Care Plan Essay

previous ones. The main reason for this was the fact that I was the required to actively take part in the assessment, planning, implementation and evaluation of a patients care within the service. Doing this came with responsibility that I had not had in previous placements. My preceptor had explained to me the process involved in care planning for a patient on the unit, the doctor will do the majority of the assessment, the nurse carries out the risk assessment and completes Roper Logan and Tierney

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

he may currently be on, whether he has dentures as well as his weight and BMI. During this phase, communication with the patient and family is essential to ensure that correct information is obtained so that a proper informed decision concerning his care can be made. In this case there may be some barriers that may effect the assessment process and that is the speech of Mr. smith is sometimes slurred, therefore he may need his wife to answer some of the more complex questions that require more than

Nursing Diagnosis # 1 Ineffective breathing pattern related to decreased oxygen saturation, poor tissue perfusion, obesity, decreased air entry to bases of both lungs, gout and arthritic pain, decreased cardiac output, disease process of COPD, and stress as evidenced by shortness of breath, BMI > 30 abnormal breathing patterns (rapid, shallow breathing), abnormal skin colour (slightly purplish), excessive diaphoresis, nasal flaring and use of accessory muscles, statement of joint pain, oxygen

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

clear and appropriate boundaries established at the beginning, that are based on the needs of the patient solely. With this in mind, the nurse creates a nursing care plan that is unique and individualized for the patient allowing for interventions that are tailor to fit his or her needs. I had the opportunity to create a nursing care plan for a patient that I recently cared for. My patient was diagnosed with bipolar type I and major depressive disorder and had been admitted for worsening of depression

identifies an actual or potential response of a patient to a health problem (Jones 2009). Nursing diagnoses are important because they provide the foundation for the selection of nursing interventions (Walton 2008). This care plan is the concluding half to the initial care plan that identified nursing diagnoses and goals with the aim of promoting the holistic wellbeing, mental health, and independence of a 68 year old Mr. Bertoli who has returned home from hospital after experiencing a stroke. Particular

to the care that is delivered to a patient and examine the significance of the use of models and frameworks in the nursing process. It is intended to identify a patient with biopsychosocial needs that requires nursing intervention. Their holistic plan of care will then be critiqued in relation to the nursing model and framework utilised by the nursing staff. Knowledge will be demonstrated of the importance of utilizing evidence-based practice when creating an individualized plan of care. “The

Nursing Theory Plan of Care Theoretical Foundations of Practice NUR/513 March 05, 2012 Nursing Theory Plan of Care Ida Orlando literally wrote the book on the function of nursing. Her theory of the deliberative nursing process outlines a dynamic nurse-patient relationship in which the nurse uses his or her senses of perception together with deliberate actions to create an individualized care plan for each patient. Results of current research on the application of her theory follow

NURSING CARE PLAN Student Justin De Vera Date 3-12-16 Instructor Professor Vaughn Course 316L Patient Initial X.L Unit/ Room# 310 DOB 12-21-1989 Code Status Full Code Height/Weight 5’6’’ and 150 lbs. Allergies NKDA Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 97.8 F 74 18 99% Room Air 125/78 7/10 History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with Evidence Based Citations Physical Assessment