Making Judgments

The NP offers RNs with bases for formulating nursing judgments aimed at improving patients’ health outcomes. The NP informs RNs on the best way of formulating judgments that are sensitive to and supportive of the different phases of the care they offer to patients. As the condition of a given patient improves, the RN in-charge of her or him changes his or her focus in accordance with the NP. The RN revises the applicable action plan with respect to the attendant assessment data. In addition, the NP helps RNs remain accountable for the nursing judgments they formulate.

How RNs Appraise the General Utilization of the NP

When a nursing intervention has been offered, the RN in-charge carries out evaluations aimed establishing the attainment of the related patient wellness aims (Hagos, Alemseged, Balcha, Berhe & Aregay, 2014).  As noted earlier, the RN carries out appraisals to establish if set aims for client, or patient, wellness are attained over given time. The aims may relate to the improvement or stabilization if patients’ conditions, or patients’ discharge, death or deterioration. RNs carry out the evaluations via patient interviews, patient history examinations, observations, physical reviews, or patient family testimonies. The resulting data is documented, reported and acted upon accordingly (Grossman, 2013).

Variables Influencing the Achievability of Desired Patient Outcomes

Varied variables influence the achievability of desired patient outcomes. The first variable is the patient. Patients are quite influential as regards the implementation of given nursing interventions aimed at improving their health outcomes. Some of them are unwilling to take part in given action plans. Others are in developmental stages that limit the achievability. The second variable is the nurse (Grossman, 2013; Kourkouta & Papathanasiou, 2014).  Nurses affect the achievability based on their creativity, expertise, and availability to offer care. The other variable is the set of resources that are available. Clearly, care plans are only implemented effectively with the requisite resources, including staff.

Modification of Care Plans

Nurses should amend, or modify, given care plans when the desired patient outcomes are not attained. Notably, rather than being modified, some of the plans are terminated or continued when the desired patient outcomes are not attained in the stipulated timeframes. The modification of care plans starts with the re-appraisal of the related NPs to make out the factors limiting the achievement of the outcomes or making the plans ineffective (Adeyemo, Adenike & Olaogun, 2013). Then, the data gotten from the re-appraisal is used in guiding the addition or alteration of diagnoses, modification of the outcomes, changing of related nursing orders or changing of the frequency of targeting the evaluation phase of NP.

How RNs Utilize NP to Formulate Decisions as Regards Care Priority

RNs utilize the NP to formulate decisions as regards care priority. They use different NP-related rankings in prioritizing diagnoses and interventions based to the risks facing patients’ wellbeing. First, RNs utilize the MHHN (Maslow’s Hierarchy of Human Needs) in prioritizing diagnoses and interventions. Using the MHHN, the nurses prioritize care needed to meet the patients’ physiologic needs, safety requirements, belonging and love requirements, self-esteem needs, and self-actualization needs, in that order. For instance, a nurse caring for geriatric persons who are incontinent of fecal matter know that they cannot participate effectively in music-based therapies until their more elementary need is sufficed (Grossman, 2013).

Second, RNs prioritize the diagnoses and interventions based on patient preferences. Such nurses meet patients’ needs as prioritized by the patients themselves; where doing so is compatible with the offering of all essential therapies. Third, RNs prioritize the diagnoses and interventions based on their expectation of prospective problems. The nurses exploit their knowledge bases and expertise in considerable the probable consequences of varied nursing actions on patients. The assignment of limited priorities to diagnoses that given patients want to disregard but that may bring about harmful effects for them may be deemed nursing negligence (Hagos, Alemseged, Balcha, Berhe & Aregay, 2014).

Part 2: Patient Scenario

Statement for Actual NANDA-I Nursing Diagnosis

Actual diagnoses within nursing contexts address issues regarding to responses of individuals within communities, themselves, and families to given health conditions. The conditions include specific life situations and diseases. The diagnoses ought to be adhered to by characterizing the factors relating to the actual diagnosis elements. The statement for actual NANDA-I nursing diagnosis with respect to the present case is: impaired skin integrity related to friction and shearing and mechanical tissue damage secondary to pressure as evidenced by a pressure ulcer on patient’s right buttock ischium and skin infections.

Why the Diagnosis is a Priority

The skin integrity diagnosis with respect to the 78-year old patient is a priority since his skin is at a heightened threat of being further altered adversely. As well, the patient has risk factors that put him at a marked threat of having the ulcer that he has worsen or develop other pressure ulcers. The factors are hyperlipidemia, hypertension, weakness of lower extremity, and the advanced age.

Assessment Data

Various assessments will be gathered to establish whether the patient has the diagnosis. First, his age will be established. The skin of aged patients has limited elasticity and moisture, increasing their skin impairment risks. Second, the patient’s general skin condition will be assessed for turgor and capillary refill rate. Third, the skin will be assessed specifically over the patient’s bony prominences. Fourth, the patient’s awareness of the pressure sensation will be evaluated. Fifth, the patient’s skin will be reassessed frequently and every time his treatment plan or condition shows the heightening of particular risk factors.

Expected Outcome

The skin of the 78-year old patient becomes intact, as proved by no ulcer on any of his bony prominences, no wounds, and no yellowness or redness over and around the prominences within two months. The outcome is physiologic (Tissue Viability Team, 2013).

Time Frame

The timeframe selected for the appraisal, or evaluative, criteria in the case is two months. The 78-year old patient will have no ulcer or wounds on any of his bony prominences within a month. The patient will have no yellowness or redness over and around the prominences at the end of the two months.

