Start by introducing your patient/service user (age/diagnosis/ presenting problem/past medical history and the context of care i.e. outpatient’s appointment/home visit/endoscopic procedure)
Provide details of the holistic nursing assessment carried out i.e. note aspects of physical / social / psychological wellbeing
You will then need to focus on one or two specific aspects of your assessment and explore these in more detail e.g. pain assessment /diabetes management/pre-op anxiety etc. You can then critique the assessment process, for example, the time/context in which it took place; assessment tools used i.e. reliability / validity; skills of the nurse in assessing the patient e.g. communication skills (verbal / nonverbal) etc.
Summarise any actual or potential nursing problems identified as a result of this assessment e.g. patient is immobile due to fractured neck of femur (actual problem), as a result the patient is at risk of developing a pressure ulcer and deep vein thrombosis etc. (potential problems)
PLANNING
(900 words approx.)
Outline the pathophysiology of the medical condition you have selected. Identify any nursing considerations in planning their care as a result of this condition i.e. noting for any particular signs/symptoms to indicate an exacerbation/deterioration or improvement in this condition etc.
Outline the pharmacology of the specific medication you have selected for your care study, and any key nursing considerations in planning their care e.g. therapeutic doses, noting for side effects/contraindications/drug interactions or any specific instructions for administration etc.
Briefly summarise the priorities of nursing care for your patient/ service user and how these decisions were made.
IMPLEMENTATION
(900 words approx.) Now critically discuss the care that was carried out for your patient/service user in relation to a specific problem(s) identified from the assessment. You will need to discuss this care in relation to the evidence base i.e. research evidence / policy / guidelines etc. For example, consider why you did x instead of y? Was the plan of care amended or adapted as time progressed, and if so, why?
Also consider the input of the interprofessional team i.e. what contribution did they make / or could they have made? Were there any particular benefits / challenges in working as part of an interprofessional team? Was there anyone else that could / should have be involved?
EVALUATION
(900 words approx.) Consider the evidence the health care professionals used to inform their decision making? Was it appropriate/relevant/ applicable to your patient or service user?
How was the patient’s/service user’s preferences including in their overall plan of care? Could this have been improved?
Could the quality pf care have been enhanced or improved in any way and, if so, how?
What findings/recommendations would you make as a result of reflecting on this care study?
CONCLUSIONS
(200 words approx.) Conclude by summarising what you did, what you found, what recommendations you have made as a result of undertaking this care study. You could also say how these findings will inform your future nursing practice.
