Care Documentation
- No references required
- Arial font 12
- Complete both part 1 and part 2.
Part 1: Care Documentation
1. Person-centred Nursing assessment
1a. You are required to show proficiency in actively participating in the completion of one person-centred nursing assessment for a user who has complex needs OR for someone receiving end of life care.
1b. Complete a Learning Achievement Record and Address the following proficiency for Person centred Nursing assessment:
(i)Understand the need to base all decisions regarding care and interventions on people’s needs and preferences, recognising and addressing any personal and external factors that may unduly influence their decisions
(ii). Provide and promote non-discriminatory, person centred and sensitive care at all times, reflecting on people’s values, beliefs, diverse backgrounds, cultural characteristics, language requirements, needs and preferences, taking account of any need for adjustments
(iii). Understand the principles and processes involved in supporting people and families with a range of care needs to maintain optimal independence and avoid unnecessary interventions and disruptions to their lives
2. Plan of Care
1. Based on your completion of a person-centred nursing assessment, use two care needs namely : (Anxiety and Confusion )and actively participate in the completion of evidence-based plans of care for each care need.
2. Complete a Learning Achievement Record and address the following proficiency for Plan of Care
(a)Demonstrate and apply knowledge of human development from conception to death when undertaking full and accurate person-centred nursing assessments and developing appropriate care plans
(b) Demonstrate and apply knowledge of body systems and homeostasis, human anatomy and physiology, biology, genomics, pharmacology and social and behavioural sciences when undertaking full and accurate person-centred nursing assessments and developing appropriate care plans.
(c) Demonstrate and apply knowledge of all commonly encountered mental, physical, behavioural and cognitive health conditions, medication usage and treatments when undertaking full and accurate assessments of nursing care needs and when developing, prioritising and reviewing person-centred care plans.
(d) Understand and apply a person-centred approach to nursing care demonstrating shared assessment, planning, decision-making and goal setting when working with people, their families, communities and people of all ages
(e) Demonstrate the ability to accurately process all information gathered during the assessment process to identify needs for individualised nursing care and develop person centred evidence-based plans for nursing interventions with agreed goals
(f)Demonstrate the knowledge and skills required to identify and initiate appropriate interventions to support people with commonly encountered symptoms including anxiety, confusion, discomfort and pain
(g) Demonstrate the knowledge and skills required to prioritise what is important to people and their families when providing evidence-based person-centred nursing care at end of life including the care of people who are dying, families, the deceased and the bereaved
(h) Demonstrate an understanding of co-morbidities and the demands of meeting people’s complex nursing and social care needs when prioritising care plans
(3) Care Evaluation
1. Actively participate in the completion of a written evaluation of nursing care provided for one person in your care over a minimum period of one shift.
2. Complete a Learning Achievement Record and address the following proficiency for the Care Evaluation.
(a) Demonstrate the ability to work in partnership with people, families and carers to continuously monitor, evaluate and reassess the effectiveness of all agreed nursing care plans and care, sharing decision making and readjusting agreed goals, documenting progress and decisions made
4. Risk Assessment
There are a number of different risk assessment tools used in different care settings. Here are some suggested tools that you may wish to consider (this list is not exhaustive):
· MUST
· Bedrails
· Infection prevention and control
· Moving and Handling
· Pressure Sore Risk (e.g. Braden Scale)
· Falls risk
· NEWS2
· Mandatory Risk Screening (mental health services)
1. Using active participation, for two identified risks arising from your participation in nursing assessments in at least two different care settings, complete two risk assessments using recognised risk assessment tools.
2. Complete a Learning Achievement Record for each (2) and address the following proficiency for the Risk Assessment
(a) Recognise and assess people at risk of harm and the situations that may put them at risk, ensuring prompt action is taken to safeguard those who are vulnerable.
(b) Comply with local and national frameworks, legislation and regulations for assessing, managing and reporting risks, ensuring the appropriate action is taken
(c) Demonstrate the ability to accurately undertake risk assessments in a range of care settings, using a range of contemporary assessment and improvement tools.
Referral
1. With active participation, select a user who requires referral to another service. Complete a referral form for this person
2. Complete a Learning Achievement Record for each, outlining the process and rationale for the referral and address the following proficiency for Referral.
(a) Demonstrate knowledge of when and how to refer people safely to other professionals or services for clinical intervention or support.
(b) Demonstrate an understanding of the complexities of providing mental, cognitive, behavioural and physical care services across a wide range of integrated care settings
Discharge/Transfer
1. Select one person in your care who is either being discharged home or being transferred/discharged to another facility/care provider. Actively participate in the completion of the documentation relating to this discharge/transfer.
2. Complete a Learning Achievement Record for each and address the following proficiency
(a) Demonstrate the ability to co-ordinate and undertake the processes and procedures involved in routine planning and management of safe discharge home or transfer of people between care settings
(b) Understand the principles and processes involved in planning and facilitating the safe discharge and transition of people between caseloads, settings and services
Part 2: Summary of the Care Documentation
Summarise your learning and development in completing this care documentation, making explicit reference to the proficiency(ies) being addressed below.
(a) Identify ways in which your ideas, thinking, knowledge, understanding and practice have been challenged and/or changed
(b) Explain how you overcame any difficulties experienced and what you learned about yourself in the process
(c) Identify key factors that have enabled you to grow in confidence and competence when delivering person-centred care
(d) Describe what was learned from/through this learning experience
(e) Explain what you might do differently if completing this/similar learning experience/ task again