Assessment and Care Planning of the Adult in Hospital Hospitalisation has a big impact on a person’s life. When dealing with people in hospital health care professions use care planning to make sure that an individual’s needs are met and that there is an on-going personalised plan for the duration of the stay, however long or short this may be (National institute of clinical excellence[NICE], 2010). During this essay I will be following a patient that has been on my clinical placement. I will be discussing the models and theories that underpin nursing in my clinical area. I will be looking more in depth at two needs of my patient and state how we assess these. To abide by the Nursing and midwifery council code of conduct (2008), I will …show more content…
Another problem bought up by Habermann and Ulys was that most problems that were identified in the assessment stage were not cared for as the nurses focused on the priorities. They believe that there is a lack of evidence for the relevance to the patient outcomes. Pearl Gardener (2003) seems to agree with the relevance saying that a patient’s independence was removed as the goals are rarely shared or implemented by the patient, but by the nursing staff. She goes on to state that it needs more adaptability in order to meet patients goals for themselves rather than that of the nurses for the patient. She also believes that there is a high use of trial and error methods as there is not a stated “cure” that works for a problem for every patient. When I discussed the admission booklet with Peter I had to ask questions that involved living circumstances, marital status, social or professional support at home, religion, occupation, relevant past medical history, what facilities his house has and whether things are on the ground floor or upstairs. I had to ask him also if he was aware of the diagnosis, which he was. The next step of the admission booklet is based on activities of daily living. This was a model set up by Nancy Roper, Winifred Logan and Alison Tierney in the 1960’s but has since been adapted. This model
The aim of the essay is to demonstrate the process of a patient assessment and care plan formulation in accordance with the assignment instructions. It is based on a case study, which illustrates a patient who has a diagnosis of paranoid schizophrenia, the patient was admitted to a medium secure hospital unit, please see appendix for more details of the case study. The pseudonym Peter will be used to address the patient to maintain confidentiality as required by the Nursing and Midwifery Council(NMC,2008).Firstly the essay will explore the philosophies of CPA; Care Programme Approach and then demonstrate the assessment of a patient with an assessment tool and including the formulation of a care plan.A KGV assessment tool was utilized(Lancashire,1998).In addition,the essay will examine and analyse the strengths and limitations of principles and philosophies which underpin existing service models for instance biopsychosocial model which is applied in mental health care delivery.Subsuently the essay will demonstrate an in-depth analysis of holistic assessment principles within mental health care.Futhermore the essay will analyse collaborative working in relation to planning and
In today’s healthcare system, nursing is a challenging field as a result of rapid technological advances and changes in healthcare policies. As a dedicated nursing professional, with a great passion for learning, I strive to stay on top of these changes. I am determined to increase my knowledge to be an instrumental part of providing quality healthcare. The demands of nursing are high; however the rewards are even higher. Nursing requires both a supreme understanding of the science of health, and a caring bedside manner befitting only those who seek a position of such a personal involvement in the well-being of a patient. Academically, I will put forth all of
(Polit & Beck, 2010). As nursing is person-centred and relies on a multidisciplinary team approach it has to take into account the care setting, patient predilections, clinical judgement and best available evidence. (Holland & Rees, 2010).
Since the early 1900’s nurses have been trying to improve and individualise patient care. In the 1970s this became more structured when the nursing process was introduced by the general nursing council (GNC), (Lloyd, Hancock & Campbell, 2007) .By doing this their intentions were to try and understand the patient in order to give them the best care possible (Cronin & Anderson, 2003). Through the nursing process philosophy care plans were written for patients. It was understood that this relationship would ensure the patient received the best care possible to suit them individually. This would consist of not just the patient as a physical being but their spiritual emotional and holistic being also (Cutler, 2010). The
This assignment will explore and critically evaluate the role of the registered nurse in the development of a plan of care that is patient centred. This will involve examining and critically analysing the chosen nursing model in a holistic assessment of the patient and the use of the nursing framework ASPIRE (Barrett, Wilson and Wollands, 2012).
Within this case study I am going to use two of the Chapelhow et al. (2005) enablers to discuss and reflect on the care of a patient I have been involved with on placement over a period of 5 weeks. ‘Enablers are the essential and underpinning skills that come together to provide expert professional practice’ (Chapelhow, C et al. 2005, p.2). These include; assessment, communication, documentation, risk, professional decision making and managing uncertainty. The enablers work together to provide a holistic approach to the care of patients in health care settings. I am going to focus on and discuss two of the enablers, linking them both together, which will be assessment and communication as I believe these two enablers can be related most to my patient.
