Table of Contents
Complex patient plan of care and individual written report
ASSESSMENT TASK 1: Complex patient plan of care and individual written report
Length: 1500 words (+/- 10%) plus completed care plan from Part 1 submitted as an appendix.
INSTRUCTIONS
Part 1: The purpose of this assignment is for students to demonstrate their ability to effectively plan person centred, evidence based, holistic care for complex medical-surgical patients. Students will need to demonstrate the utilisation of patient assessment data, policies, current guidelines and the literature to inform a plan of patient care and subsequent written report.
Part 2: The purpose of this assignment is for students to explore in detail, two of the actual or potential patient problems identified in Part 1. Students will have the opportunity to evaluate patient assessment data in order to determine the health care needs of complex medical surgical patients and identify appropriate nursing care interventions. Students will apply the relevant evidence base and/or policy/guidelines to generate rationales for care. Students need to also demonstrate their understanding of how the effectiveness of each intervention would be determined.
Assessment 1 Part 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
ASSESSMENT TASK 1: 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 the case study 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 doctor’s 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 (Airway, Breathing, Circulation, Disability, Exposure, Fluids, Glucose) 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 the basis of Assessment task 1 Part 1.
Problems may be:
- an actual health problem: 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 ….
- a potential health problem: a health problem which has not yet occurred, however based on assessment items is likely to occur if no intervention or prevention is initiated within a short period of time. The patient is ‘at risk of’.
At risk of falls due to …
At risk for DVT 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 or nursing 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 nursing interventions expect to achieve for the patient.
Focus on those problems and nursing/patient outcomes that nursing interventions could contribute to or could be completed during one standard nursing shift.
| Actual or potential problem | Assessment data | Nursing outcome |
| Actual problem: the patient is dehydrated related to decreased fluid intake | Low blood pressure (or ↓BP)Tachycardic
Patient states he is thirsty Dry mucous membranes |
Patient will return to a normotensive state as evidenced by an acceptable blood pressure (for this patient), stable and acceptable pulse, and a lack of reported thirst, moist mucous membranes. |
Note: you can use common abbreviations or symbols, e.g. BP for blood pressure.
Assessment 1 Part 2 – Individual written report
The focus on the implementation of nursing care, the rationale for care and its evaluation.
Select 2 of the problems identified on the Complex Patient Plan of Care from Part 1 – 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 why is this 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. But this is not a biology essay.
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:
- Address each problem in turn, so all the discussion on problem one, followed by all the discussion on problem 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.
- 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. Don’t use Wikipedia – this is not an academic source – the reason being that anyone can go in and amend or add information at any time so you can’t rely on the validity/truth of this source.
Spelling – this should be Australian spelling – so make sure your spellcheck is set for this and not US spelling.
Interventions
Many interventions are undertaken in conjunction with other members of the healthcare team for example many direct interventions require doctor’s orders prior. This table gives examples of some different types of interventions and what evidence would be expected for each type. It is not exhaustive:
| Intervention type | Example | Required information |
| Direct action | Administering oxygen | · Evidence for rationale· Amount/quantity you would use and evidence for this
· Type/device used if applicable · Duration- for how long · Safety – must be prescribed, though protocols allow initiation in an emergency |
| Notification | Informing the doctor | · Rationale for why this would be most appropriate nursing action to take· What information would you give to the doctor
· What recommended action would be appropriate according to the evidence/ why |
| DirectAssessment | Neuro-obs | · What is your rationale for conducting this type of assessment, with evidence· How frequently and for how long would you conduct this assessment, with evidence
· What parameters would you consider abnormal- and if abnormal what would be your next response, with evidence |
| Referral | Referral to dietician | · What specifically would you want the referring person to address, why· How would this referral reasonably lead to the outcome being achieved
· What information would you give to the person receiving the referral |
| Monitoring | Watching for signs of LOC | · How would you monitor this over and above your normal nursing care· Provide evidence that this type of monitoring is recommended for the health problem
· What signs/symptoms would be considered abnormal and what would your response be, with evidence |
| Teaching/education | Teaching post-op exercise | · Rationale· Summary of what these entail
· Frequency required · How you would confirm patient understanding +/or is compliant |
NURSING CARE PLAN TEMPLATE – INTRODUCTION
| Part 1 Focus | Part 2 Focus | ||||
| ASSESSMENT/NURSING DIAGNOSIS/OUTCOME | PLANNING/ IMPLEMENTATION /EVALUATION | ||||
| PATIENT or NURSING ORIENTED PROBLEM OR PATIENT NEED | PATIENT ASSESSMENT DATA | OPTIMAL PATIENT OUTCOME or GOAL | IMPLEMENTATION | RATIONALE | EVALUATION |
| Patient problem/issues/need – which is related to <insert>
Patient problems/issues/needs can be actual present and occurring now
Or potential when the patient is considered to be ‘at risk of’.
|
As evidenced by (or how do we know this problem exists)
Objective patient data
Subjective patient data
Lab and other test results |
What do we (patient and nurse) want to achieve:
Specific, measurable, attainable, realistic and time orientated (SMART goals) |
Independent interventions – nurse led or nurse focused
Collaborative interventions – with other members of the multidisciplinary team
Dependant interventions – require doctors orders or supervision
|
Evidence base, best practice guidelines, policy | Patient response to nursing interventions. Results of reassessment |
| One row per problem | |||||
| Up to 6 prioritised problems (minimum 4) | |||||
Resources:
Gordons Functional Health Patterns and/ or the A-G assessment approach
Tanner, C.A., 2006. Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6) 204-211.
NANDA – North America Nursing Diagnosis Association. Uses the “problem-etiology-symptom” (PES) method. Whilst such a formalised approach and language has not been adopted in Australia the PES approach can be a useful learning tool to link what am I ‘seeing/finding’ (symptoms and signs), what might be happening (aetiology) to generate patient and nursing focused problems.
