Select a patient with whom you have been working on clinical placement.
Introduction
• Include the context of the clinical case study and a statement confirming that written consent from the patient was received.
• A pseudonym for the patient must be used and stated as such, with all other potentially identifying patient data anonymised at the source.
Formulate a Care Plan using the Nursing Process (ADPIE)
A - Using the comprehensive health assessment framework, collect subjective and
objective data and summarise the patient`s health history USING ASSESMENT TOOLS FOR EACH IDENTIFIED CLINICAL PROBLEM LIKE respiratory assessment, neurological assessment and so on.
D – Formulate THREE nursing diagnoses related to data collected during the
comprehensive health assessment. In collaboration with the patient, list the goals
according to the patient`s preference.
P - Use this information, including the relevant literature, to develop a patient-centred care
plan with the patient (where possible) using identified goals (SMART goals) for each
nursing diagnosis.
I – Identify all of the relevant nursing interventions that will address each nursing
diagnosis
E - The care plan will consist of a holistic summary of expected patient outcomes in
response to the nursing interventions identified in the care plan using relevant literature.
Following the comprehensive health assessment, provide a comprehensive discussion of the care plan and relate this to person-centred care.
• Include presentation of medications used in the pharmacological therapy for the patient, rationale for their use and nursing considerations noted for this patient concerning these therapies.
• Critical thinking should be indicated by using best practice guidelines where appropriate and applying current and relevant references.
Summary of comprehensive health assessment and linkage of pathophysiology to clinical manifestations. Thoroughly conducted and well documented health assessment. Comprehensive and accurate explanation of pathophysiology and clinical manifestations Well integrated with source materials.
Identify & discuss key nursing issues and create a nursing care plan. Identified and discussed key nursing issues effectively. Created a comprehensive care plan based on the clinical reasoning cycle, with clear steps and rationale. Evidence of wide reading with a range of relevant source materials integrated into discussion
Describe & critically discuss the nursing care delivered as outlined in the care plan. A comprehensive plan of care, clearly linked to patient. Provided a thorough and insightful critical discussion of the care plan, addressing potential challenges and alternative approaches. Evidence of wide reading with a range of source materials integrated into discussion.
Describe & evaluate the effectiveness of the nursing issues identified. A comprehensive description of a relevant Evaluation of thoroughly elaborated & discussed. Evaluation of modality supported by well-chosen source materials.
Presentation. Excellent writing style and. linking of ideas between paragraphs Structure clear & supported by introduction, conclusion & headings Presentation of work is largely flawless.
