Care planning, assessment and diagnosis in practice
Assessment and diagnosis
- The assessment and diagnosis stage of care planning
- Review previous work you have completed on the care planning process and summarise in two paragraphs the assessment and diagnosis stage of care planning.
The nursing model
- Application of a nursing model
- Select a client from your workplace or one of the people in the scenarios and carry out an assessment using Roper, Logan and Tierney or another suitable nursing model.
- Make a care plan for your chosen client.
- Present and discuss the care plan with your class.
What this icon means
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Legislation refers both to laws and the process by which a policy becomes law. Laws are passed by governing bodies. In the UK, this is by Parliament and laws are known as Acts of Parliament.
Legislation is also known as statutory law and must be approved by vote. Statutory laws are enforceable; that is, they must be followed. If the law is not followed, it could lead to a court case.
Example: The Health and Safety at Work Act 1974
Policies are the equivalent to a set of decisions that are taken towards achieving a long-term purpose and are very often based on reviews. They are a plan of action with specific goals and activities - a list of what must be done in the future.
There is, however, no guarantee that policies will be successfully followed.
Public policies are implemented within a nation’s legal framework. They can be created, revised, updated or deleted by organisations involved in the administration of that policy.
Examples: Better Health, Better Care Action Plan (2007) and Transforming Care After Treatment: (TCAT) (2013).
It is your second day on a busy ward and you are working with your mentor, a staff nurse. Your induction was on day 1. You have been allocated to six individuals on your ward but your focus for this activity is Mr Achmed, who is due to go for a hip replacement later in the day. Mr Achmed has never been in hospital before and is feeling anxious.
Avril is an 82 year old lady, who has been resident in a care home for the last six months. She has found it difficult to manage at home because of her arthritis, which affects her general mobility.
Avril is a single lady who was a personal assistant to a diplomat, working in the Foreign Office until she retired. She is the youngest but only surviving sister of five sisters. She remains in close contact with one niece, who lives close by and visits regularly. She has a circle of international friends who write to her frequently.
Calum is a forty year old man who has been admitted to Accident and Emergency after being found collapsed in the street. He smells strongly of alcohol and cigarette smoke. He has a large cut on his head which is bleeding. Calum has been seen in the department twice before with minor injuries while under the influence of alcohol. He discharged himself immediately after being treated.
Calum was a soldier in the army until five years ago when his health deteriorated and Bi-polar disorder was diagnosed. He then worked as lorry driver but unfortunately was dismissed from his job 3 months ago. Calum is also now homeless as his wife and two children could no longer cope with his erratic behaviour and the distress he was causing within the family.
ns in close contact with one niece, who lives close by and visits regularly. She has a circle of international friends who write to her frequently.
Claire is 16 years old and has Down’s syndrome. She attends the special department of the local secondary school where she has learned to read and write simple text, can add and subtract to 100, enjoys working on the computer and likes cooking. She wanted to leave school in the summer but her mother refused and Claire now often won’t get out of bed in the morning so misses the taxi to school.
She lives at home with her sixty-one year old mother. Claire does not know her father as he left her mother when she was born. Her sister Yvonne is much older, has two children of her own and has recently become a grandmother. Claire adores the new baby and wants to have a baby just like her niece Zoe. Claire likes walking round to their house because Zoe does her hair and make-up and now lets her give the baby her bottle and play with her. When her sister’s out, they play loud music and dance.
Dafic is 47 years old. He fled from Iraq 18 years ago due to violence and persecution and was a refugee initially. His wife joined him two years later and they have a family of four girls aged, six, ten, twelve and fifteen and years old. He has worked hard since he came to Scotland; initially, in restaurants and he now has a small cafe which he runs with his wife. They live in the flat above the shop and Dafic is very happy that he has been able to provide for his family. Dafic had complained of tiredness for some time before he went to his G.P. After some tests, he was diagnosed with cancer, which, unfortunately, has not responded to treatment.
Dinah is a 46 year female who has been in hospital for a hysterectomy. She is married to Douglas and they live in their own home. Dinah works in a local residential care home for older people as a care assistant. Her husband is a Postman.
