Nursing Care Interventions: A Case Study

Care Planning Proforma 5NH008
Patient/Client……………………………………………………………………………………
PBL Group/Site/Facilitator…………………………………………………………………
Problem/Need
Outcome
Nursing Care Interventions
Evaluation

Write a problem statement identifying an actual or potential need
How does this impact on the patient/user?
Ensure this statement is personalised

Patient problems should have been identified with the patient/carer/parent following holistic assessment

Identify a short term and long term goal
Ensure they follow SMART criteria
Goals should be decided in conjunction with the patient/carer.
Is your goal relevant to the theoretical model of nursing?
Consent/informed consent – has this been sought from your patient before any interventions are carried out or referrals are made?
Evidence that you are working in partnership with the patient/carer – have you involved the patient and carer in the plan of care and in the evaluation process
Risk management – have you ensured that you have assessed all possible risks and that you plan care to minimise these
Specify the nursing care – have you been specific and documented the nursing interventions that you are proposing in the order that they should be carried out. How often will these interventions be required i.e. daily, twice weekly, monthly. Ensure you take into account the environment that the care will be carried out in. Is this care evidence based?
Privacy, dignity and compassion – are you promoting privacy and dignity throughout the assessment and planning process and in all your nursing interventions?
Health promotion – have you documented how you are promoting health with the patient and carer, and what resources you may need?
Involvement of the multidisciplinary team – have you shown who and how the MDT is involved with the patient /