Nursing Care Plan for a Client in a Community Setting

Topic: Nursing care plan for a client at home in a community setting.

Guidelines of the assignment

The case to be studied was a client suffering from chronic diseases and requiring nursing procedures at home.

Students are given a referral letter for Community Nursing Service, a patient discharge summary by a doctor and a nursing discharge summary by a ward nurse (see attachment).

In the assignment, the students are going to act as outreach community nurses and completed the first home visit for the client.

Students need to perform the assessment and identify the problems of the patient at home in the community.

Students need to plan the nursing care (the top three prioritized health problems) for the patient with relevant nursing skills.

Students are required to suggest the related educational materials and empower the client with a learning contract.

Evaluations of the effectiveness of the plan of care should be included.

o Describe the background of the client.

o Reasons for referring Community Nursing Service (CNS)

The plan of the nursing care for the client:

You are suggested to utilize the approach of “Assessment (initial & focused assessment), Expected Patient/ Carers Outcomes, Interventions/ Education and & Evaluations” for each of the following aspects in your plan.

• Physical status
• Psycho-social Status
• Home environment
• Medication
• Nutrition
• Elimination
• Hygiene
• Activities & Exercises
• Consultation
• Community Resources

• Initial and focused assessment based on the aspects of ten care elements as mentioned above.
• Please do the assessment related to the problems from the above ten care elements and refer to the case

For example, in terms of Community Resources, the data does not mention about this, however, Community Resources are also vital for COPD patient, so we have to assess whether any community resources around patient’s home or we can introduce community resources to the patient

• List out all the actual and potential problems from the above ten care elements
• Identify top three prioritized health problems with relevant subjective data and objective data and with rationales ( why these are important than the others?)
• Plan the nursing care based on the top three prioritized health problems for the patient with relevant nursing skills

Some subjective data maybe missing in this part, you can estimate the patients’ feeling and thoughts , the teacher will accept once they are reasonable

For example, if the patient had wound infection in the case, only exudate appear is stated which is the objective data, the subjective data is not given, therefore we could estimate the subjective data is the patient is complain of pain.

All subjective data and objective data should be included in the top three prioritized health problems. 

• Set at least one goal, two expected outcomes(short term& long term if words are allowed) with using SMART framework (Specific, Measurable, Achievable, Realistic, Time-bound), and five interventions for each problem
• Education and advice are included in the intervention part
• Write at least 5 interventions in each health problem
• Write 2-3 interventions under each expected outcome
• Empowerment plan Lecture3 Slide31,73eg self-management skill
• Learning contract. Lecture5 Slide13,14,25,36 (similar to intervention ,skill-wise in this case, patient suffered from COPD ,we should teach the patient how to use aerochamber , take what medication, oxygen, breathing pattern, 88-93%SPO2, think how to control these situation at home aside from visiting the Emergency Department of the hospital,the patient should know the above information)

• the expected effectiveness (What you expect from the next visit, what is the difference , thus you can evaluate whether the plan you write is effective to the patient)