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Care Plan

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Care Plan
Part B
I found this particular portfolio more challenging than previous ones. The main reason for this was the fact that I was the required to actively take part in the assessment, planning, implementation and evaluation of a patients care within the service. Doing this came with responsibility that I had not had in previous placements.
My preceptor had explained to me the process involved in care planning for a patient on the unit, the doctor will do the majority of the assessment, the nurse carries out the risk assessment and completes Roper Logan and Tierney nursing assessment which is the nursing model used by the Louth/Meath services. The nurse also carries out an admission checklist. When the patient has been admitted and the nurse has gathered all the relevant information they will then incorporate the care plan. I familiarised myself with the documents, I will admit I felt a little apprehensive; I was worried I might say the wrong thing or ask the wrong question. As John had a previous history, I had been informed that he suffers severe paranoid delusions. This immediately alarmed me in the sense of communication difficulties.
When John arrived on the unit by Gardaí escort he was extremely paranoid and agitated. Initially he was seen by the duty doctor who conducted the assessment (appendix “A”). The assessment took place on the unit, my preceptor and myself were present. Throughout John remained guarded and uncooperative, it was difficult for the doctor to gather information from him. This is evident in the recovery care plan section as John would not engage or answer any more questions. Assessment is the decision making process, based upon the gathering of relevant information, using a formal set of ethical principles, that contributes to an overall estimation of a person and his circumstances (Arnold & Boggs, 2007).
Throughout the assessment I was thinking how am I going to gather information from John when the doctor who has years of

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