A Care Plan
A 1,000 word care plan relating to the planning of healthcare needs and potential risks based on a patient scenario
Assessment brief: You are required to write a care plan for a patient within your field of nursing (Adult Nursing), which meets the Nursing and Midwifery Council (NMC) code, keeping clear and accurate records relevant to your practice (2018) The care plan will be based around a patient scenario. You will be provided with personal information about the patient, and an assessment of their current problem/s which you will use in planning their care.
The assessment information may be presented using a tool of assessment relevant to your field of nursing practice. A template for the care plan, using the nursing process (Toney-Butler & Thayer, 2020) will be provided. You may need to choose a model of nursing in order to structure or arrange your plan of care, for example, the Activities of Daily Living (Roper, Logan and Tierney, 1996), the Self Care model (Orem, 2001) or another nursing model relevant to your field of clinical practice. If a model is chosen you should include referencing and a reason for choosing this model. Using the patient information provided, assess the patient’s needs and plan their care, showing how you can communicate effectively with your patient, their family (if relevant), and other health and/or social care professionals. Your care plan should be based on the best practice based evidence available and be referenced in order to provide reasoning for the care plan you have developed.
Students will be able to:
● Explore the principles of assessing, planning, providing and evaluating people’s healthcare needs. ● Explore the principles of communicating safely and prioritizing care in collaboration with other professionals, service users and service providers.
Student Guidance
● Assess the information provided and Identify the patient’s care needs.
Think about assessing the patient’s observations. Consider how frequently and why you would do this. You also need to ensure that references are used to support your statements, are there any other observations that you could carry out that would support a problem with breathing? Consider the NEWS chart.
Is there anything you could consider to help with anxiety levels, for example effective communication, regular reassurance, as the patient is very SOB ensuring that he can communicate effectively with you
Aim to highlight the key nursing diagnosis in the diagnosis section. Focus on what the patients presentation is
Focus on the patients acute symptoms that require urgent consideration
Address the patients acute needs within your care plan, this patients symptoms are consistent with acute asthma and he requires nursing input such as oxygen, effective communication, the patients acute presentation would also require escalation to other members of the MDT to review the patient. Think about preventing deterioration.
● Plan person-centred and holistic care based on the identified needs.
● Explain any use of a model of nursing to base the care plan on. If a model is chosen, use that framework of assessment to provide structure for the care plan.
● Make sure that the care you plan is Specific, Measurable, Achievable, Relevant and Time specific (SMART).
● Show how safe & effective communication with patients, their families and the wider multidisciplinary and social care team can be achieved during the process of care planning. This includes meeting NMC standards for written information contained in the care plan.
● Identify any risks to patient safety relating to any planned care and show how you would plan evidence based care to minimize these risks.
● Give a good, reliable rationale for your care plan using professional literature and referencing to show that the best evidence-based care has been planned for the patient.
● Please do not exceed the care plan word-limit of 1000 words (+10%) and make sure it meets the attached level 4 rubric. In addition:
● Support your writing with evidence from a range of literature. This should be fully referenced in the care plan using APA 6th edition as set out in the referencing guide.3 Fundamentals of Nursing Practice assessment brief-care plan. SC 2020
● The words provided by the patient scenario and those in the title of the assignment are excluded from the 1000 word count.
