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The purpose of this essay is to carry out an assessment of a patient and present a plan of care of three specific problems that the patient has encountered. The model chosen to guide the care plan is the Roper, Logan and Tierney's Model of Nursing

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Introduction

Fact Essay INTRODUCTION The purpose of this essay is to carry out an assessment of a patient and present a plan of care of three specific problems that the patient has encountered. The model chosen to guide the care plan is the Roper, Logan and Tierney's Model of Nursing (Roper et al 2000). This will enable me to develop my skills in assessment, problem-solving and planning care. The essay will begin by introducing the patient and outlining the rationale for choice. Following this, I will identify and discuss the care required through all stages of the nursing process (Roper et al 2000). I will discuss this in relation to assessment of three patient needs. I plan to show an understanding of holistic care and how it is used in each stage of the nursing process. Pseudonyms will be used in accordance with the Nursing and Midwifery Council (2004) which states that "you must guard against all breaches of confidentiality by protecting information from improper disclosure at all times. CHOSEN PATIENT AND RATIONALE FOR CHOICE Jane is 81 years old, widow who lives alone in a bungalow, married for 54 years and has 2 daughters, one of which lives abroad and the other locally. She stated she has had a good life with many memories and had travelled to several countries with her late husband. She had enjoyed going to dance halls and outdoor bowling. Jane suffers with osteoarthritis which is a degenerative disorder in bone and cartilage (Hinchliff et al, 1998). She had fallen at home and was presented at the Accident and Emergency department. After a short stay on Medical Assessment ward, she was transferred to the unit for rehabilitation following her fall she developed urinary tract infection, with catheter in situ and reduce mobility. More than 300,000 pensioners each year require hospital treatment because of falls-related injury (Alexander 2000). The rationale for choosing Jane was because I was involved in her care. ...read more.

Middle

Jane was referred and seen by the physiotherapist. Implementation: The Oxford Dictionary for Nurses (1998, p.313) defines implementation as "the stage of the nursing process in which the patients individual care plan is utilized and executed, in collaboration with other members of the healthcare team". To help her maintain a safe environment I made sure her buzzer was within easy reach so that if she needed anything, she could always call for assistance and not attempt to do it herself. To help her maintain her own body temperature, I had to regulate the room temperature for her because temperature plays an important role in wound healing, (Taylor 2005). The physiotherapist comes in every day for session with Jane and encourages her to mobilize in other to avoid the complications. However Jane indicated that most of the time she did not understand what tell or want her to do. Hand over was a good source of information used in order to find whether the care being given is right for the patient (Roper et al 2000). The ward uses pre written handover sheets which were kept updated by the ward clerk, this allowed more time to write important details in a short space of time. Verbal and written communication skill helped in the care delivery of Jane, as information was given and shared amongst health care professionals (Nicol et al 2003). Evaluation: This is the final stage in the nursing process, which occurs continuously while providing care. Evaluation refers to goals which were set, any reassessment and documentation relating to specific goals. It was documented and handed over that my client had appeared to have progressed in all that was set. Newton (1991) confirms this by stating Value is also placed on observablee behavior as an indication of the need for nursing and the basis of evaluation of the effects of nursing. On reflection, all the care plans were maintained well. ...read more.

Conclusion

Since the entire MDT was based in the same unit, the communication was excellent. This ensured a timely advantage for patients and for tasks to be delegated to the correct healthcare professional. Handovers were essential tools in this phase as information could be exchanged between nursing staff and the rest of the MDT, and further strengths and weaknesses could be highlighted, despite that there were communication breakdown at times. Jane benefited from the MDT as there was continuity of care and there was proper caring of the patient (Potter and Perry 2007). Evaluation: Jane's short-term goal was achieved within 36 hours despite only a 1500mls increase in fluids. The long-term goal was achieved before discharge, as Jane's usual bowel pattern had resumed. She fully comprehended the measures to be taken to prevent a recurrence and implemented them with encouragement. Overall Conclusion As both care giver and observer, I found that the care planned matched the care given. Collaboration between the Multidisciplinary Team and working closely with patient and family enabled outcomes to be achieved. This experience has taught me the importance of holistic care in relation to the nursing process and how an effective therapeutic relationship between patient and healthcare professional allows more information to be retrieved, thus creating a more precise and individualized care plan. My client had commented how she enjoyed the 4 weeks on the ward. I think that the social aspect of the ward helped a great deal. Jane was encouraged by the whole team and maintained as much independence possible throughout her stay. I have benefited as a result of this placement, as it has taught me the importance of the nursing process. I have become more efficient in collecting information from the client and utilizing it appropriately in order to care for the client in a holistic way. The skills gained whilst gathering the information during the assessment, for instance communication skills, will be invaluable to me throughout the rest of my training and beyond. ...read more.

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The ideas contained in the essay were generally conveyed in a clear manner; however it

Marked by teacher Diane Apeah-Kubi 05/09/2013

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