Assessment and Care Planning of the Adult in Hospital
Assessment and Care Planning of the Adult in Hospital
Hospitalisation has a big impact on a person’s life. When dealing with people in hospital health care professions use care planning to make sure that an individual’s needs are met and that there is an on-going personalised plan for the duration of the stay, however long or short this may be (National institute of clinical excellence[NICE], 2010). During this essay I will be following a patient that has been on my clinical placement. I will be discussing the models and theories that underpin nursing in my clinical area. I will be looking more in depth at two needs of my patient and state how we assess these. To abide by the Nursing and midwifery council code of conduct (2008), I will be changing my patients name to Peter and making sure confidentiality is kept at all times.
To first understand the assessment process I am going to explain the nursing process. This is a vital part of a patients care plan as it is the basis that all health care professionals follow (NICE, 2010). The nursing process consists of 5 stages. These stages are assessment, diagnosis, planning, implementing and evaluation. Assessment is the first stage of the nursing process. For this stage you must collect information about the person, family and their social groups. When asking for information you are looking for the strengths in the person as well as their relationships. When talking about diagnosis, you are looking at the assessment to see any risk, problems within the data or the person’s strengths and groups. Planning is the next stage. This is where you decide the priority of the problems, identify goals within care, select the appropriate interventions and create your plan of care using this knowledge. Giving the care and interventions is the implementation stage. This stage also includes the documentation of the care that is given and maybe any on-going care that is being received by the patient. The evaluation process is the
Hospitalisation has a big impact on a person’s life. When dealing with people in hospital health care professions use care planning to make sure that an individual’s needs are met and that there is an on-going personalised plan for the duration of the stay, however long or short this may be (National institute of clinical excellence[NICE], 2010). During this essay I will be following a patient that has been on my clinical placement. I will be discussing the models and theories that underpin nursing in my clinical area. I will be looking more in depth at two needs of my patient and state how we assess these. To abide by the Nursing and midwifery council code of conduct (2008), I will be changing my patients name to Peter and making sure confidentiality is kept at all times.
To first understand the assessment process I am going to explain the nursing process. This is a vital part of a patients care plan as it is the basis that all health care professionals follow (NICE, 2010). The nursing process consists of 5 stages. These stages are assessment, diagnosis, planning, implementing and evaluation. Assessment is the first stage of the nursing process. For this stage you must collect information about the person, family and their social groups. When asking for information you are looking for the strengths in the person as well as their relationships. When talking about diagnosis, you are looking at the assessment to see any risk, problems within the data or the person’s strengths and groups. Planning is the next stage. This is where you decide the priority of the problems, identify goals within care, select the appropriate interventions and create your plan of care using this knowledge. Giving the care and interventions is the implementation stage. This stage also includes the documentation of the care that is given and maybe any on-going care that is being received by the patient. The evaluation process is the