Assessment, Delivery, Documentation, and Evaluation of Health Consumer Care

The student will be able to demonstrate safety and competence in assessment, delivery, documentation and evaluation of health consumer care. ?The student will be able to demonstrate a practical understanding of the nursing process, to plan and evaluate the nursing care of a patient they cared for during their clinical placement.Assessment key words and concepts:

Informed consent?Holistic Health Assessment?Nursing Care Plan?Clinical placement settingAssessment task/activities:?The student will complete one patient profile, holistic health assessment and a nursing care plan, for a focus patient/client in their clinical placement setting.?Identify one patient/client from your clinical setting to complete your portfolio/case study on. o Ensure informed consent is obtained by gaining verbal (informed) consent from the patient you select. The patient should understand that you will use the information you gathered during the holistic health assessment and in caring for them, within your assignment, BUT that ALL information that could identify the patient, such as dates, names, places, will be withheld.?Complete one patient profile using the template provided.?Complete one holistic health assessment on your focus patient, using the assessment tool provided.?Complete one nursing care plan for your focus patient, on the Care plan template providedStructure:Introduction: Provide a general introduction including:o Purpose of the case study and overview of content o Description of clinical setting and environmento Process for gaining consento Process for managing privacy and confidentiality issuesWritten clinical profile of the patient:o Provide a clear overview/description, introducing your patient/client, using the template provided.Holistic Health Assessment:o Provide a clear clinical overview of your focus patient/client, using the “Holistic Health Assessment Tool” provided.o Include correct nursing terminologyo Objective and subjective dataNursing Care Plan:

Two patient/client goals that are related to the nursing diagnoses. o ALL patient goals must written using the SMART format.?Three appropriate nursing interventions for each of the patient/client nursing diagnosis and goals.o All nursing interventions should be clearly identified and related to your focus patient nursing diagnosis and goals.?Provide the rationale/reason for these nursing interventions ?Provide an evaluation of the nursing interventions and patient/client goals. Do not include a coversheet or marking guide/rubric?Please ensure your student ID number is on the header of each page?Every page is numbered in the page footer?5cm margin on the left side of every page?