Case Study, Care Plan

Introduction This essay will include a case study about a patient nursed with the supervision of a registered nurse during a clinical placement. It will demonstrate the ability to assess and develop a care plan for this patient. For this case study, the patient’s name will be changed to Paul and confidentiality will be kept at all times. The nursing process will be described and used to develop a nursing care plan for the above patient. The setting is an integrated hospital service made up of Older Peoples health which provides services such as assessment, treatment and rehabilitation care for the over 65 years old population. These services are provided by a team of professional such as nurses, physiotherapists, occupational therapists, speech language therapists, dieticians, and social workers to name a few. They work in collaboration to care for patients who are ill and support them to be as independent as possible (Health Point Corporation, 2013).

In order to plan care for a patient it is essential to understand the nursing process as it is a vital part of the care plan (Crisp & Taylor, 2010). Potter and Perry describe the nursing process as systematic way to collect client data, examine and analyse it in order to identify client’s problem so individualised nursing care can be provided. The nursing process consists of five steps: assessment, diagnosis, planning, implementation and evaluation (Crisp & Taylor, 2010). Assessment is the first step in writing a care plan. It is a meticulous and systematic collection of data (Crisp & Taylor, 2010). For this essay the functional health pattern format from Lewis’s medical surgical will be used to collect client data (Graber O’Brien & Thompson, 2010).
Paul is an 81 years old European male who lives alone in a private rest home. He was admitted due to an unwitness fall which he has no recollection of. On admission he was diagnosed with multiple rib fractures on the left side ribs 4,5 6 and on

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