Complex Nursing Care Report Writing – Medical Science Assignment Help

Assignment Task

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:

• Objective data: data which is empirical or which can be verified by an external source. Examples include: patient vital signs or lab tests.
• Subjective data: this is information which comes from the patient, family, or other sources and cannot be verified independently. An example is the quality of pain described by patients (it is the patient’s perception of pain and cannot be verified by tests), patient descriptions about how they are feeling or a patient’s history told by the patient or family.

Organising the data:

• Group the assessment data, for example using an A-G style format may assist or use an organising system such as Gordons Functional Health Patterns.
• After collecting both the subjective and objective data start to make connections between various assessment items and consider actual or potential health problems.
• Identify as many problems as you can for the patient then prioritise up to 6 patient or nursing orientated problems that are the most immediate for this patient. This will form your plan of care which will be the basis of your individual written report.

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:

1. Address each problem in turn, so all the discussion on problem one, followed by all the discussion on problem two.
2. Alternatively you could introduce both problems, then both outcomes, then all interventions and evaluations). This can work well if there is a relationship between the two patient problems.

3. Items to include in the report:

• Background on your patient (please keep it very brief, only include enough for your reader to understand your content).
• Assessment data – this will only be needed in order to explain how you arrived at your chosen health problems.
• Identified health problems- you will only need to choose two from the original list in your care plan.
• The identified health outcomes for your problems- these will be key to linking your health problem and interventions through to evaluation of care (s). What you will need to accomplish within the report
• Using assessment data from the case study and scholarly evidence provide a pathophysiological rationale for arriving at the two health problems from the collected data.
• Using scholarly evidence and reasoning provide a rationale for the chosen health outcomes.

• Using scholarly evidence prioritise the main nursing interventions which can be undertaken by a new graduate registered nurses to assist the patient to achieve the desired health outcome. What evidence, policy or guidelines supports these interventions. For some patient problems there may potentially be a wide range of possible interventions, so focus on the exploring the key interventions to generate some depth.
• How would you measure (evaluate) the effectiveness of your chosen interventions, what evidence would be required to demonstrate if the goals of care had been achieved.

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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