Devising a care plan for a patient

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The following care plan will be based on a personal experience with a patient who was nursed on a hospital ward. This interaction took place on an Orthopaedic Ward. The patient was selected as the subject of this assignment because the author carried out the initial assessment. During this pre-admission assessment a good rapport was developed.

This made for positive communication. Moreover, the patient had many different and complex needs. Catering for these different needs illustrates the benefit and the importance of carrying out a structured and holistic assessment to create a total picture of an individual from which to plan care.In selecting a patient to draw up a care plan, confidentiality and privacy were assured and both the patient and her husband were made aware of the nature of the exercise and were quite happy to continue on that basis. The author agreed with the husband to name the patient Mrs. Smith.

It is essential that such assurances and permissions are sought before embarking on an assignment such as this (NMC, 2002). Mrs. Smith is a retired 62 year old lady, who lives with her husband. She has been married for almost forty years and has two sons who both live abroad.

She has enjoyed a long career with a well known Market Research Company as a mentor to both new and experienced interviewers, a position that enabled her to travel around most of the country. Unfortunately due to a road traffic accident two years ago in which she suffered a broken arm, whip lash and injured her knee rather seriously, she also sustained a head injury which resulted in epilepsy. Mrs. Smith used to be a keen gardener and line dancer, but due to her health problems she has not enjoyed these activities in recent months.

Her husband took a keen interest in his wife’s care and was a good source of past information regarding the health of his wife. Whilst in a seizure Mrs. Smith had a bad fall at home in the garden, which necessitated her initial admission to hospital. She fell awkwardly down some steps leading towards the patio, striking her already injured knee, leaving herself in considerable pain.

Contribution of Nursing Care Plans There are various models which are useful in the formulation of care plans, for example the Roper, Logan and Tierney’s twelve activities of daily living, (Roper et al, 1998).This is especially helpful because it provides a framework and logical structure for nursing assessment. The author feels that this is an appropriate model for Mrs. Smith. The reason for this is that it is possible to get a more in-depth understanding of Mrs. Smith as an individual and identify her needs.

This model advocates understanding the needs of individuals, through a detailed assessment of their physical abilities (Aggleton and Chalmers, 2000). The model also provides recognition of the nurse’s role in that it is different to that provided by the doctors and other health care professionals, because the model promotes a holistic view.Care plans are an effective form of communication between ward staff, hospitals and the community, and need to be accurate regarding patient details and treatment (Walsh, 1997). A care plan is a means used to record the progress to smooth the process of communication between care givers and to ensure continuity of care. The care plan should be dictated by the needs of the individuals and the setting in which it is used.

A care plan involves nurses to realistically assess and identify patient’s problems, involving the patient in setting goals and outcomes, (Gordon 1994).Some models focus on the nurse striving to help the patient or client to care for him or herself. The nurse concentrates on helping patients to do things for themselves as they progress rather than doing everything for them, a principle known as self care (Orem, et al. 2001), so more then one model could be used to produce a comprehensive care plan. Care plans look not only at the aspects of daily care within the hospital setting but also at the continuation of care in the community. (Cavanagh, 1991).

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