Brooker D. Person-centred dementia care.London: Jessica Kingsley; 2007
Centre for Policy on Ageing. The effectiveness of care pathways in health and social care. 2014. //tinyurl.com/3t835kfd (accessed 1 November 2021)
Department of Health. Refocusing the Care Programme Approach. Policy and positive practice guidance. 2008. //tinyurl.com/anyrzhy6 (accessed 3 November 2021)
Department of Health. Personalised care planning: improving care for people with Long term conditions. 2011. //tinyurl.com/uc3u3tkh (accessed 1 November 2021)
Department of Health. Care planning in the treatment of long term conditions: final report of the CAPITOL Project. 2013a. //tinyurl.com/7399vphc
Foundations of nursing practice: making the difference, 2nd edn. In: Hogston R, Simpson PM (eds). London: Palgrave Macmillan; 2002
Kozier B, Erb G, Berman A, Snyder S, Lake R, Harvey S. Fundamentals of nursing: concepts, process and practice, 8th edn. Harlow: Pearson Education; 2008
Leach M. Clinical decision making in complementary & alternative medicine.Chatswood (NSW, Australia): Elsevier; 2010
Lloyd M. A practical guide to care planning in health and social care.Maidenhead: Open University Press; 2010
Matthews E. Nursing care planning made incredibly easy!.Philadelphia (PA): Lippincott Williams and Wilkins; 2010
Monitor. Delivering better integrated care: A summary of what delivering better integrated care means and how Monitor is supporting the sector. 2015. //tinyurl.com/825k8kd6 (accessed 1 November 2021)
NHS website. NHS launches accredited suppliers for electronic patient records. 2019. //tinyurl.com/4fzs4up5 (accessed 1 November 2021)
National Institute for Clinical Excellence. What to expect during assessment and care planning. 2021. //tinyurl.com/63hm5vvp (accessed 1 November 2021)
NHS England. Personalised care and support planning handbook: the journey to person-centred care: Core information. 2016a. //tinyurl.com/9fyrtw45 (accessed 1 November 2021)
Nursing and Midwifery Council. Future nurse: standards of proficiency for registered nurses. 2018a. //tinyurl.com/yddpadva (accessed 1 November 2021)
Nursing and Midwifery Council. The code: professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018b. //tinyurl.com/gozgmtm (accessed 1 November 2021)
Revello K, Fields W. An educational intervention to increase nurse adherence in eliciting patient daily goals. Rehabil Nurs. 2015; 40:(5)320-326 //doi.org/10.1002/rnj.201
The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care.
Assessment
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style
factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.
Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions
or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.
Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and
long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.
Implementation
Nursing care is
implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.
Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.