Care Plan

Albertine is 80 retired pensioner who lives alone in a house. Albertine lost her husband 30 years ago, and they had four children, two of which lives abroad and the other two who lives just miles away from her but visits her at home on regularly basis. Albertine has got no past medical history. She has been referred by her GP surgery for a total hip reference to the hospital due to frequent falls at home which has made Albertine to have an impaired mobility. On admission, Albertine complained that she is having difficulties when mobilising around the house. From Albertine assessment, an actual and potential problem will be identified, and this will be explained in the twelve activities of living in appendix one and a care plan in appendix two.

 

Introduction

 

Suggested words: 200

A clear introduction will explain the focus for your assignment.  In this section you should explain your aim and objectives and a brief summary.  Refer here to the topic question or task.  You should introduce, briefly, your patient and family/significant others.  Introduce the nursing model that was used, define any key terms and help the reader to understand how your work will be set out and organised

 

Main Section

 

 

Suggested words: 1600

In this section you will be presenting your main ideas and arguments.  Your points/arguments will need to follow in a logical sequence and be supported by relevant literature taken from a variety of sources.  In this section you should:

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Use the ASPIRE Framework to structure your work

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Include key elements of Person Centred Care throughout to support the role of the nurse and individualised care

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Using each part of the ASPIRE Framework you could consider some the following aspects when critically discussing the nurse’s role:-

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ASSESSMENT and its meaning

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What was the nurse’s role in carrying out a holistic assessment?  What skills did the nurse use?  What were the sources of information?

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How did the nursing model inform the nurse’s role in carrying out this assessment?

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SYSTEMATIC NURSING DIAGNOSIS:- and its meaning

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What was the nurse’s role in identifying actual and potential nursing problems?  You will have identified one of these for your care plan so should refer to this in this section of your assignment.  Why was this problem chosen?

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How did the nurse prioritise the patients needs?

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How did the nurse write the problem statement? 

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What nursing assessment tools were used?  Why and How are they important?  Refer to one of the tools here in more detail.

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PLANNING:-and its meaning

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What was the nurse’s role in care planning?  Were short, intermediate or long term goals set?  Were they evidence based?

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How did the nurse ensure the nursing goals were SMART?  What was the role of the nurse and patient in this process?

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IMPLEMENTATION:-and its meaning

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Discuss some of the planned nursing interventions and the evidence base?  How did the nurse consider patient preferences?

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Who else in the MDT did you involve in your care plan – why and how?

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What was the nurse’s role in care coordination and working with the MDT to achieve the nursing goals?

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What was the nurse’s role in health promotion?  You may consider the role of the nurse in “Making Every Contact Count”

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Where there any ethical, legal or professional issues to consider in your patient assessment and care planning? 

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RECHECK AND EVALUATION:- and its meaning

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What and how did the nurse recheck and then evaluate care? Were outcomes achieved?  Were any modifications required?

 

Conclusion

 

 

Suggested words: 200

An effectively structured assignment will end in a strong conclusion.

Summarise the main issues and draw conclusions – what was found from the analysis of the role of the nurse in assessment and care planning.

You may find it helpful to consider:

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A summary of the main discussion

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What were the main debates/arguments in your assignment

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What sense can you make of this in relation to the nurses role in assessment, care planning and person centred care?

 

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