Care Plan Based on Activities of Daily Living Model

Orem’s Self-Care Model (2001) was developed by the American nurse Dorethea Orem and is very person centred by concentrating on what the patient is able to do independently and focussing care around that aspect (Barratt, Wilson and Wollands, 2012). However, it has been criticised for the use of complex language, terminology and concepts (Murphy, Williams and Pridmore, 2010). RLT was used in this case due to Susan’s main concern of shortness of breath (SOB) affecting all her AL and is the sole model used on the admitting ward and local NHS trust admittance paperwork.

The ‘APIE’ framework consists of Assess, plan, implement and evaluate, the nursing process should include nursing diagnosis and recheck (Barrett et al 2009). Therefor the ‘ASPIRE’ framework was used to create Kora’s care plan, which is as follows assess, systematic nursing diagnosis, plan, implement, re-check and evaluate (Wilson et al, 2014). The problem of SOB had affected Kora’s oxygen saturation level assessment and this needed to be acted upon promptly as it could quickly be detrimental to the patient’s health. The nurse caring for Kora completed the local trust single assessment process (SAP) holistic assessment document to gather a range of information about Kora and her medical history, if the patient had any dependant relatives, “presenting complaint, concerns, current medications and social history” (Bennett et al, 2009). This enabled the nurse to gather information which could be incorporated into Kora’s care plan. Furthermore, it highlighted that the patient was worried about the care of dependant grandchildren, which could impact on the patient’s wellbeing. Treatment and care should take into account patients' needs and preferences. People with COPD should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals (Nice, 2010).The SAP 1 documentation the nurse involved in Kora’s care completed incorporated RLT

In the first step of the Tanner (2006) model nurses use their personal knowledge and experience to notice whether the patient requires attentions based on their expectations and looking at environment of the patient. Therefore, for an experience nurse it is easier for them responding to the similar situation if she or he revisit because the knowledge is already there through experience. In the case of Mr Devi, assessment will perform using systematic assessment based on the ABCDE approach (Airway, Breathing, circulation, Disability and Exposure). The ABCDE approach is an evidence-based practice widely accepted and used by all the members of a multidisciplinary team (MDT) to assess an acutely ill patient (Harrison and Daly 2011). First, life-threatening

This assignment is a case study of a patient who was admitted to a respiratory ward with acute exacerbation of asthma. This assignment will discuss nursing an adult patient with asthma, also it will aim to critically assess, plan, implement and evaluate the patients nursing needs using the Roper, Logan and Tierney nursing model (1980). This case study will focus on the maintaining a safe environment. It is worth noting that the activities of daily living are interlinked e.g. according to Roper et al (1980) breathing is an activity that is crucial for life therefore all other activities are dependent on us being able to breathe. The nursing management, pharmacological agents and the tools used will be critically

Assessment of a patient is a big process of decision making, it is about the collection of information which will contribute to an overall judgement of a person and the illness they may have. Lloyd (2010) states that assessment is one of the first steps which is needed to be done in the nursing process, it is a building block for a relationship and an ongoing process which lets health professionals gather the correct information to help them understand the problems and needs that the patient is going through. Most of the nursing assessment which are in use today will all have very similar aims. The difference is that how the assessment’s are carried out is where the differences come from.

In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.

This week, I was given the opportunity to care for two female patients – 205(1) and (2). The first patient, 205-1, was admitted with respiratory distress and had a past medical history of hypertension, schizophrenia and bipolar disorder. She was initially put on 2 L/min of oxygen and placed on oxygen titration protocol with orders to maintain O2 saturations between 88-92%. The patient was oriented to person and place, but had difficulty with time. She was also obese (BMI 30) and deemed a moderate assist with ambulation. Her care plan included total assistance with ADLs, smoking cessation and oxygen protocols, limited salt intake (3mg), and chronic pain management. The second patient, 205-2, was admitted with a right pelvic fracture and had

The issue of consistency is raised when discussing how to ensure assessments are comprehensive, complete and that the data is recorded using the same guidelines as other nurses. To enable consistency of assessment, the same nurse should be taking the observations of a patient for the duration of a shift (Moore, 2007). This ensure that the interpretation of results don’t differ each time the vital signs are done. It also allows the nurse to detect subtle changes in the patients state that may not have been written down. For example, in most clinical environments the respiration rate is recorded as just a number, and the rhythm, degree of effort, quality of breathing and evidence of wheezing or other abnormal breathing sounds are not recorded. The rate may stay the same over a period of time while other aspects of respiration may change, and this is something that a nurse is more likely to notice if they have assessed that patient before. During handover, a nurse should tell the next nurse looking after their patients how they took observations and detail what tools they used to ensure consistency is maintained.

Asthma triggers and response to medications does not affect individuals in the same ways. Moreover it is not always simple to manage due to its affectability on people on age, sex and ethnic background (Cockett,2003). However, specialist nurse can achieve a successful outcome by ensuring that management plans are tailored to suit each patients/clients needs.

This essay will now analyze the nursing intervention that requires for the acutely ill patient to prevent an exacerbation of chronic obstructive pulmonary disease. The nurse carried out an initial assessment of a full history, taking in consideration that the patient was over 35 years of age who has been, or still is, a cigarette smoker, with vascular related diseases and had symptoms of breathlessness on exertion, chest tightness, wheezing, coughing, sputum production especially in the morning and chest infection (Currie 2009). A physical examination was done to check the patient respiration rate, depth and rhythm, blood pressure, pulse, temperature and oxygen saturation (Lynes 2007). The acutely ill patient’s respiration was between 30-34 breaths per minute, blood pressure 580/98, pulse 110 beat per minute and saturation levels 80-82%. Increase respiration indicates that the patient was in fear, pain and anxious. Anxiety causes stimulation of sympathetic nervous activation which forces bronchioles

7. Which collaborative problem will the nurse include in a care plan for a patient admitted to the

Assessment is described as”The first stage of the nursing process, in which data about the patient’s health status is collected” (Oxford dictionary of nursing, 2003, p23), following this phase a care plan can be devised.

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.

The Nurse of the Future Nursing Core Competencies (NOF Core Competencies) were selected to show the correlation of competency based education and practice partnership. This is being done nationwide so new student nurses would be more prepared with critical thinking and competent learned skills during clinicals. It encourages many nurses to continue their education with some becoming Doctors of Nursing, Nurse Practitioners’, Educators, Managers, and many more specialties.

Complete the Care Plan below only on the #1 Nursing Diagnosis that you identify here.