2.2. Describe how to take into account the history, preferences, wishes and needs of an individual when planning care and support.
To begin with the person is the centre of the plan, to be consulted with and their views must always come first: It should include all aspects of their care, and every professional should work together to provide it. (Leathard 2000) Autonomy refers to an individuals’ ability to come to his or her own decisions and requires nurses to respect the choices patients make concerning their own lives (Hendrick 2000).However Gillon Argues that the principle respect for autonomy may need some restriction, otherwise we may be morally obliged to respect an autonomous course of action with unthinkable consequences.( Gillon 1986) Every human being has an intrinsic value, they all have a right to well being, to self-fulfilment and to as much control over their own lives as is consistent with others (British Association of Social Workers 2002).Professional Judgement and patient preference cannot be suspended if practice is to be safe and effective rather than routine(DOH 2005) Alex had to attend this session as it was within his Timetable, how could it have been effective?, he was unhappy and
This assignment will critically analyse and justify the decisions based around a fictitious patient using a clinical decision making framework highlighting its importance to nursing practice. The chosen model will demonstrate clinical decision making skills in the care planning process. The patient’s condition will be discussed in-depth explaining the pathophysiology, social, cultural and ethical issues where appropriate in the care planning and decision making process. Any vulnerability that the patient may experience will be discussed and dealt with in the care planning and decision making process. The supporting evidence based literature will be analysed and
This assignment will investigate a needs orientated approach to care, critically discussing the nursing process. It aims to show an understanding of what a nursing model and the nursing process is, looking in detail at the relationship between this nursing process and the Roper, Logan and Tierney (RLT) model of nursing. This essay will explore how the nursing model and process is implemented in practice, considering how the RLT model assists nurses to adapt a problem-solving technique when developing care plans for individuals. Strengths and limitations of the RLT model and the nursing process, in relation to developing care plans, will be critiqued along with the effectiveness of
In this essay I will discuss a service user I encountered on recent practice placement who was referred to the hospital after she has been deteriorating in mental health and she has bipolar disorder. I am going to discuss the assessment and development of the care plan of the service user. The essay will also consist of a brief biography of the patient’s contributing factors towards her present mental health circumstances. The relevant culturally sensitive engagement and assessment skills used by the nurse in their relationships with the service user will be discussed. I will also explore legislative and nursing frameworks that influence and contribute to positive and hopeful service user’s care. The assignment will also explore the
The aim of this assignment is to critically discuss the nurse’s role in planning care. The case of care is a 60-year-old lady named Mary. The names in this assignment have been changed in order to remain confidentiality in line with the Nursing and midwifery Council (2015). Mary has a son and lives with her husband of 30 years. Mary was diagnosed with type one diabetes mellitus when she was 18 years old. Mary also has a leg ulcer which is effecting many aspects of her life. Although Mary has other health problems I will be mainly focusing on the leg ulcer.
The aim of this essay is to demonstrate the assessment process of a patient using the Roper Logan and Tierney (RLT) model of nursing framework and to show how the nursing process works alongside this model. This will be shown by a holistic history of the patient being shown, followed by how the RLT model is applicable to this patient. This is then followed by one nursing intervention being discussed showing how the nursing process is applied to patient care. The patient will be referred to as Mr Frederick Valentine to protect the patient’s anonymity as stated in the Nursing and Midwifery Council Code of Conduct (2008) guidelines.
The purpose of this essay is to reflect on a challenging situation I experienced during clinical practice as a student nurse. The essay will discuss my thoughts and feelings surrounding the situation and analyse the coping strategies I used in managing the situation, linking to relevant theory throughout in order to provide evidence for practice. The essay will also consider person-centred care and whether this was delivered to the patient. To conclude, the essay will discuss what I have learnt from the experience and how this experience will improve my future
In this situation the patient was awaiting an isolation bed as outlined in part A, it was essential to begin planning Mays’ care as she required complex health planning. Through reading the literature I have observed a common criticism of the model is to do with what conditions fit under which AL and also the use of models in general in nursing practice as taking up time caring for patients (Roper et al 1996). Having only ever used the RLT model I don’t feel I have enough understanding of other models to compare it to but through reflection, I feel that as outlined in the literature, fitting physical conditions under ‘headings’ of care plans can be difficult.