This assignment will focus on assessing, planning, implementing and evaluating a specific care need for a patient from a chosen case study. It will explain the nursing process and why it will be used as a framework for the care need of the patient. This assignment will discuss the assessment of the patient’s care need and how this will be done while also looking at the considerations one must have when carrying out an assessment. It will also present a plan for the care need chosen using the SMART tool to devise three goals. The principles of implementation will be discussed along with what one would need to consider when implementing a care plan. This assignment will also discuss the principles of evaluation and how one would evaluate a patient properly, along with what steps would be taken if the patient was not responding to the care being implemented.
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Lucy is a 70-year-old widowed lady who lost her husband a number of years ago. For the last 6 months she has been experiencing symptoms of anxiety, including excessive worry, difficulty in sleeping, a reluctance to leave the house and panic attacks. Her GP referred her to the older person’s community mental health team for assessment. Lucy was assessed at her home. The nurse recorded that Lucy has been going out less and withdrawing from social contacts. When she awakens at night, she lies in bed worrying about being in difficult situations and can become quite restless. She no longer goes into town to do her shopping due to the long bus journey which she is now unable to face having also experienced several panic attacks whilst on the bus and feeling very fatigued. She has also found it difficult to concentrate on anything and sometimes feels physically tense. Overall, Lucy feels out of control with her anxious thoughts. No underlying physical cause is suspected.
Lucy is a 70-year-old woman who has lost her husband a few years ago. Lucy has been experiencing symptoms of anxiety over the past 6 months, some of these being worry, panic attacks and trouble sleeping. Lucy has been withdrawing from her social contacts and is having trouble leaving her house to complete daily tasks, such as food shopping. Lucy has feelings of being restless and is having difficulty concentrating. Overall, Lucy is feeling out of control with her anxious thoughts.
The care need chosen for this assignment is social inclusion. Social inclusion is the process of improving the terms on which individuals and groups take part in society (Bank, 2019). Lucy has been withdrawing from her social contacts and is also finding it difficult to leave the house due to her panic attacks and worrying thoughts, this has then led her to withdraw from social inclusion even further. By increasing and promoting Lucy’s level of social inclusion it can also promote opportunities for Lucy to achieve her full potential to recover (Boardman, et al., 2009).
Increasing Lucy’s levels of social inclusion can lead to her becoming more confident in herself at completing everyday activities and can gradually facilitate her to hold and maintain responsibility for her own self-management (Boardman, et al., 2009). By doing this, Lucy may feel more comfortable in being able to complete her food shopping and in turn, can benefit Lucy in increasing her nutritional intake as she is not avoiding her food shopping and more focused when doing so. Increasing Lucy’s level of social inclusion has the potential to reduce her feelings of worry which may lead to improving her sleep habits and reduce the number of panic attacks she is having. It is suggested that by increasing integration into community recreation types it can reduce symptoms associated with mental illness (Fenton, et al., 2017).
The Nursing Process is a systematic, dynamic and goal-orientated framework for problem-solving that enables the nurse to plan care for the patient along with promoting critical thinking (Henry, et al., 2014). This process is being used as a framework for the care need chosen as it increases the patients participation in care, improves efficiency and promotes the continuity of care (Henry, et al., 2014).
The assessment stage of the Nursing Process allows the nurse to have their initial contact with the patient and establishes a database of the patient’s healthcare needs (Henry, et al., 2014). In nursing, assessment is “the foundation upon which all else is built” (Berman, et al., 2010). When beginning an assessment with a patient, it is essential to introduce yourself and to explain the purpose and process of the assessment (Wilkins, 2005). Establishing a therapeutic relationship with the patient is of extreme importance as by building trust with the patient, they are more open to answering questions truthfully and factually (Wilkins, 2005). Displaying effective communication throughout the assessment can help to relax the patient and put them at ease. This can be achieved by displaying appropriate body language, eye contact and facial expressions while also showing that the nurse is actively listening to the patient by responding and gesturing appropriately (Wilkins, 2005). Choosing a quiet, private setting for the assessment is vital to obtain the most information as possible and to reduce the likelihood of interruptions or distractions (Wilkins, 2005). During the assessment, the nurse should be professional but friendly and maintaining appropriate eye contact throughout, giving the patient their undivided attention (Wilkins, 2005).
