A care plan of a student of ONP
As a student of ONP (Overseas Nursing programme ),through learning theory of care plan and undertaking clinical nursing practice ,I will be discussing my learning experience about the care plan .the following is my own understanding .
A care plan is a central part of the nursing process. It outlines how the team of nursing care will carry out to resolve or relieve the nursing problems and how to provide the nursing care for a patient .It is usually written by the team of health professional which may include doctors,nurse,cares,social workers and psychologists…,and written with the patient as it is their plan of care .All the information in the care plan is confidential which is seen only by the patient and the people who give the patient care or support ,and those who the patient gives permission to see it .The above care plan which I copied ,The patient’s name has already been changed to M rs smith .
A care plan describes the following aspects :
1.What health and social problems have been found by assessment from a patient .
2.What interventions have been agree to do .
3.When these interventions will be starting .
4.How these interventions will be implemented .
5.How the effectiveness of these interventions are .
The care plan is formulated using the nursing process,which includes the following five steps .Beretta.R(2003)interpreted the relationship between them.‘ …assessment identifies the strengths and weaknesses of the patient or client. This assists in the formulation of a plan of care, nursing care can then be provided as per plan and evaluated to review its effectiveness. Evaluation of care results in re-assessment of the patient’s or client’s needs .’
Nazarko. L. (1995) The matron /manager is normally responsible for all aspects of running the home ,including admitting individuals to the home .A nominated responsible individual collects data or information about a patient through the patient ,the patient’s relatives and friends or the patient’s carers .Mrs smith was accompanied by her daughter to this nursing home .The data and information were collected from her daughter and previous nursing home ,such as diagnosis ,accuracy and full knowledge of medicine usage … .These information or data may be objective or subjective ,including current and past health problems ,family history ,the details of medical ,nursing and social history ,and so on .Then using a nursing model ,such as Roper et al. (1996) do a physical assessment .
The team of nurses discuss and study these data or information gathered about the patient,find out the patient’s actual and potential health problems. identifying the
problems will enable the nurse to meet the patient’s needs,enhance the quality of care.
then make the decisions about the nursing interventions .Mrs smith’heath problems have been identified .recurrent UTI is one of them .
After determining the nursing interventions ,the nurses need to write down goals or aims for the patient .State which the nursing care action can be done and what the expected outcomes are.One of Mrs smith’nursing aims is to ensure preventative measure to prevent UTLs and when they occur they are treated promptly .This is the plan of nursing care to be followed to assist the patient in recovery.The interventions must be specific, noting how often it is to be performed, so that any nurse or appropriate faculty can read and understand the care plan easily and follow the directions exactly .Still take Mrs smith for example ,The nursing interventions adopted include ,a.Ensure adequate fluid intake find out patient’s preferred fluids commence fluid chart if concern.
b.observe for freqency or pain on micturition.
c.If possible do urinalysis and send urine sample to laboratory
d.If offensive with above found inform GP.
e.Antibiotics may be prescribed by GP and administered as per prescribtion.
f.Monitor temperature and pulse ,record and report any changes.
g.Ensure personal hygiene in the genital area being careful to wipe from front to back only.her skin is throughly cleansed and dried well following each episode of incontinence.Soiled linen in proper laundry bag to wash it thoroughly.
NMC(2002a)Obtain consent before you give any treatment or care. An agreement must be obtained by patient before performing any nursing interventions.The patient must sign if possible ,or the relative must sign on their behalf if the patient is unable to sign. Then the nursing care can be provided to the patient as per the care plan.
Review the goals and the patient’s condition after all the interventions that were planned have been achieved. If the patient reaches the goals ,then the care plan has been successful . If the patient did not meet some or all of the goals , this needs reviewing so that a new plan of care can be developed .This nursing interventions which were adopted to Mrs smith are effective ,she has had no signs of UTI until now .This nursing care plan should be in continuous use , being updated as often as any changes occur . write down evaluation outcomes. Therefore evaluation is both an end and a beginning.
As mentioned above ,the care plan is also an agreement between the patient and
her(his) health situation .it helps the patient manage her(his) health day to day.
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