Identify care needs in order of priority.

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  1. Identify the information needed to care for the client and structure assessment to provide you with the information required to plan care for this particular client’s specific problems
  2. Identify all the domains of health to be assessed
  3. Identify the tools needed to perform the assessments in each domain
  4. Identify additional information needed and method to collect the required data, e.g. urine tests
  1. Brief introduce the domains of health: physical, psychological, social, cultural, spiritual, intellectual
  2. Brief introduce the conditions from the 6 domains of health – such as from physical domain, the patient is experiencing chronic pain, decreasing the level of daily activities, overweight, blisters, ect. , and the structure assessments need to be done for the 6 domains as a community nurse.
Please mention the side effects of medications need to be awar, for example, Ibuprofen may cause hypertension, Baclofen may cause headache, Diazepam may cause hypotension. ect.
  1. What are the nursing assessments need to do for the each domain (and brief reasons) as a community nurse at the patient’s home? – You are a community nurse
  1. Additional assessments and why(something must do in hospital, such as urine tests)
Care Plan
  1. Identify care needs in order of priority
  2. Construct a plan of care that meets the needs of the client.
  3. Consider care planning across all domains of health: physical, psychological, social, cultural, spiritual, intellectual and other domains you may identify
  4. Include method of evaluation in the care planning
  5. Review care planning from ethical perspective to include client consent, autonomy and adherence to nurses’ code of conduct, legal requirements etc
  1. In this case, the two priorities are pain and depression. Explain why these two would be the priorities, other words – why you think the pain and depression should be focused firstly in this case?
  2. Explain the reason and results of chronic pain (Pathology and process of spinal stenosis, other additional reasons such as his occupation, and what are caused by pain, such as depression, serious influence his level of function such as daily activities ect.)
  3. Create the care plan part 1 for pain as a community nurse from the 6 domains of health.
Eg.
Physical – ongoing assessments? Medication? More experts involved? The method to reduce or delay the process of illness? The home environmental hazard assessment?
Psychological – Ongoing assessments? Medication? Social work involved because his children are living far away?
To sum up, indicate the reason of pain, and the influences of his pain from 6 domains. Indicate the interaction of these influences, and create a plan for his pain from 6 domains
  1. How to evaluate the care plan part 1– eg, pain assessment …
  2. Explain the reason and results of depression (the results such as medication adherence, stopping work with physiotherapist, cause the symptoms more serious…)
  3. Create the care plan part 2 for depression as a community nurse from the 6 domains of health.
To sum up, indicate the reason of depression, and the influences of his depression from 6 domains. Indicate the interaction of these influences, and create a plan for his depression from 6 domains
  1. How to evaluate the care plan part 2
  2. Review care planning from ethical perspective to include client consent, autonomy and adherence to nurses’ code of conduct, legal requirements etc
Implementation
Identify possible obstacles to implementation and how you could address it
  1. Possible obstacles such as his emotion, irreversible symptoms of chronic pain and illness, etc. Brief explain why
  2. The possible method to fix it, such as how to give an appropriate education such as the correct position during bed time. Brief explain the expecting result
Evaluation and reassessment
  1. How to evaluation and reassessment the care plan
  2. Identify tracking of progress of long term care goals
Conclusion