Assessment 1 Individual Community Assignment

TEMPLATE PART A: NURSING CASE STUDY (1500-2000 wds DO NOT include the scenario)

Please fill in the details as per the patients condition. Remember to always prioritise the patients safety and well-being. This template is a guide and may need to be adjusted based on the specifics of your case.

Introduction

Patient Information

Name:

Age:

Gender:

Social background:

Pathophysiology

Condition(s):

Nursing Process (ADPIE/SOAPIE/Clinical Reasoning Cycle)- Briefly outline the nursing process tool to demonstrate your understanding of the nursing process- including what the acronym stands for.

Assessment: (objective/subjective data; include any relevant laboratory results or clinical findings from your chosen scenario)

Patient/Whanau Assessment (Te Whare Tapa Wha/Fonofale/Te Wheke/Socio-ecological model)

Please select an appropriate holistic health model to inform your client assessment and your rationale for its use (appropriate to the scenario you have chosen).

Under the following headings, please indicate the questions that you would ask the client in your chosen scenario to demonstrate how you would collect the relevant subjective health information.

Physical Health:

Mental Health:

Family/Whanau:

Spiritual Health:

Psychosocial Assessment: (age and culture appropriate)

Nursing Diagnoses/Problems (NANDA framework)

Problem 1: ...related to secondary to as evidenced by

Problem 2: ...related to secondary to as evidenced by

Problem 3: ...related to secondary to as evidenced by

Problem 4: ...related to secondary to as evidenced by

Problem 5: ...related to secondary to as evidenced by

Plan: (what do you plan to address and why)

Nursing Interventions (including evidence-based rationale)

Intervention for Problem 1:

Intervention for Problem 2:

Intervention for Problem 3:

Intervention for Problem 4:

Intervention for Problem 5:

Evaluation of the Plan and Interventions

Evaluation Method:

Expected Outcomes:

Effectiveness of the Plan to be measured by:

Effectiveness of the Interventions to be measure by:

Conclusion

Reference List