Evaluation Of A Care Plan

initial step of assessment. I find it important to read patient’s biographical details, medical history, social background and their health progress by then inviting 10 of my clients. Within the community ,who has respiratory illness such as asthma suffering from exacerbation of symptoms of shortness of breath.

Staff are required to make an entry in to an individuals care plan once in twelve hours. This entry is in the daily life and review and will contain details regarding medication administration, dietary and fluid intake, elimination, mobility, mood, behaviour exhibited and any changes or deteriation of the individual. There is also a requirement to record visits from doctors, nurses and other health proffessionals.

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

The second step that I used in the nursing process was diagnosing. Based on my results from my assessment, I was able to use that information to come up with a couple nursing diagnoses. This step is used to offer effective nursing care because it helps me set an intervention and plan of care to help my patient’s health outcomes for the better.

Assessment is the initial stage of the nursing process. Roper et al consistently use the term ‘assessing’ to signify that it is an on-going process, and highlights its continuity throughout the patient’s episode of care (Aggleton & Chalmers, 2000). It is divided into two stages to allow for a holistic representation of the patient to be established (Barrett et al, 2009). Effective assessment allows the prompt identification of any changes in a patient’s health status, and if necessary; allows any action to be carried out immediately supporting the delivery of safe, effective care DH (). The formulation of an accurate assessment is a fundamental skill for a student nurse as outlined by the NMC (2004), and so it is important that a holistic approach is adopted for this skill to be achieved. An holistic approach supports the consideration of……..needs,(THEME?) which

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.

Assessment in the nursing process will establish the patients' ongoing needs and provide a quality of care best suited to the individual, to achieve a desirable health outcome.

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 essay sets out to discuss the importance of comprehensive and accurate assessment on a registered nurses’ ability to make excellent clinical decisions. It will examine what factors can change a nurses’ capability to be aware of, and act on abnormal assessment findings. As well as assessment being part of the nursing process that is used in every day nursing, it is also a critical part of patient safety (Higgins, 2008). Assessment findings are used to determine what needs to be done for the patient next. Early warning scoring systems currently exist to aid in the early detection of patient deterioration (Goldhill, 2005). The rationale for the use of these systems is that early recognition of deterioration in the vital signs of a

The first stage of the process is assessment. Roper et al (2001) refer to this process as ‘assessing’ indicating an ongoing activity; this encourages nurses to recognise the on-going nature of this initial phase. The assessing stage includes gathering information about a patient, reviewing this information, identifying actual and potential problems and prioritising (Roper et al 2001). Roper et al (2001) explain the importance for assessing, as early as possible in the patient’s stay. Extensive, in-depth information may not be gathered on an initial assessment, however any information obtained contributes towards individualised care (Roper et al 2001). Ambrose and Wittig (1998) explain that the initial assessment becomes a foundation for ongoing assessing and holistic care. Barrett, Wilson and Woollands (2009) concord with Roper et al and Wittig in that assessing is an ongoing process and elaborate on this explaining that assessment should not be confused with admission. They state “an admission tends to be a one-off process when you first meet the patient, whereas assessment carries on throughout your relationship with the patient” (pg22). Assessment enables the nurse and patient to identify actual and potential problems. Although, some problems can be directly related to biological needs, holistic needs must be considered, i.e. psychological state and cultural/social standing

Care planning is encouraging a person to be independent and setting realistic goals that they will be able to achieve. (The National Archives, 2009). The goals that wanted to be achieved in each care plan, followed the S.M.A.R.T system. This meant that they were specific, measurable, achievable, realistic and time orientated. (Parkinson and Brooker, 2004). Every patient care plan is individualised on the patient’s ability and problems and they ensure goals are specific for each patient so that their progress can be monitored. Within each care plan for James, the goals were realistic and promoted as much independence for the child as

Alice needed an assessment of her needs and to have a care plan that is regularly reviewed by professionals. Assessment is the decision making process, based upon the collection of relevant information, using a format set of ethical criteria, that contributes to an overall estimation of a person and her circumstances (Barker, 2004). I was going to get most of the information from Alice. Barker (2009) suggests that wherever possible information should be obtained directly from the person, either in the form of some kind of self report or via observation. Good communication and a systematic approach to data collection are needed for a successful assessment.

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.

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.