Obtaining correct and factual information is imperative in the assessment stage as all other stages in the Nursing Process rely on valid and complete data collected and documented at this point (Henry, et al., 2014). There are a variety of different methods of collecting valid data that the nurse can use during this assessment. The nurse should verify the information they have collected from the patient’s family members or friends, along with checking any previous medical records that are on file for the patient (Wilkins, 2005). The nurse should also use their observational skills during the assessment to form their own opinion as to where the patient is by examining her behavior, speech, appearance etc. (Wilkins, 2005). The rule is to use the method that gives you the most valid information for the least amount of effort used (Barker, 2004). Since Lucy has been experiencing symptoms of anxiety, she may feel anxious and restless during the assessment. Providing an environment where Lucy feels comfortable and at ease is imperative to the assessment as if Lucy feels uncomfortable, she may not relay the correct information or could possibly want to end the assessment. Lucy’s lack of sleep may also affect her concentration levels and to maintain a good rapport during the assessment the nurse should keep Lucy involved in the conversation, repeating questions if needed and explaining the process thoroughly.
There are a variety of ways in which one could assess Lucy’s level of social inclusion. This assignment will explore a focused, subjective approach paired with a comprehensive, objective assessment. The main assessment for Lucy’s level of social inclusion will involve using the Recovery Star Tool. This is a focused, subjective and informal assessment. The Recovery Star Tool is an outcomes measure which enables people to measure their own recovery progress, along with the care worker involved (Forum, 2009). This tool is beneficial to Lucy as it provides a baseline for where she feels she is regarding her relationships, living skills, social networks and responsibilities. The Recovery Star Tool gives Lucy a visual look of where she currently is and where she would like to be over a certain period of time. This assessment helps Lucy to identify her goals, the support she will need to achieve these goals and ensures that progress is being made, however gradual, which can also instill hope (Forum, 2009). Lucy would mark on the star where she feels she is at the minute and after a set amount of time, she will revisit the star and again mark where she feels she is during that period. The Recovery Star Tool is a great indicator of progress for the patient and gives them a visual as to where they are and how far they have come (Forum, 2009).
Another assessment that would be undertaken would be the Mental State Examination. This is a comprehensive, subjective and objective informal assessment. It is both objective and subjective as during the assessment information is being taken in from the patient along with any observations from the nurse. This is a semi-structured interview used mainly to assess a person’s neurological and psychological status (Elder, et al., 2013). This assessment involves both an interview and observations (Elder, et al., 2013). The Mental State Examination will assess Lucy’s appearance and behavior, speech, mood and affect, thought process, level of cognition, perception and insight (Elder, et al., 2013). This assessment allows the nurse to observe Lucy and form her own basis as to what would be the best plan of care for them to take regarding Lucy’s level of social inclusion.
The planning stage of the Nursing Process involves creating a care plan in order to plan out how to achieve outcomes or solve problems that have been identified in the assessment stage (Henry, et al., 2014). Using the SMART goal setting model brings structure and trackability into goals and objectives (Coach, 2019). The chosen goals need to be Specific, Measurable, Achievable, Relevant and Time-limited (Doran, 1981).
Three care goals that have been devised between the patient and the nurse are:
- Sign up for yoga classes at the local gym
- Walk around the block three times a week
- Arrange a visit with daughter twice a week
During the implementation stage, the nurse implements the individualized care plan that has been prepared for the patient (Henry, et al., 2014). It is important to remember certain principles when the nurse is implementing a care plan. Confidentiality is essential throughout the implementation stage. As a nurse, it is their legal and ethical responsibility to maintain a patient’s confidentiality (Walker Seaback, 2012). Accurate reporting and documentation during this stage is vital in order to pass on the correct information to the appropriate parties. Reporting information includes verbal communication about the client’s current health status and the on-going care provided (Walker Seaback, 2012).
When implementing a care plan, it is important to consider a variety of factors. Communicating with the patient about their care plan and how they are feeling is essential during the implementation stage. The nurse should relay to the patient that their thoughts and feelings are understood and that they have a knowledge of what is being put into their care plan as an individualized plan of care. The nurse should always keep in mind that human responses are unpredictable, and the patient’s progress should be monitored in order to promote progress (Alfaro-LeFevre, 2014). During this stage, the nurse should always be aware that it should be a person-centered approach and the implementations should be tailored to fit the needs of the patient.
