plan of care and individual written report On Complex Nursing Care - Assessment Task 1

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Nursing Care Plan Template
In the care plan template provided, identify 4-6 actual or potential physiological patient problems.
Identify all objective and subjective patient assessment data which supports your clinical reasoning in selecting these issues (i.e. how do you know that this is a problem for this patient?).

  • This should be specific assessment data e.g. SBP 88mmHg instead of just saying ‘hypotensive’ Identify the optimal outcome that your patient should achieve before they are discharged.
  • This should be a specific target that is appropriate for your specific patient e.g. SBP 110-130, urine output > .5mls/kg/hr, GCS 15/15, etc.

Nursing Care Plan Report - 2000 words
From your nursing care plan template select 2 physiological problems. These may be actual problems, potential problems or one of each.  Do not select psychosocial problems as you will not be able to discuss the pathophysiology of these.

For each of your chosen problems:

  • Explain the pathophysiology and how this relates to the patients clinical presentation. I.e. What is happening in the body to cause the signs and symptoms that the patient has?
  • Identify the key nursing interventions required specifically to treat or prevent the problem you have chosen. These interventions should be supported by contemporary clinical guidelines, policies and high quality best-practice evidence. Nursing interventions should include a rationale supported by evidence. Nursing interventions may be
  • Independent interventions – nurse led, nurse initiated
  • Collaborative interventions – with other members of the multidisciplinary team
  • Dependant interventions  - for example dependent on a doctors order
  • These interventions should focus just on interventions which will specifically treat or prevent your chosen problems. Please do not include general nursing care which would be applicable here, or interventions which are required for all care (i.e. there is no need to identify obtaining consent, hand hygiene, etc. as this is required for all nursing interventions always). You do not need to describe the intervention, just state what you would do and why (not how you would do it). 
  • Identify the intended goals of care and patient outcomes for your problem, considering how you would evaluate this. I.e. what do you want to achieve for your patient specifically, how will you measure the patient’s progression towards this goal and how often will you take these measurements?

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