Information Exchange: A Case Study

I will now talk about each patient needs as they all differ from each other. Nusrat Patel is 19 years old and has learning disability. This means Nusrat has difficulties in keeping knowledge and skills to the expected level of those the same age as her. Nusrat also has epilepsy which is neurological brain disorder when someone has epilepsy, it means they tend to have epileptic seizures, a seizure is a sudden attack of illness. Nusrat has left residential school to receive full time carer from her mum who has stopped working to care for Nusrat. At times this can be stressful so Nusrat attends the community centre on Tuesday and Thursday which allows Nusrat mother to have a break. Maria montanelli is 34 years primary school teacher who is much like Nusrat mother and takes care of her 96 years old mother who has dementia. Dementia is memory loss and difficulties with cognitive development. Being a primary care for her mother Maria feels she not performing at her best ability because of her lack of sleep which occurs when she assists her mother to the toilet several times. The last patient I would like to mention is Alice Fernandez she is 74 years old who recently lost her husband who had lung cancer. Alice doesn't use her pension the right way as she purchases many drinks as an alcoholic and has increased since her husband passed away. She has been prescribed antidepressant tablet by her G.P but made her lethargic this means she's become slow and sluggish.

Within this essay, I will reflect and critically analyse an OSCE which has increased my awareness, or challenged my understanding, in assessing the holistic needs of a service user (John), referred by his GP, whilst incorporating a care plan using the Care Programme Approach (CPA). By utilising this programme and other sources of current literature, I hope to demonstrate my knowledge and understanding in relation to this skill as well as identifying areas with scope for learning.

The level of care a person needs or the type of care they require varies from person-to-person. All assessments should be done with a person-centred

During an initial assessment an individual’s ability and communication methods are established. This is done when an individual arrives into care. Everyone involved in the care of this service user is made aware of their needs and preferences regarding communication and any changes are recognised during reviews and shared with the team to ensure the individual’s needs are met.

Assessment tools are used in the care planning process to build up a holistic picture of an individual’s needs. When all the details have been recorded an assessment can be made and suitable care and support can be identified. A few of the assessment tools are information from the individual such as diaries, observations, medical histories and checklists.

Assessment of a patient is a big process of decision making, it is about the collection of information which will contribute to an overall judgement of a person and the illness they may have. Lloyd (2010) states that assessment is one of the first steps which is needed to be done in the nursing process, it is a building block for a relationship and an ongoing process which lets health professionals gather the correct information to help them understand the problems and needs that the patient is going through. Most of the nursing assessment which are in use today will all have very similar aims. The difference is that how the assessment’s are carried out is where the differences come from.

It is important to review care and support plans as people’s needs change. By including the person, their family then everyone knows what is happening and the family can help to monitor mood swings and behaviour. The individual and the family can express their views and preferences and any relevant risk assessments may be done with everyone involved. By monitoring the individual, a decision can be made as to whether the changes are effective and if the best care is being given to encourage independence and promote dignity.

It is necessary to involve the individual in the plan of care and support. Encourage the individual to make choices. This includes their needs, their culture, their means of communication, their likes and dislikes, wishes and feelings, advance directives, beliefs and values, involvement of their family and other professionals. This should be considered and documented. Also, there must be evaluation in assessing effectiveness in the plan of care.

As a care worker you can find out information about the individual by putting the individual in the centre of any kind of planning and supporting. You can do this by communicating with the individual and find out more about their history, preferences and wishes. It is extremely important that you work in a non - judgemental manner. You have to make sure that you don’t discriminate in against the individual. By supporting the individual to be independent, you can also ensure the equality and general practice. You can kindly encourage and empower the individuals

Upon completing a care assessment, the assessor will work with you to develop a care plan. Each plan is tailored to provide you, or your loved one, with the support needed to continue living in your current situation, if this is the best option.

The first stage of the process is assessment. Roper et al (2001) refer to this process as ‘assessing’ indicating an ongoing activity; this encourages nurses to recognise the on-going nature of this initial phase. The assessing stage includes gathering information about a patient, reviewing this information, identifying actual and potential problems and prioritising (Roper et al 2001). Roper et al (2001) explain the importance for assessing, as early as possible in the patient’s stay. Extensive, in-depth information may not be gathered on an initial assessment, however any information obtained contributes towards individualised care (Roper et al 2001). Ambrose and Wittig (1998) explain that the initial assessment becomes a foundation for ongoing assessing and holistic care. Barrett, Wilson and Woollands (2009) concord with Roper et al and Wittig in that assessing is an ongoing process and elaborate on this explaining that assessment should not be confused with admission. They state “an admission tends to be a one-off process when you first meet the patient, whereas assessment carries on throughout your relationship with the patient” (pg22). Assessment enables the nurse and patient to identify actual and potential problems. Although, some problems can be directly related to biological needs, holistic needs must be considered, i.e. psychological state and cultural/social standing

Care planning is encouraging a person to be independent and setting realistic goals that they will be able to achieve. (The National Archives, 2009). The goals that wanted to be achieved in each care plan, followed the S.M.A.R.T system. This meant that they were specific, measurable, achievable, realistic and time orientated. (Parkinson and Brooker, 2004). Every patient care plan is individualised on the patient’s ability and problems and they ensure goals are specific for each patient so that their progress can be monitored. Within each care plan for James, the goals were realistic and promoted as much independence for the child as

Alice needed an assessment of her needs and to have a care plan that is regularly reviewed by professionals. Assessment is the decision making process, based upon the collection of relevant information, using a format set of ethical criteria, that contributes to an overall estimation of a person and her circumstances (Barker, 2004). I was going to get most of the information from Alice. Barker (2009) suggests that wherever possible information should be obtained directly from the person, either in the form of some kind of self report or via observation. Good communication and a systematic approach to data collection are needed for a successful assessment.

Assessment is described as”The first stage of the nursing process, in which data about the patient’s health status is collected” (Oxford dictionary of nursing, 2003, p23), following this phase a care plan can be devised.

The patient in this particular case study is an adult man of 45 years with Down syndrome and a moderate intellectual disability. This man also has a chronic illness, which is type 2 diabetes. This man lives in a community group home that is staffed by support workers and he attends a disability-specific day program Monday to Friday. This case study will be reviewed from the point of view of the community nurse managing the holistic case needs of this particular patient. Holistic needs involve a number of different considerations, and must include an overall understanding of the patient’s medical needs, as well as his physical and emotional needs. The goal as the nurse will be to develop a holistic care plan, including an analysis of the health challenges of this individual, an analysis of activity and participation using the ICF model, and an overall recommendation for an intervention strategy for the patient. The intervention strategy will include consideration of all the different aspects of this individual’s difficulties and disabilities.