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Chronic care plan sickle cell anaemia 

Joi has been hospitalised for 3 days and her condition has improved. The intravenous therapy has been removed and she is requiring less analgesia. As a result, she is scheduled for discharge tomorrow. As part of the discharge planning, you meet with Joi, Sharyn & Chloe to develop a family centred care plan for Joi when she goes home. Chloe has many questions regarding sickle cell disease. She is very concerned about her daughter and what will happen in the future, asking: • “Does Joi need to be taking any medications for her condition” • “What should we do if Joi gets this pain again?” • “Where can we get more information about sickle cell anaemia?” • “I wish I knew somebody else who was going through this. It would be good to talk to someone” • “What can we do to ease the pressure on mum?” • “Is there anything we can do to prevent this from happening again?” Joi asks: • “Can I still go to church and school?” • ” What can I do to have fun” Sharyn asks • “How will I know if Joi is unwell in the future?” • ” I am so worried about Joi, will she be able to live a normal life” • ” Will Joi require more care when she goes home?”

 

Assessment data – Firstly outline the assessment data (subjective and objective) obtained from the case study provided. Secondly, what other assessment data (subjective and objective) would you need to collect in order to conduct a holistic assessment? Please note how this data would be collected. Nursing diagnosis/Collaborative problems – Based upon this assessment, identify and list two nursing problems the patient is experiencing and two collaborative problems the patient is experiencing. Planning/Expected outcomes – This is where goals and outcomes are formulated that directly impact patient care. These expected outcomes/goals should be written as per the SMART system (S – specific; M – measurable; A – achievable; R – realistic; T – timely) and include both short-term and long-term outcomes/goals. b)  Nursing interventions – Expand upon all four of these problems and describe the nursing and interprofessional interventions that should be implemented to provide holistic patient-centred care. You are to provide rationales for each of these interventions supported by current relevant evidence. Evaluation – This evaluation is to occur to determine if the goals/expected outcomes have been achieved. Please evaluate the interventions, specifying patient data that would indicate patient improvement and deterioration. As you are not providing care to this person in the real world, you need to detail what you would expect to see if the patient was improving due to the implementation of these interventions. Additionally, you need to detail what you would expect to see if these interventions were not successful and the patient was deteriorating. e) Please remember that this unit is about caring for persons with a chronic condition. Therefore, the focus of your care plan should be on health promotion, education, disease prevention and self-care and should focus on the patient, her family and the community setting

 

Assessment data for nursing diagnosis

Include your answers from Question 1a here 

Subjective data 

 

This information should come primarily from ‘Appendix for Assessment 4’document as you are preparing a care plan for when Joi is discharged

 

Objective data

This information here could be gained from the whole case study however the focus is on Appendix Ic as you are preparing a care plan for when Joi is discharged

Further assessment data to collect (& how you would collect it):

What information might be useful to know as you prepare your care plan 

 

 

 

 

 

 

Nursing Problem 1

Nursing Diagnosis 1

 

Nursing Problem 1. 

Planning/Expected Outcomes 

Nursing Problem 1

Short Term goals( Using SMART goals)  – Nursing Problem 1

Provide 2 short term goals for Nursing Problem 1

1.

2. 

Long Term Goals (Using SMART goals) – Nursing problem 1

Provide 2 long term goals for Nursing problem 1

1. 

2. 

Nursing interventions

& specific rationales for these interventions

What are you going to do & why are you performing the above interventions?

Nursing problem 1

Provide as many nursing interventions as required for the problem. Provide a rationale as to why you will perform this intervention.

Realistic evaluation 

Improvement 

data

Nursing Problem 1 How would you know if the interventions were effective?  

You are required to state the types of data that would indicate this.

 

 

 

 

 

Deterioration data

Nursing Problem 

How would you know if the interventions were not effective?  

You are required to state the types of data that would indicate this.

 

 

 

 

 

 

Nursing Problem 2

Complete the table as above for your 2nd nursing problem 

Nursing diagnosis 2 

 

Nursing Problem 2 

 

 

Planning/Expected Outcomes 

Nursing Problem 2

Short Term goals( Using SMART goals)  – Nursing Problem 2

1.

2.

Long Term Goals (Using SMART goals) – Nursing problem 2

 

1. 

2.

Nursing interventions

& specific rationales for these interventions

 

Nursing problem 2

 

 

 

Realistic evaluation

Improvement data

Nursing Problem 2

 

 

Deterioration data

Nursing Problem 2

 

 

 

 

 

Collaborative Problem 1

Complete the table as above for your 1st collaborative problem

Diagnosis

Collaborative problem 1

 

Planning / Expected outcomes

 

Short term goal (using SMART goals) – Collaborative problem 1

1.

2.

 

 

Long term goal (using SMART goals)Collaborative problem 1

1.

2.

 

Nursing interventions & specific rationales for interventions

 

Collaborative problem 1  

 

 

 

Realistic evaluation

 

Improvement data

 

Collaborative Problem 1

 

 

Deterioration data

 

Collaborative Problem 1

 

 

 

Collaborative Problem 2

Complete the table as above for your 2nd collaborative problem

Diagnosis

Collaborative problem 2

 

Planning / Expected outcomes

 

Short term goal (using SMART goals) – Collaborative problem 2

1.

2.

 

 

Long term goal (using SMART goals)Collaborative problem 2

1.

2.

 

Nursing interventions & specific rationales for interventions

 

Collaborative problem 2.

 

 

Realistic evaluation

 

Improvement data

 

Collaborative Problem 2

 

 

Deterioration data

 

Collaborative Problem 2

 

         

 

SCIENCE
HEALTH SCIENCE
NURSING

 

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