Assessment and Care Planning of the Adult in Hospital
Hospitalisation has a big impact on person’s life. When attending with people in hospital health care professionals use care planning to make sure that individual needs are met and that there is on-going personalized plan for the duration of the stay, however long or short it may be. In the course of this essay, I will be following a patient that has been on my clinical placement. I will be discussing the models and the theories that predicate nursing in my clinical area. I will be looking at two needs of my patient and state how we assess these. To abide by the Nursing and Midwifery Council Code of Conduct (NMC, 2008a), I will be changing my patient name to Tony and make sure that confidentiality is kept at all times.
The patient I have chosen to study is Tony. He is an eighty five year old gentleman. He was admitted to the care of the Acute Stroke Ward in the local hospital where I had my nursing placement. Tony was admitted in Emergency Department after collapsing at home. On admission, he presented with facial droop, left sided weakness, frontal headache, slurred speech and mild confusion. According to Computed Tomography (CT scan) and other blood examination this patient has been diagnosed of having Ischaemic Stroke. Ischaemic stroke occurs when the arteries in your brain are narrowed or blocked causing severely reduced blood flow (ischemia) due to in-situ thrombus or embolus( Mant and Walker, 2011). Tony has past medical history of heart attack (MI), hypertension and type 1 diabetic mellitus. He lives with wife in a three bedroom bungalow. He is very independent with his activities of daily living. While in the hospital, Tony’s care is being managed by the stroke team which consist of doctors, stroke specialist nurses, ward nurses, physiotherapist, speech and language therapist, occupational therapist and dieticians.
To understand the nursing assessment process, the author feels it is important to...