Highlights
Task
Assessment 1 - Complex Patient: Plan of Care
Your Complex Patient Plan of Care is to be submitted with your individual written report as an appendix. A template is provided at the end of these guidelines
Complex Patient: Plan of Care
Focus on patient assessment data, problem identification and optimal patient outcomes Patient problem identification
Use the principles of the nursing process or clinical reasoning cycle and the assessment data from one of two case studies provided to identify actual or potential patient problems which can be dealt with using nursing interventions. Nursing interventions can be:
• Independent interventions – nurse led, nurse initiated
• Collaborative interventions – with other members of the multidisciplinary team
• Dependant interventions - for example dependant on a doctors order
The process to do this will involve:
Gathering the patient data and processing of the assessment data, which may comprise:
Organising the data:
Problems may be:
Actual health problems: a health problem that is currently present or occurring and needs intervention to either end or reverse its effects. There will be patient signs and/or symptoms that support the manifestation of the problem.
Examples: Anxiety related to.....
Dehydration due to ........
Wound infection related to ......
Acute pain related to ....
Impaired skin integrity due to ....
Inadequate tissue perfusion related to……..
Potential health problems: a health problem which has not yet occurred, however based on assessment items there is a risk that the patient may develop this problem if no interventions or prevention measures are initiated.
The patient is ‘at risk of’ falls due to ...
The patient is ‘at risk of’ developing a DVT due to....
The patient is at risk of infection due to………
Once the actual or potential health problems are identified, the patient and/or nursing outcomes need to be considered. The outcome, like the problem, needs to be of a patient focused or nursing orientated nature. This means that the intervention should be one that a Registered Nurse can perform/is involved with. The nursing outcomes (dot points) describe what we expect to achieve for the patient if appropriate nursing interventions are implemented.
Focus on those problems and nursing/patient outcomes that nursing interventions could contribute to or could be completed during one standard nursing shift.
INDIVIDUAL WRITTEN REPORT
The focus is on the implementation of nursing care, the rationale for care and its evaluation.
Select 2 of the problems identified on the Patient: Plan of Care – it is suggested that at least one should be an actual problem but this is not essential.
The individual written report expands on the information presented in the Patient: Plan of Care plan for 2 of the identified problems. The written report will need to hold more detail and explanation than in the care plan. In particular you will need to give the rationale for the nursing intervention (s), and the evidence for why this is the appropriate care to provide. In addition you will need to demonstrate an understanding of the underlying pathophysiology – as applies to the chosen interventions/nursing care.
As this is a written report assignment you can use headings/sub headings. It is your choice to use headings; they are not required but can make it easier to organise your work. There are two possibilities for the layout of the assignment:
3. Items to include in the report:
Support your work with in text citation to references and associated reference list. Please take care with websites/online materials. These must be of a scholarly nature and focused at health professionals. Acceptable online content includes journal articles accessed online, policies or guidelines e.g. NSW Health policies, identifiable documents from government sources or organisations like WHO.
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