Care Plan

This assignment will critically discuss the nurse’s role in assessment and care planning for a patient in a case study. Confidentiality which is required by the NMC (Nursing Midwifery Council, 2008) and the Data protection Act (1998) will not be broken through out the assignment because the case study used is a scenario not a fictional character. The care plan will focus on Jean’s incontinence needs using The Roper, Logan and Tierney model (2000).

This essay will discus a decision that was made on a local male acute ward. Using this example, an analysis of the decision making process has been made and a reflective model has been used in order to generate personal knowledge that will inform further practice (Rolfe, 2011a). A pseudonym of Tim has been used for the discussed patient to maintain confidentiality in accordance with the NMC code of conduct (2010a).

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

Care plans are developed by the service users, and when needed with help and assistance from friends and family. These plans are then to be agreed by a social worker or senior care manager e.g. the nurse or senior care worker depending on if the person is nursing or a residential client. The planning system allows the individual’s to:

circumstances can be taken into account when planning care that will empower individuals. I will use a variety of examples from health and social care. I will also extend these examples by assessing the potential difficulties in taking individual circumstances into account when planning care that will empower an individual, and make suggestions for improvement.

In this assignment I will be exploring the issues around communication and assessment in relation to the care given to the patient. I will look at how care was delivered and how successful it was. The NMC (2008) states that healthcare professionals must respect a person’s right to confidentiality; to ensure this I will be using pseudonyms for the service users mentioned in this assignment. I will be referring to the patient as ‘John’ and his wife as ‘Brenda’. I have gained consent from Brenda to talk about her husband’s situation in this assignment, as he did not have capacity to grant consent himself due to dementia.

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

When Jim first attends hospital a care plan will be put into place to ensure quality patient care. When structuring the care plan Jim 's history, medication and allergies will be recorded followed by his daily routines and his personal needs. In order to produce the care plan a risk assessment will need to be carried out. A plan of the action will then be enforced, this plan will then be implemented and evaluated at the end to see whether Jim has taken to the treatment or whether he has deteriorated. However when putting Jim 's care plan into place it is essential that the data is specific, measurable, achievable, realistic and time specific to ensure Jim is getting the best possible care. Due to Jim 's lack of vocal communication his friend Sam may have to pass the nurses as much personal information about Jim as possible.

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.

64). Assessment is the first step which leads to planning. During placement I went through the admission process with a new resident. Before they arrived, the hospital faxed all their information to the nursing home. Using this information, we started to educate ourselves about this resident, what their diagnosis are and then started to determine appropriate nursing interventions.

Care plan meeting was held for initial review. Resident is alert and oriented x3. Resident is able to make all needs known. Resident was present and was able to participate in care plan meeting. No issues or concerns were voiced at this time. Advanced Directives were reviewed, MOLST-CPR remains in effect at this time. Resident was admitted to the facility for short term rehabilitative care. Upon completion of rehabilitation, resident will be discharged to the community. Resident is stable at this time. All disciplines will continue to monitor the resident for any changes in his overall status.

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

In the professional setting, knowing the patient through his or her diagnosis, name, history of present illness, laboratory results or reason for staying in the hospital only contributes to the manner of physical care of the patient. However, recognizing the patient 's spiritual needs such as emotional support, mental positivity, and intellectual understanding of his or her situation gives a better assessment, as well as a trusting relationship between the nurse and the patient, as per personal experience. In the ward, it is evident that most of the staff nurses spend their time doing documentations, preparing medications, following-up laboratory requests, as well as reading through the patients ' charts to affirm the physician 's order. Throughout the duration of our shifts as student nurses, I see that the most that the staff nurses get to be conversant with the patient is when certain procedures (such as feeding through nasogastric tube, taking

As individuals age changes occur physiologically that are part of normal aging. These changes occur in all organ systems and can impact an individual’s quality of life. The changes related to aging can be attributed to an individual’s genetic make up, lifestyle, physical activity, and dietary lifestyle. Being able to differentiate between normal changes in aging against disease process is important because it can help clinicians develop a plan of care (Boltz, Capezuti, Fulmer, & Zwicker, 2012). Creating an accurate plan of care for older adults will greatly impact their quality of life.

This assignment focuses on my practice as a Senior Care Assistant within the hospital. The aim of this essay is to carefully reflect on the Roper-Logan Tierney model and evaluate its efficiency in regards to patient admission. In terms of upholding patient confidentiality as stated in the Nursing and Midwifery Code of Conduct (2015), the name of my patient will be changed to Mr. George Matthew. In addition the code also states that a patient must be aware about information being used and thus I have also obtained permission from Mr. George for this reason. Reflecting and analysing on this topic has enhanced my learning and knowledge as a whole. The model that I will be using to reflect on patient care and admission will be Gibbs reflective cycle (1988).