Good care planning allows healthcare professionals make evidence-based decisions about care based on a comprehensive assessment, and to prove this, if necessary (Barrett, Wilson and Woollands 2012a). Overall the nurse must work in a professional manner and abide by the policies set out by the trust, NMC (2002) code of professional conduct and government legislation. Without a specific document delineating the plan of care, important issues are likely to be neglected. The main (primary) source would be from the patient or advocate and secondary sources would be from the patient’s relatives, patient notes or any documentation on the patient file. In nursing, the use of language must be appropriate to the patient and be clear, free from jargon and encourage feedback. She presented with severe dyspnoea, wheezing, chest tightness and immobility. No information regarding the hospital or ward will be mentioned, in accordance with the Data Protection Act 1998. This is the first stage of the nursing process and therefore any issues affecting the patient can be identified. immediately after assessment, namely nursing diagnosis (American Nurses Association, 2017). Care plans also help in assigning the correct and most qualified staff to provide the care outlined in the plan. Gordon (2008) stated that understanding that any admission to hospital can be frightening for patients and allowing them some time to get used to the environment is important for nursing staff. She was also checked for any pallor, jaundice, cyanosis or dry skin that needed attention. regarding that which is relevant and important (Barrett et al 2012). Considering Kate’s age and her breathing problem, she needed multi- professional teamwork. However, the system was not as efficient as it should have been: Kate spent unnecessary time in hospital after recovery because the care plan was not yet in place. During planning, priorities are set due to multiple nursing diagnoses assigned including a variety of proposed interventions. Although there was a room available, Kate and her daughter said it was fine for the assessment to take place at the bedside especially that Kate was so restless. Most assessment tools have a scoring system, the scores are added up to give an overall score. Checking and recording of breathing rate and pattern is very important because it is the only good way to assess whether this patient is improving or deteriorating, and it can be a very helpful method for nurses to evaluate the care of the patient (Jamieson 2007). Therefore attention needs to be paid to the biological, psychological and social situations of the patient. Care planning provides a "road map" of sorts, to guide all who are involved with a patient/resident's care. Kate was on oxygen since admission; therefore she was taught about importance of healthy breathing and taught her about breathing exercises to help her wean from oxygen. Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse.Nursing assessment is the first step in the nursing process.A section of the nursing assessment may be delegated to certified nurses aides. The aim of the tool is to help pick out certain information which may not have been picked up during initial observations of the patient. She has a daughter who lives one street away and visits her frequently. In the UK the early warning scores system and the modified system trigger a call to the patient’s own team or an intensive care unit outreach team. Carpenito-Moyet (2006) stated that it is important to take the first observations before any medical intervention, in order to assist in the diagnosis and to help assess the effects of treatment. Physiological observations should be monitored at least every 12 hours unless a decision has been made at a senior level to increase or decrease this frequency for an individual patient. Overall it’s a way of delving deeper into a patient’s il… Members of the public cannot always see the difference between a student nurse and someone who is qualified and registered with the NMC . Identifying usual habits helps individuals to maintain their social life if things are done according to their wishes. Therefore, whenever Kate was being assisted with personal care, it was ensured that the screens were closed and she was properly covered. Therefore competency in holistic assessment is crucial to successful nursing care planning and maximising positive patient outcomes (Bolster & Manias 2010). The frequency of monitoring should increase if abnormal physiology is detected, as outlined in the recommendation on graded response strategy. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Evolution of planning nursing care. Depending on that score would depend on the care for the patient or medical intervention. In a qualitative study, Carroll (2004) found broad agreement from experts about the core assessment skills that are required for nurses working in this field. (2005) stated nursing assessments are non-static. Her confidentiality was not compromised because she agreed to the presence of a family member. Personal details such as name, age, address, nickname, religion, and housing status were recorded. She was discharged on a continuous care package comprising care three times a day, although discharge was delayed by one week so that the care package could be ready. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for … Furthermore, the role of inter-professional skills in relation to care planning and delivery will be analysed, and finally the care given to the patient will be evaluated. Therefore, more time is needed to be sure that the necessary progress has been achieved before taking further steps. Integrating health & social care at the point of assessment and planning means the person will not have to repeatedly share their story time and time again, as they will have one assessment & planning experience that results in a single integrated personalised care and support plan. She was admitted with asthma and a chest infection. Monitoring should be more frequent if abnormal physiology is seen. Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings. Kate’s initial assessment was carried out in a professional way, taking account of the patient’s particular circumstances, anxieties and wishes. It is also information that be gathered by the nurse and their perceptions at the time of the assessment. Information was also recorded about any agency involved, along with next of kin and contact details, and details of the general practitioner. Newson suggests that for the process to commence a model of assessment is utilised. Rennie (2009) stated that subjective and objective data, as well as medical and social history are collected during patient’s interview. • Strengthening assessment and care planning: A guide for HACC assessment services in Victoria. Progress from assessment to care goals was good, and at this point an inter-disciplinary team was used successfully. It focuses on the patient’s needs at that moment in time and possible needs that may need to be addressed in the future. 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