Dolina MacGregor is an 80 year old lady who was admitted with a fractured neck of femur after a fall at home. The fall has left her feeling very vulnerable and with her arthritis her ability to physically support and dress herself is no longer possible. While in hospital it was also noted that her memory had deteriorated significantly and she was now experiencing dementia which was putting her at great risk of living alone. There seems no other option but to be discharged to a care home.
Jason is twenty two years old and was diagnosed with Crohn’s disease at the age of fourteen. He had previous surgery twenty months ago and has a colostomy. Jason is hoping for colostomy reversal.
Jason’s upbringing has been complicated and he has spent periods of time away from his mother while growing up. He has also had several admissions to a young offender’s facility following a range of crimes. He is currently on a work programme with the college but his attendance has been erratic.
Mrs Jones on the Nurse Sarah: introductory video (1 minute 9 seconds).
Mrs Jones is admitted to hospital for an assessment. The focus of this video is on the standard of care she receives.
Mr Kings's Story (22 minutes 17 seconds)
This videos follows the care pathway of a gentleman, Mr King, just turned fifty who has a sudden unexpected stroke and is admitted to hospital. The video contains interviews with doctors and nurses who work in the stroke team. Particular focus is placed on team working and the value of professional meetings.
Recognising Risk and Improving Patient Safety - Mildred's Story (24 minutes 38 seconds in total.
Mildred is a resident in sheltered housing. When she fails to respond to his calls, the warden enters her flat where she is found to be suffering from a suspected stroke. The focus is on the importance of non-clinical skills, behaviour and attitudes in assuring patient safety.
Mr Kirby's Story - Case Study for Inter-Disciplinary Teaching (22 minutes 17 seconds)
Mr Kirby, a 72 year old patient in the Acute Hospital, is referred for rehabilitation at the Community Hospital. The video highlights issues around caring for elderly patients who become too infirm to continue to cope with living independently at home. It focuses on the relationships between care professionals, the patient and the patient’s family.
The activities in these materials provide you with an opportunity to develop your academic skills. Academic skills, such as research and study skills, will help you become a more effective learner and achieve your full potential both in further study and in the workplace.
UHI Essential student skills provides access to information on academic skills as well as other skills and information that will be useful during your course of study and beyond. You can access information on:
- becoming an effective learner
- core skills
- learning with us (uhi)
- preparing for work
- using technologies.
In the Nurse Sarah video none of the following elements are being demonstrated effectively:
Treat people as individuals
||What happens in the video
|1. You must treat people as individuals and respect their dignity
||Called by first name.
|2. You must not discriminate in any way against those in your care
||No value, age discrimination.
|3. You must treat people kindly and considerately
||No introduction, no information, no respect.
|4. You must act as an advocate for those in your care, helping them to access relevant health and social care, information and support
||Staff are more important.
Respect people's confidentiality
|5. You must respect people's right to confidentiality
||Talking about deceased person
Gibbs’ model of reflection (1988)
Viewing the materials
You can view these materials on a PC, laptop, tablet or mobile phone. The materials also contain video content so use of a headset is required for these.
Content is accessible via the main menu on the left and by using the navigation arrows at the top and bottom.
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The content is presented in 3 main ways:
- Standard web page presentation.
- Tabbed content: clicking on a tab reveals the content for that particular tab.
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This topic is one of a series of four that focuses on care and administrative practice taking you through the main phases of care:
- Meeting the client
- Integrating and implementing care
The materials consist of a series of activities based around each particular topic. These activities provide you with the opportunity to apply theory to practice. Each topic includes research, videos, individual, collaborative/group work or reflective activities with guidance on adding information to your portfolios. Activities with feedback also appear in the topics; these can be used to check your knowledge and understanding and as an aid to revision.
Your tutor will provide guidance on how to use these materials.
Activities are shown within a rounded box. The nature of the activity is indicated by an icon:
- an individual activity that you should work through on your own.
- group work/collaborative activity that requires you to work with others.
- a video activity.
- a reflective activity.
- research activity that requires you to discover relevant information in order to carry out the activity.