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Evaluation is the final stage in the Nursing Process. This stage can only take place when all other stages have been implemented (Henry, et al., 2014). This stage involves the nurse reviewing the nursing interventions and then decides if they have met the desired outcomes that were identified in the care plan (Henry, et al., 2014). Evaluation is an ongoing process that is designed to improve patient care by constantly reviewing the results of nursing care against the goals that were set in the care plan (Henry, et al., 2014).
Evaluating a care plan should involve identifying the criteria that needs to be evaluated. The nurse should review the care goals set out in the care plan and evaluate the patient’s response to this and modify appropriately if necessary. This should then be documented correctly in the patient’s notes. During the evaluation stage, the nurse should also make a decision on whether to continue the plan, change the plan or terminate the plan and discharge the patient if the outcomes have been achieved (Alfaro-LeFevre, 2014).
In order to evaluate the patient accurately, the nurse should consider the following questions: Have goals set out in the care plan been met? If not, why? Does the plan need to be altered? (Henry, et al., 2014). The nurse should be sensitive to any subtle or obvious changes in the patient’s psychological condition, behavior or emotional status (Walker Seaback, 2012). The data that the nurse has obtained from the evaluation of the care goals should be documented accordingly and this is then analyzed to determine what behaviors indicate progress towards goal achievement (Walker Seaback, 2012).
If a patient is not responding to the care being implemented, it may indicate that the care plan needs to be modified or updated to reflect the patients changing needs (Walker Seaback, 2012). This would involve continuously reviewing and assessing the clients care needs (Walker Seaback, 2012). Along with this, further referrals may be required to assist the patient with their care. This could include being referred to an in-patient setting or other health care professionals that will benefit their recovery such as a psychiatrist. Assessment is about reassessment and changing the care plans to suit the patients changing needs as they progress through their journey of recovery (Wilkins, 2005).
This assignment has looked at the assessment, planning, implementation and evaluating of a chosen care need for a patient from a chosen case study. It has explained the nursing process and why it was used as a framework for the chosen care need. This assignment has also discussed the assessment of the patients care need and how it was completed while also exploring the considerations one must have when carrying out the assessment. It has also presented a plan for the care need chosen using the SMART tool and devised three goals for the patient. The principles of implementation were discussed along with what one would need to consider when implementing a plan. This assignment has also discussed the principles of evaluation and how one would evaluate a patient properly, along with what steps would be taken if the patient was not responding to the care being implemented.
- Alfaro-LeFevre, R., 2014. Applying Nursing Process: The Foundation for Clinical Reasoning. 8th ed. s.l.:Lippincott Williams & Wilkins.
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- Berman, A., Kozier, B. & Erb, G., 2010. Kozier & Erb’s Fundamentals of Nursing. Frenchs Forest, NSW: Pearson.
- Boardman, J., Currie, A. & Killaspy, H., 2009. Social Inclusion and Mental Health. London: The Royal College of Psychiatrists.
Coach, Y., 2019. Your Coach. [Online]
Available at: https://www.yourcoach.be/en/coaching-tools/smart-goal-setting.php
[Accessed 30 April 2019].
- Doran, G., 1981. There’s a S.M.A.R.T. Way to Write Management’s Goals and Objectives. AMA Forum , 70(11), pp. 25-26.
- Elder, R., Evans, K., Nizette, D. & Trenoweth, S., 2013. Mental Health Nursing – A Manual for Practice. s.l.:Elsevier Health Sciences.
- Fenton, L. et al., 2017. Leisure Sciences. The Benefits of Recreation for the Recovery and Social Inclusion of Individuals with Mental Illness: An Integrative Review, 39(1), pp. 1-19.
Forum, M. H. P., 2009. Mental Health Partnerships. [Online]
Available at: https://mentalhealthpartnerships.com/resource/recovery-star/
[Accessed 30 April 2019].
- Henry, M., Traynor, A. & Phillips, D., 2014. An Introduction to Nursing Theory and Practice. Dublin: Gill Education.
- Walker Seaback, W., 2012. Nursing Process: Concepts and Applications. 3rd ed. New York: Delmer Cengage Learning .
- Wilkins, L. W. &., 2005. Assessment Made Incredibly Easy. 3rd ed. Philadelphia : Judith A. Shchilling McCann.
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