This assignment will use a case study approach to discuss the plan of care that was observed for a 66 year old lady whilst in clinical placement on the Trauma and Orthopaedic ward. It will do this by highlighting the importance of using four stage nursing process framework to plan care effectively and discuss how the patients care needs were assessed, a plan of care developed and implemented, and finally how the plan of care was evaluated. To comply with the Nursing and Midwifery Council (NMC), (2008) code of conduct that states a person’s right to confidentially must be respected all locations and names have been changed. In addition to this consent was obtained from the patient to use her care plan for this assignment.
Mrs Jane Smith was a 66 year-old lady who lived with her husband. She had no previous medical history, no known allergies and fully independent. She was admitted to the Accident and Emergency department (A&E) complaining of pain, swelling and redness to her left hand, fingers and elbow following a cat bite on her left wrist one week ago whilst on holiday in France.
In A&E, the orthopaedic consultant carried out an examination which resulted in Jane been admitted to the Trauma and Orthopaedic ward due to a suspected diagnosis of osteomyelitis and/or bacterial infection. Osteomyelitis is an infection of the bone that can cause pain, loss of movement and show signs of an infection such as erythema, tenderness and fever. A blood test including a full blood count (FBC) of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and white blood cell (WBC) may be useful in determining an infection (Scholnick, 2012). Her care needs arising from the assessment were identified as treat and maintain the infection, th...
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...he setting of goals and interventions.
Finally the evaluation involved reviewing the care plan by checking if the patient’s condition has improved, goals achieved and interventions applied successfully (Alfaro-LeFevre, 2010). The issues highlighted in the previous stages made it difficult to assess the effectiveness of Jane’s nursing interventions and the achievement of goals as the criteria was unclear. Despite this, all three care needs had either shown signs of improvement and/or not deteriorated further. The patient also expressed that the care plan had working effectively for her because she felt involved in the process as the orthopaedic consultant and nurses talked to her on a daily basis and that it was addressing her needs. To support this Kitwood, (2007) states that it is ultimately the patient who will say if the care plan has met their needs effectively
In nursing, the patient is often viewed as the main priority of the nursing staff. The nurse works to provide care for the patient based on the patient 's admitting diagnosis. However, the patient must be looked at as a part of the greater system they exist in such as their family or home environment. While the patient may be ill due to a bacterial infection or virus, their family environment also plays a role in their overall health and wellness.
At the multidisciplinary meeting, the nurse will collect and assess the information provided by the other disciplines and family members stating that the patient is not at her prior level of functioning and then analyze the information to develop a diagnosis of deconditioning. Next, the nurse identifies outcomes for the patient to get stronger, achieve prior level of function, have activities of daily living (ADL’s) met in a safe environment by planning for home health, equipment, and 24/7 supervision through family or placement in a facility. This will be implemented by coordinating delivery of a walker and a 3 in 1 chair prior to discharge to daughter’s home with the home health agency nurse, physical therapist, and aide scheduled to start that day. In a week, the nurse evaluates that outcomes are being met by following up with patient, daughter, and home health agency evaluating that the patient is getting stronger, ADL’s are being met, and will soon be able to return to living independently. To achieve these standards of practice, every nurse should be aware of her own nurse practice act to ensure to be functioning with in the laws of the nurse’s state and to ensure the best outcomes and safety of the patients. In closing, it is every nurses duty to be the best nurse they are capable of being by looking at the scope of nursing practice which gives us the framework to achieve
Facts of the victim’s case are laid out one by one, as if clues to a whodunit game where the culprit is ubiquitous MRSA. Descriptions are lengthy and vivid, describing everything from the patient’s painful symptoms to gruesome surgical procedures that will upset even the toughest of stomachs. This is definitely not the book to read before a large meal. The book reads like an episode of Frontline, keeping the reader on the edge of their seat until the end.
This essay will critically analyse Care Programme Approach (CPA) assessment and care plan in an OSCE I undertook. By utilising the CPA and sources of current literature, I hope to demonstrate my knowledge and understanding in relation to this skill as well as identifying areas with scope for learning.
There are six set standards of the nursing practice; assessment, diagnosis, outcome identification, planning, implementation, and evaluation (ANA, 2010; pp. 9-10). Throughout a typical shift on the unit I work for, I have set tasks I am expected to complete in order to progress the patient’s care, and to keep the patient safe. I begin my shift by completing my initial assessment on my patient. During this time, I am getting to know my patient and assessing if there are any new issues that need my immediate intervention. From here, I am able to discuss appropriate goals for the day with my patient. This may come in the form of increasing mobility by walking around the unit, decreasing pain, or simply taking a bath. Next, I plan when and how these tasks will be able to be done, and coordinate care with the appropriate members of the team; such as, nursing assistants and physical therapists. Evaluating the patient after any intervention assists in discovering what works and what does not for the individual. “The nursing process in practice is not linear as often conceptualized, with a feedback loop from evaluation to assessment. Rather, it relies heavily on the bi-directional feedback loop...
