patient's whole lifestyle and the effect that that can have on the successful treatment of their condition or illness.
Whether in the community or in hospital, the nurses will do a full assessment for appropriate planning of care, which will be more tailored to the patients needs and requirements. As a plan of treatment is implemented there is usually a goal set for a desired outcome to be achieved (i.e. the reduction in size of a wound) with a review to see how effective the treatment has been and whether adjustments or changes need to be made according to the condition. This is called an evaluation, and it provides both the nurse and patient with a chance to review whether treatment has been completely successful; and if not, decide what other avenues, if any, can be explored. There can be many different problems/needs identified for just one person's care. Each problem/need will require a separate Care Plan to be completed and kept up to date so that any nurse delegated from the nursing team to provide care has relevant, good quality information and can meet the individual's nursing needs.
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When the Community nurse first visits, they will fill out a Personal Record file in which all the details discussed in the assessment are
recorded. These notes are the property of the hospital Trust to which the patient belongs and are usually kept in the patient's home for use by the community nursing staff for information regarding treatment and also to
record nursing visits and actions. When a course of treatment is finished and nursing input is no longer necessary, the Personal Record file is collected along with any unused supplies and is kept confidentially
filed.During an Assessment some of the questions asked may seem intrusive or inappropriate, but it is often through a detailed assessment that factors inhibiting recovery may be brought to light and gives the patient a
chance to ask questions and express concerns or worries. This valuable assessment provides a baseline from which progress and changes in a patient's condition can be measured. |
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The first page of the Personal Record will contain the details of the Patient, next of Kin, nearest friend or keyholder .Next
allergies, relevant medical history and a list of current medication is recorded . The nurse will then complete a physical health assessment.
Under this heading the nurse will be required to record a profile of the patients day to day lifestyle. This is sub-divided into specific headings:Senses, Communication, Pain, Mobility, Eating and Drinking, Elimination,
Resting and Sleeping, Personal/Oral Hygiene, Skin Condition The pulse , blood pressure and respirations are usually recorded, and depending on the patient's problem a urine sample may be required for testing.The
physical assessment alone does not give an holistic picture therefore a Psychological/Emotional Assessment is made.Headings in this section include:Memory, Orientation, Mood, Self Esteem/Body Image, Spritual
Beliefs/Cultural Concerns.Social lifestyle is also recorded in headings that include:Occupation, Recreation,Contact with Others, Health Education Needs, Home Safety/Environment, Social Support/Other ServicesEquipment
will be listed that has been provided as well as looking at what may need to be provided.With answers to these questions in place, the nurse can now start to develop a Personal Care Plan which is to identify the
patient's problems/needs, decide on an Action Plan of care to achieve a preset goal and decide on a time at which to review it's effect . |