Highlights
Learning Outcomes
a) Explore and discuss the impact of chronic health problems on care planning needs of a person, family and community, using an evidence-based approach.
b) Develop a person-centred care plan for the person with a chronic health problem through health promotion,education, disease prevention and self-care.
c) Demonstrate clinical reasoning through nursing assessment, interventions and evaluation, to support the health care of persons with chronic health problems.
d) Discuss legal, professional and ethical considerations in care delivery.
e) Explain and integrate the impact of co-morbidities, quality use of medicines principles, risks to self and others into care plans.
f) Demonstrate interprofessional collaboration in developing holistic person-centred care plans.
Task Summary
For this assessment, you are required to prepare a care plan in consultation with the patient and her family members for managing her chronic health condition using an interprofessional and holistic person-centred approach. The aim of this care plan is to enable the patient, her family and her interprofessional health care team to plan and co-ordinate on-going health care for her life-long complex chronic condition. For this individual assessment, you have been given a hypothetical case study of a patient suffering from a chronic condition (see the Appendix 1C). Further information has been added to this case study for this assessment task.
Context
This assessment task provides an opportunity for you to demonstrate the theoretical knowledge you have acquired in CPC105, by the development of a care plan for a patient with a complex chronic health condition. This assessment allows you to demonstrate your skills in the planning of holistic, interprofessional and person-centred care, while focusing on health promotion, education, disease prevention and self-care.
You are required to:
1. Complete the Torrens University Nursing Care Plan template that you will find in the assessment resources area with the following information:
a) Assessment data – Firstly outline the assessment data (subjective and objective) obtained from the case study provided. Secondly, what other assessment data (subjective and objective) would you need to collect in order to conduct a holistic assessment? Please note how this data would be collected.
b) Nursing diagnosis/Collaborative problems - Based upon this assessment, identify and list two nursing problems the patient is experiencing and two collaborative problems the patient is experiencing.
c) Planning/Expected outcomes – This is where goals and outcomes are formulated that directly impact patient care. These expected outcomes/goals should be written as per the SMART system (S – specific; M – measurable; A – achievable; R – realistic; T – timely) and include both short-term and long-term outcomes/goals.
d) Nursing interventions - Expand upon all four of these problems and describe the nursing and interprofessional interventions that should be implemented to provide holistic patient-centred care & You are to provide rationales for each of these interventions supported by current relevant evidence.
e) Evaluation – This evaluation is to occur to determine if the goals/expected outcomes have been achieved. Please evaluate the interventions, specifying patient data that would indicate patient improvement and deterioration. As you are not providing care to this person in the real world, you need to detail what you would expect to see if the patient was improving due to the implementation of these interventions. Additionally, you need to detail what you would expect to see if these interventions were not successful and the patient was deteriorating.
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