Patient Care Planning

Patient care planning is the organised assessment and identification of patient problems, the setting of goals and the formation of techniques and plans based on the best evidenced based practice for achieving them (Australian Commission on Safety and Quality in Healthcare, 2011). The aim of this task is to analyse a case study provided and create a nursing care plan based on the patient’s physiological and psychological problems. Grace is an elderly woman with emphysema and hypertension. She has recently moved into an aged care facility and is now receiving care from this facility. Background information about the patient’s medical diagnosis is given and two prioritised nursing problems have been recognised. Attention is made on the key

A nursing care plan has been developed to individually suit Grace’s needs. It includes the planning and implementation of care, evaluation of the effectiveness of the treatment and rationale using best evidenced based reasons for the proposed plan.

The nursing process is a problem solving framework on which professional nursing practice is based (Luxford, 2015). It is important for nurses to be able to understand and apply the nursing process. This process involves several steps; these include; Assessment- During this stage nurses collect information about their patients. This information may be either subjective or objective data. In addition to the patient’s direct health information, nurses should take into account spiritual, cultural and psychological traits when assessing the patient. Diagnosis- next the data must be organised and interpreted, with the goal being to establish a nursing diagnosis. In this assessment there were two diagnoses’ these being Grace’s emphysema and hypertension. Planning- the nurse uses information collected to make short and long term goals for the patient’s care, these are usually discussed with the patient as patient

A thorough understanding of the needs and wishes of the patient with the long term condition is needed in this case this being Grace All aspects of the patient’s lifestyle, age, gender, and how they are feeling need to be obtained. In the case study Grace is now an ex smoker but had smoked all her life from the age of 25 and has recently quit so she can go on in home oxygen therapy. Due to her smoking most of her life she has now developed emphysema. While the nurse is doing the assessment they must use all of their skills and can take the registered nurse standards into account and use them as a guideline. Therapeutic communication, listening, eye contact, and touch may be used to connect with the patient on a therapeutic professional manner (Day & Levett-Jones 2015). When developing a care plan for Grace nurses need to take into account a number if things to suit the individual. These include Grace’s perception of their health issues, Grace’s beliefs towards these conditions, the impact the present issue has on her social, spiritual, sexual and interpersonal life, what they feel might help improve the condition and also factors and things that might make the condition worse. Looking at the care plan we can see that Standard two, engages and therapeutic and professional relationships, from the