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Chapter 17 Planning person-centred care
You should have then recorded the clustered assessment
data that led to the determination of each identified issue in
the assessment findings column. Recording these data helped
you to link specific defining characteristics with problem
statements.
Identifying health problems
You identified Mrs Jones’ health problems and recorded them
in the assessment findings column in a prioritised list beginning
with the top-priority problem for each identified health prob-
lem, a clear and concise problem statement that was followed
by a statement that identifies specific contributing factors.
Planning achievable health outcomes
The plan of care column contains the expected changes in
health status or in personal behaviours (i.e. goals for Mrs
Jones). If achieved, these resolve the problem statement in
the identified health problem.
Implementing care interventions
Specific care interventions are written for each rationale.
These specify what care interventions are to be performed,
how they are to be performed, when they are to be performed
and who is to perform them. In many nursing and midwifery
S T U D E N T P L A N O F C A R E 1 7 . 1
(continued)
for Mrs Jones
The more support people who have knowledge and are
committed to the plan of care, the greater the
probability the person will achieve their goals.
New self-care behaviours are dependent on knowledge.
New self-care behaviours are dependent on motivation.
Unless the person is committed to stroke prevention
and values this outcome, she will not follow the
treatment plan.
2. Plan teaching and learning sessions to involve
family members or significant others.
3. Include in the teaching plan a description of TIA and
stroke and the underlying disease process, causes,
symptoms and treatment plan.
4. After the treatment plan has been developed, make
sure the person and family can restate it (teaching)
and value the prescribed lifestyle modification
(counselling).
Evaluation of care
[This section requires a date for the evaluation to be
undertaken.]
•
9/10/20XX: Goal not met. Mrs Jones says her head is
‘too old to learn all this stuff’. Equates stroke with
death. Need to re-teach content in simpler terms.
Reassess learning readiness.
•
9/10/20XX: Goal partially met. Mrs Jones speaks freely
about how much she misses her husband and how
fearful this hospitalisation makes her. When asked
about living with her daughter, she becomes
uncharacteristically quiet.
•
9/10/20XX: Goal met. Mrs Jones talks about how
everything seemed better in the past after she talked it
over with her husband and God.
•
9/10/20XX: Goal not met. Mrs Jones couldn’t think of
anything about herself that is healthy or strong. She
says that her family ‘maybe’ can help her now.
•
9/11/20XX: Seen by social worker.
Rationale
The nurse’s unhurried, attentive and caring presence
communicates to the person that she is important to the
nurse and that they value her well-being. It is an
invitation to the person to become actively involved in
their recovery. Also, it is logical to explore the adequacy
of past and current coping mechanisms before
suggesting new approaches.
Adult children of ageing parents frequently experience
overwhelming stress as they try to deal with their own
and their parents’ problems. Supporting this family is
supporting the person indirectly.
Engaging other appropriate members of the healthcare
team will enhance the planning and delivery of
ongoing care.
Problem 2 care interventions
1. Each shift the assigned nurse should sit with
Mrs Jones for several minutes to communicate
caring and to explore with her the current stressors
and the adequacy of her coping response.
•
Assess factors compounding her losses.
•
Reinforce her personal strengths and support
systems; counsel her to tap into these now.
•
Suggest local support groups if indicated.
2. Explore with her daughter, Lisa, how her mother’s
moving in with her has affected the family.
Recommend support systems.
3. Refer to social worker for consultation.
Problem 1 care interventions
(continued)
Rationale