Nursing Interventions


  1. Whenever the patient is on bed, the RN will encourage him to follow a schedule of turning, limit the duration he spends on a given position to one hour, and customize the schedule to the routine preferred by the patient and the needs of those offering him care. Notably, turning schedules that match or accommodate caregiver and patient activities and needs are highly likely to be adhered to.
  2. The RN will encourage the patient to maintain a body alignment that is functional by limiting the time he spends sitting down to one hour every time he does so. Sitting down for long increases the risk of developing skin ischemia.
  • The RN will massage the skins around the ulcerated areas. The massaging of affected tissues improves tissue perfusion.
  1. The RN will clean, as well as moisturize, the affected skin particularly over the prominences thrice daily. The moisturizing of skin that has lost integrity particularly over given bony prominences lessens the related friction.
  2. The RN will teach the patient and those offering him care how pressure ulcers develop, especially owing to pressure on the prominences, poor nutrition, and skin shearing. Patients who know how the ulcers develop have a marked likelihood of taking the requisite preventive measures.


  1. The RN will counsel the patient on the proper nutrition, as well as hydration regimes to adopt as per the orders issued by a dietician. When the skin is sufficiently hydrated, its susceptibility to breaking down is reduced.


  • The team offering care to the patient will encourage the usage of devices, especially air and water mattresses, for relieving pressure with respect to the level of the patient’s skin impairment. The mattresses help lessen pressure especially over the prominences.
  • The team will wrap the ulcers in gauze, apply appropriate hydrocolloids to them, and have them stay intact. When ulcers are left intact they bar pathogens from accessing the underlying skin.

Part 3: Teaching Plan

How RNs Decide on Teaching Plan Formats

As noted earlier, the planning step occurs following the concurrence of a nurse and his or her client on a given diagnosis. The phase involves the development of appropriate action plans, including teaching plans. RNs make a range of considerations when deciding on the teaching plans’ formats. First, RNs consider the anticipated outcomes. The formats chosen should clearly communicate the outcomes to all the relevant stakeholders. Second, RNs consider the scope and depth of the content to be taught to patients and other relevant parties. In a given teaching plan, the content may include learning goals, instructional approaches, lesson timeframes as well as evaluation. The format of the teaching plan settled on eventually should allow RNs to customize or modify the contents accordingly depending on the attainment of desired patient outcomes over time.

Third, RNs consider the possibility of tailoring the teaching plans they come up with to particular conditions prior to settling on their formats. For instance, a RN in-charge of caring for a patient who is increasingly losing his or her eyesight should consider the possibility of switching from using written teaching plans and contents to use verbalized one as the eyesight deteriorates over time. Fourth, RNs consider whether the teaching plan formats they settle on allow for the adequate addressing of the questions that may be posed by patients. The formats should allow for the proper communication of the answers to the questions. Fifth, the formats should allow for easy and cost-effective evaluation of whether patients appreciate the taught content sufficiently.

Lastly, RNs consider the need to match the information they include in the plans with suitable learner activities and instructional strategies. They exclude the information that they cannot match with the activities and strategies. They include the information that they can match with the activities and strategies. For instance, information explaining why given medications and treatments are required to children may go with audiovisual or printed materials. Children react well to the strategies if they all them to involve themselves in teaching activities actively.

How RNs Know the Information to Include In Teaching Plans

Various factors guide RNs in deciding the content to include in the teaching plans they formulate. First, RNs consider the anticipated outcomes. They should include information on the outcomes in the plans. That helps communicate the outcomes to all the relevant stakeholders clearly. Second, RNs consider the scope and depth of the material to be taught to patients and other relevant parties. In some cases, they may decide that the most important information to include in the plans relate to the symptoms and management of particular patient conditions. In other cases, they may decide that the most important information to include in the plans not only relates to the symptoms and management of particular patient conditions but also the related risk factors. In some cases, the RNs may decide that it is critical to include information about the relevant learning goals, instructional approaches, lesson timeframes, as well as evaluation, in the teaching plans they come up with.

Third, RNs consider the particular conditions that their target patients have prior to settling on the content to include in the plans (Bruylands, Paans, Hediger & Müller-Staub, 2013).  For instance, the teaching plans targeted at obese patients ideally contain information on the foods that help diabetics manage their body weights effectively rather than information on how one can improve the integrity of his or skin. Information on how one can improve the integrity of his or skin is most useful in teaching plans aimed at patients with dermatological problems. Fourth, RNs consider the views of their patients on the information that would be useful to them when included in the plans targeted at them. The plans targeted at given patient populations should ideally contain information addressing the questions that may have.

Appropriate Times for Determining When to Appraise Teaching-Learning Processes

            The most ideal time for determining when teaching along with learning processes should be appraised is when developing the relevant teaching plans. The plans should spell out the times when the processes should be appraised. The plans may indicate that the evaluation of the processes should be executed when particular contents are covered. With respect to some teaching sessions, the plans may indicate that the processes should be evaluated at the end of each of the sessions.

Notably, evaluations after each teaching session helps patients and other learners reflects their knowledge level as regards the content covered in the session. When return demonstration evaluations are executed at the end of each session, they serve as excellent means of appraising learners’ proficiency especially in psychomotor competencies. The evaluations help those teaching evaluate their instructional efficiency.

The other ideal times of carrying out evaluations are informed by the dynamics of learning and teaching processes. Such times are not fixed at the beginning of the processes. First, those teaching can decide to carry out evaluations based on patient feedbacks or comments. Second, evaluations should be carried out at appropriate times whenever changes are made on the teaching plans to meet the needs of specific patients and when teaching approaches and content are changed. The strategies and content are changed when the related objectives prove to be unrealistic.

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