Develop a Care Plan

Assessment Task 2:
Simulated Clinical Activity: Self Evaluation

The learning in this assessment has three parts.
This assessment task requires you to record and critically analyse a clinical
reasoned approach that you used to understand the significance of patient
data, identify actual or potential patient problems, and make clinical decisions
to assist in holistic care delivery.
Part 1. Develop a Care Plan (equivalent to 500 words)
Download the Care Plan template.
Select ONE patient scenario from the Case Scenarios and Group Sign Up at the
bottom of this page.
Consider the patient scenario and identify the cues to assess the situation.
Process information and identify the problem that you would like to address as
the Registered Nurse caring for the patient.
Identify the goal that is to be achieved.
Identify the expected outcomes to inform your actions or interventions.
Outline the interventions required and provide a rationale for each action.
Identify an evaluation strategy for each expected outcome that was identified.
Identify the probable pathophysiology that is contributing to the patient’s
health condition and how this related to the goal of care you identified.
The care plan should be informed by evidence based guidelines and/or
protocols.

Case scenario 4
Reginald Simons a 75 year old and has regular visits from the community nurse. Reginald has
COPD and has been on home oxygen for several years. The extent of his disease means that he
is unable to walk short distances without the aid of oxygen. Despite his disease progression,
Reginald wishes to stay in his own home and maintain his independence with the aid of
community nurses. Reginald’ s target 02 of > 89% using the home oxygen concentrator.
However, his usual machine required servicing and a replacement medical oxygen cylinder was
supplied. Reginald was educated on the appropriate use of medical oxygen.
When you attend his residence, Reginald is propped up in his recliner with his nasal prongs in
place and the oxygen on. You notice a packet of cigarettes and lighter on the table beside him.
He is observed to be distressed and has difficulty breathing (not unusual for him though).

History
Reginald Simons a 75 year old gentleman who is in considerable poor health. He has an
extensive medical history including diabetes, peripheral vascular disease and COPD. Despite his
ill health, Reginald continues to smoke a packet of cigarettes a day for which he has a 60 year
history when he commenced smoking at the age of 15. He has a poor diet, limited social
network and relies on community services such as Meal on Wheels. Due to his poor health,
Reginald rarely leaves his apartment.

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