OLD CARTS – Nursing is a profession within the healthcare sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other healthcare providers by their approach to patient care, training, and scope of practice. Nurses practice in many specialisms with differing levels of prescriber authority.
Many nurses provide care within the ordering scope of physicians, and this traditional role has shaped the public image of nurses as care providers. However, nurses are permitted by most jurisdictions to practice independently in a variety of settings depending on training level. In the postwar period, nurse education has undergone a process of diversification towards advanced and specialized credentials, and many of the traditional regulations and provider roles are changing.
Nurses develop a plan of care, working collaboratively with physicians, therapists, the patient, the patient’s family, and other team members, that focus on treating illness to improve quality of life. Nurses may help coordinate the patient care performed by other members of an interdisciplinary healthcare team such as therapists, medical practitioners, and dietitians. Nurses provide care both interdependently, for example, with physicians, and independently as nursing professionals.
Data Collection Method According to the Use of Pneumonic OLD CARTS:
A. Investigate the chief complaints by eliciting more information through the use of pneumonic “OLD CARTS”:
- Onset (setting, circumstances, rapidity, or manner in which it begun).
- Location (Exact place, where the symptom is felt, radiation pattern).
- Duration (How long, if intermittent the frequency and duration of each episode).
- Character / Course (Nature or quality of the symptom, such as sharp pain, interference with the activity, how it was evolved or changed over time; ask to describe a typical episode).
- Aggravating / Associated factors (medications, rest, activity, diet; associated nausea, fever and other symptoms).
- Relieving factors (Line down, having bowel movement).
- Treatment tried (Pharmacologic and non-pharmacologic methods attempted and their outcomes)
- Severity (The quantity of symptom e.g. how severe on scale 1 to 10.
B. Obtain “OLD CARTS” data for all the major problems associated with the present illness as applicable. C. Clarify the chronology of the illness by asking questions and summarizing the history of present illness for the client / patient to comment on.
D. In case of actual infection inquire possible exposure or an incubation period.
E. In both acute and chronic illnesses note whether the client / patient has experienced a changed in function or activity due to illness.
F. Get the patient’s subjective appraisal of whether the symptom or problem is getting better or. worse.
G. Organize the information for recording.
Principles of Prioritizing:
A. Setting high priorities for the clients:
- A life threatening situation (e.g. difficulty in breathing, hemorrhage, burn)
- Something that needs immediate attention (e.g. preparationdi for a test, discharge from the facilities that will occur shortly)
- Something that is very important to the clients (Pain, anxiety).
B. Setting medium priority:
- Nursing diagnosis involve problems that could result in unhealthy consequence such as physical or mentali impairment but are likely to threaten life (e.g. Pain, stress etc)
C. Setting low priority;
- Nursing diagnosis involve problems that usually can be resolved with minimal interventions and have little potential to cause significant dysfunction (e.g.-mild dehydration).
Definition of Interview:
The word interview comes from Latin and middle French words meaning to “see between” or “see each other”. Generally, interview means a private meeting between people when questions are asked and answered.
or
Interview is a planned communication or conversation with a purpose.
Purposes of Interview:
- To gather data.
- To give information.
- To identify problems of mutual concern.
- To evaluate change.
- To teacher
- To provide support
- To provide counseling and therapy.
Nurses’ Roles for Interview:
The nurse is often the first person from the health care team to interest with the patient. The nurse frequently assumes the role of intermediary y for the patient to the larger health care system.
- A critical role of the nurse is to assist the patient in effectively utilizing the system.
- The climate and tone of the initial patient interview may influence all future interactions the patient has in the health are setting.
- The nurse attitudes and expectations both positive and negative set the stage for the interview.
- First impressions of individuals are important and imprint long lasting thoughts and feelings.
- The personal appearances of both the patient and nurse contribute significantly to the formation of first impressions.
- The nurse is the facilitator of the interview and thus collaborates with the patient in establishing mutuality respectfully.
- Encouraging the patient to speak freely and expressing consent for the patient are expressing in this process.
Interview Techniques:
The nurse is often the first person from the health care team to interact with the patient. The nurse frequently assumes the role of intermediary to the patient longer health care system. These roles and techniques are:
- Provide privacy in as a quite place as possible and see that the patient is comfortable.
- Begin the interview with courteous greeting and an introduction, address the patient as Mr., Mrs., Ms. And shake hand if appropriate. Explain who I am and the reason for my presence.
- Make sure that facial expressions, body movements and tone of the voice are pleasant, unhurried and nonjudgmental, and that they convey the attitude of sensitive listener so the patient will feel free express his thoughts and feelings.
- Avoid reassuring the patient prematurely (before I have adequate information about the problem). This only cuts off discussion; the patient may then be unwilling to bring up a problem causing concern.
- At times, a patient gives cues or suggests information, but does not tell enough. It may be necessary to probe for more information to obtain a through history, the patient must realize that this is done for his benefit.
- Guide the interview so the necessary information is obtained without cutting off discussion. Controlling a ramping patient is often difficult but with practice, it can be done without jeopardizing the quality of the information gained,
Types of Information Regarding Past Illness:
General health and life style pattern sleeping, diet, stability of weight, usual exercise and activity, use of tobacco, alcohol and drugs
- Acute infectious diseases.
- Immunization.
- Operation.
- Previous hospitalization.
- Injuries.
- Major acute and chronic illness.
- Medications.
- Allergies.
- Obstetrics history if applicable.
- Psychiatric history.
Types of personal and social information:
- Personal status: Birth place, education, position in family, satisfaction, with life situation (home and job), personal concerns.
- Habits and lifestyle pattern.
- Home condition:
✓ Material status, nature of family relationship.otzid dilton siberiqi
✓ Economic condition, source of income, health insurance, Medicare, Medicaid.
✓ Living arrangement and housing.
Occupation: Past and present employment and working condition including exposure to stress and tension, noise, chemicals and pollution.
Religion of faith: It is important in coping and health practices.
Types of family information:
- Age and health status of maternal and paternal grandparents, parents and siblings.
- History in immediate and closed relatives of heart disease, hypertension, stroke, diabetes, gout, kidney disease, thyroid disease, pulmonary disease, blood problem, cancer, epilepsy, mental illness, arthritis, alcoholism and obesity.
- Genetic disorders.
- Age and health status of spouse and children
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