...r investigation and then devise a plan for best possible action recognizing the rights of the patient and its benefits followed by the application of the chosen intervention with positive outcome in mind (Wells, 2007). Delivery of excellent and quality of care at constant level (NMC, 2008) must be marked in any responsibilities and duties of the care provider to promote exceptional nursing practice
The purpose of the paper is to discuss the activities involved during the evaluation of a patient. Evaluation of a patient can be seen as the process of examining a patient critically. It comprises of gathering and analyzing data about a patient and the illness (Allan, 2012). The core reason is to make judgment about the disease one is suffering from. Such judgment will guarantee proper treatment and diagnosis. Typically, gathering of information from the patient is the role of nurses while making judgment and prescription is the doctor’s role (Jacques, 1988). In any case all practitioners are required to know how to evaluate a patient.
This essay will explain the importance of ‘Prioritising patients’ from one of the ‘P’s in the Nurses and Midwifery Council Code. The Nurse and Midwifery Council Code (NMC) is a set of standards in which nurses and midwives have to maintain to keep their registration. It is used to guide and support nurses and midwives whilst in practise. Within the code there are a set of four key principles that support the practice of all nurses and midwives, to remind them of their professional responsibilities.
Taking this into consideration the nurse began to carry out a risk assessment and care plan to address the issues recognised. According to the National Institute for Health and Care Excellence (NICE) (2015) health and social care staff should identify the specific needs of people with dementia and their carers arising from ill health, physical disability, sensory impairment, communication difficulties, problems with nutrition, poor oral health and learning disabilities. Care plans should record and address these
The nursing process is one of the most fundamental yet crucial aspects of the nursing profession. It guides patient care in a manner that creates an effective, safe, and health promoting process. The purpose and focus of this assessment paper is to detail the core aspects of the nursing process and creating nursing diagnoses for patients in a formal paper. The nursing process allows nurses to identify a patient’s health status, their current health problems, and also identify any potential health risks the patient may have. The nursing process is a broad assessment tool that can be applied to every patient but results in an individualized care plan tailored to the most important needs of the patient. The nurse can then implement this outcome oriented care plan and then evaluate and modify it to fit the patient’s progress (Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P., 2011). The nursing process prioritizes care, creates safety checks so that essential assessments are not missing, and creates an organized routine, allowing nurses to be both efficient and responsible.
Dougherty, L. & Lister, s. (2006) ‘The Royal Marsden Hospital manual of Clinical Nursing Procedures: Communication 6th Edition Oxford: Blackwell Publishing Ltd
Meeting the needs and what is best for the patient which is the outcome of the care, building
ANA describes “The Scope of Nursing Practice (as) the “who,” “what,” “where,” “when,” “why,” and “how’ (8).’ In other words, it is the responsibility of the nurse to know who their patient is, what the patient’s diagnosis and treatment are, where it is they will be delivering treatment, the rationale behind their actions, and how they will deliver the care. By following the scope of practice, nurses reduce avoidable errors and are aware of the liability their actions entail. The ANA also puts forth a nursing process to guide nurses in treatment. The constantly evolving process is currently assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation (ANA 9). Though this method has dramatically improved nursing care, it may be necessary to repeat steps to adapt to a patient’s changing needs and pathologies. By following guidelines set by the ANA, nurses are able to better connect with their patients and instill the image of professionalism to the public while also optimizing safety
Within this essay, evidence based practice will be identified and the significant effect it has on the nursing profession, barriers will also be explored in the implementation of evidence based practice. Individuals need specific care tailored to them, it is vitally important to have the correct professional and appropriate personal care. In order to receive this, we need to get the patient involved in the decision process, listen to their views and opinions and receive the relevant, accurate, professional and medical information. Once all the information is collated, a personal care package can be put into practice. Evidence Based Nursing, An introduction (2008, p. 1).
middle of paper ... ... The priority for this patient was to establish that she was fully aware of what the procedure involved and the possible risks and complications. I feel that the pre-assessment form used within the unit is far too fundamental, if elements of the roper et al activities of daily living were to be incorporated this would help in achieving a much more in-depth holistic nursing assessment enabling for the best quality and level of care to be given to all patients arriving in the unit. Whilst I feel a full nursing assessment is not fully necessary for a day case unit, as previously stated I feel that the communication element is an excellent way of ensuring a better holistic approach is achieved, it will also help to achieve better documentation and communication between all staff members.