Assessment and Care Planning of the Adult in Hospital
Hospitalisation has a big impact on a person’s life. When dealing with people in hospital health care professions use care planning to make sure that an individual’s needs are met and that there is an on-going personalised plan for the duration of the stay, however long or short this may be (National institute of clinical excellence[NICE], 2010). During this essay I will be following a patient that has been on my clinical placement. I will be discussing the models and theories that underpin nursing in my clinical area. I will be looking more in depth at two needs of my patient and state how we assess these. To abide by the Nursing and midwifery council code of conduct (2008), I will be changing my patients name to Peter and making sure confidentiality is kept at all times. To first understand the assessment process I am going to explain the nursing process. This is a vital part of a patients care plan as it is the basis that all health care professionals follow (NICE, 2010). The nursing process consists of 5 stages. These stages are assessment, diagnosis, planning, implementing and evaluation. Assessment is the first stage of the nursing process. For this stage you must collect information about the person, family and their social groups. When asking for information you are looking for the strengths in the person as well as their relationships. When talking about diagnosis, you are looking at the assessment to see any risk, problems within the data or the person’s strengths and groups. Planning is the next stage. This is where you decide the priority of the problems, identify goals within care, select the appropriate interventions and create your plan of care using this knowledge. Giving the care and interventions is the implementation stage. This stage also includes the documentation of the care that is given and maybe any on-going care that is being received by the patient. The evaluation process is the stage which is throughout the nursing process. It is the reflection on all the process, including whether the plan has worked or there needs to be some changes. There may be new data that comes up throughout the process and this should be added in at all stages to ensure the patient is receiving the best care possible (Capenito-Moyet L, 2007). This nursing process is an opportunity to collect detailed, specific information about the person on admission. It is an effective way to ensure that all appropriate interventions are offered. It is there to provide a framework to the process of assessment, enabling the appropriate care to be given. It also allows the patient-nurse relationship to be established in a professional manner (Mallet J, Dougherty L, 2004) On my clinical placement we have an admission booklet that follows the nursing process. According to the local policy, Admission booklets must be completed within 24 hours of the patient’s admission. Peter is a 59 year old male who fell from a ladder sustaining a skull fracture and various facial fractures. He was finding it very difficult to talk but managed to answer the questions with the help of his wife. This is one of the problems that Mallet L and Dougherty L (2004) discovered. They also state that some of the assessment questions set up within a trust may be inappropriate for some individual patients or they may become unwell during the assessment process. In cases like this the authors and the local policy say you may ask relatives or close friends the questions and document this with names and numbers of the person who is answering the questions. However this may cause conflicting information between various members of the patient’s social and family groups. In a study that was outlined by Habermann and Ulys (2006) they found that the nursing process was only completed for the assessment stage but stages after this were often forgotten. They found that most nurses felt that they were spending more of the...
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