Guide for Writing Care Study PDF
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Bolgatanga Nursing Training College
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This document serves as a guide for writing care studies, focusing on the essential components of a care study. It includes sections on cover pages, prefaces, introductions, and various elements of the study, like family medical histories, developmental history, lifestyle, and past/present medical conditions. This guide also details the expected format and structure of the care study.
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GUIDE FOR WRITING CARE STUDY COVER PAGE: The component of this page should be: Title of the page – Patient/Family Care study on (Disease condition). Author Name of Training Institution/Hospital Date of carrying out the Patient/Care study Plain over no designs. ...
GUIDE FOR WRITING CARE STUDY COVER PAGE: The component of this page should be: Title of the page – Patient/Family Care study on (Disease condition). Author Name of Training Institution/Hospital Date of carrying out the Patient/Care study Plain over no designs. PREFACE The preface of a document on "Patient and Family-Centred Care" would typically highlight the principles and importance of this approach in healthcare. Generally, it might include the following key points: Introduction to Patient and Family-Centred Care (PFCC): The preface often begins by explaining what PFCC is—a healthcare approach that respects and integrates the needs, preferences, and values of patients and their families in all aspects of care delivery. It emphasizes collaboration among patients, families, and healthcare providers. Core Principles: PFCC is built on principles such as dignity and respect, information sharing, participation, and collaboration. These principles guide healthcare providers to recognize patients and families as partners in the care process. Importance of PFCC: The preface usually discusses why PFCC is essential, including improved patient outcomes, greater satisfaction with care, enhanced safety, and more personalized care. It emphasizes how PFCC helps patients feel empowered and involved in their care decisions. Commitment to Quality and Compassionate Care: Many prefaces emphasize that PFCC reflects a commitment to delivering high-quality, compassionate care. It underscores the value of understanding each patient's unique experience and creating an environment that fosters empathy, trust, and effective communication. Support for Healthcare Providers: The document may also address how PFCC benefits healthcare providers by fostering teamwork, reducing burnout, and enhancing professional fulfillment through stronger connections with patients and families. Purpose of the Document: Finally, the preface might outline the document's purpose, whether as a guide, framework, or toolkit for implementing PFCC practices within healthcare settings. It often encourages healthcare organizations to embrace PFCC to transform the patient experience and improve overall care delivery. Acknowledgement It should consider the following; God if student wish Patient and family Supervision Authors Significant others Introduction: Summary of admission process from day one to the last day and mention of the home visits. Organization of work mentioning of the major chapter headings mark. The table of content This should include be chapter number, headings and pages numbers, Chapter 1: Assessment Overview of the content of the chapter Particulars Do not define topics just write the particulars - The following should be contained here in this order; name Age/date of birth Sex Address Occupation Particulars cont. Marital status number in family(number of siblings/number of kids) Next of kin height Weight complexion Family Medical/Socioeconomic history Medical Hereditary/familial diseases Social Main source of income of breadwinners Their perception of adequate resource Family system, Number of family members Living conditions Family religion Social amenities e.g. Water sources, places of defecation and refuse disposals etc. Developmental History Depending on age physical growth milestones eg. crawling walking etc. if cannot remember leave out. but that of children must be written on Do not lie, be factual and use information given to you by the patient during assessment. ✓ Age onset of schooling - ✓ Puberty (onset of secondary sex characteristics) ✓ Time of marriage ✓ 1st employment ✓ onset of reproduction Life style and hobbies Social aspect of the client: jovial, quite type, friendly etc Sleep pattern Patterns and methods of maintaining personal hygiene Meal times, food preferences Special rituals performed if any Elimination pattern Recreational activities /entertainments Smoke/drink habits Past Medical History: Illnesses that are encountered in the past Past hospitalization when & why if any Major treatments , where and why Major accidents if any Present medical history Onset, Location /affected part Duration Intensity/severity Treatment before reporting to health facility e.g. Herbal/traditional, Over -the -counter drug, health facility etc. Reasons for reporting to hospital Admission Date, time and procedure For the procedure check the rating scale in addition to the following; Reception of patient (establishment of rapport, identification of patient and introduction of self) Putting client in bed Initial assessment which include findings on; Physical appearance, Vital signs and History taken Commencement of emergency treatments including stat doses of medications Note that emergency management is based on health problem identified from the assessment. Orientation of patient if possible or else relatives to ward; Introduction to available staff Units of the ward Communicating channels Funding system Routines of the ward Visiting times Preparation for discharge Recording or documentation is the last component in the admission process ✓ Admit into A and D books, daily ward stead, folder etc. ✓ The following should also be recorded; Lab request Prescribed medications Other treatments Patient concept of illness Perception and expectation of the outcome of illness, Knowledge of the course and management of diagnosed disease. Source of information about the disease. Literature review: As outlined in the NMC guide Literature Review of Hypertension Hypertension, commonly known as high blood pressure, is a prevalent chronic condition that significantly increases the risk of cardiovascular diseases, stroke, and renal failure. According to the World Health Organization (WHO), hypertension is one of the leading causes of premature death globally, affecting over 1.13 billion people worldwide (WHO, 2021). The rising incidence of hypertension is attributed to various factors, including lifestyle, dietary habits, and genetic predispositions. Risk Factors and Epidemiology Multiple risk factors contribute to the development of hypertension, including age, race, obesity, sedentary lifestyle, high salt intake, and excessive alcohol consumption. For instance, African Americans tend to have a higher prevalence of hypertension compared to other racial groups, with more severe complications (Ferdinand et al., 2017). Age-related changes, such as arterial stiffness and loss of vascular elasticity, also contribute to increased systolic blood pressure in older adults (Franklin et al., 2019). Furthermore, the global burden of hypertension is exacerbated by the widespread adoption of Western diets rich in sodium and fat, along with increasing rates of physical inactivity. Pathophysiology of Hypertension The pathophysiology of hypertension is multifactorial and involves complex interactions between genetic, environmental, and physiological factors. The renin-angiotensin-aldosterone system (RAAS) plays a crucial role in regulating blood pressure. An overactivation of this system leads to vasoconstriction and increased sodium retention, both of which contribute to elevated blood pressure (Guyton & Hall, 2015). In addition, endothelial dysfunction, characterized by reduced nitric oxide bioavailability and increased oxidative stress, has been identified as a key mechanism in the development of hypertension (Virdis et al., 2011). Management and Treatment The management of hypertension typically involves both pharmacological and non-pharmacological approaches. Lifestyle modifications, such as dietary changes (e.g., the DASH diet), increased physical activity, weight reduction, and limiting alcohol intake, have been shown to reduce blood pressure effectively (Appel et al., 1997). Pharmacologically, antihypertensive agents such as ACE inhibitors, calcium channel blockers, beta-blockers, and diuretics are commonly prescribed to control blood pressure (Whelton et al., 2018). The effectiveness of these treatments, however, is often dependent on patient adherence, which can be influenced by factors such as medication side effects and the complexity of treatment regimens. Validation ▪ Compare data collected from the various sources of information. Mention the consistency of the data from the various sources Indicate how useful the data is. Chapter 2: Analysis of Data Comparisons should either be tabulated or presented paragraphs and reference to the literature Review. Tables must however be introduced in text before being presented Diagnostic investigation of the patient should be listed before the details are presented on table Table title and Number should be presented as on the example of table one. In the comparison table, the 1st part of the table should contain the standard or the information from the literature and the 2nd from the patient Table 1: Comparison of clinical features Lit. Rev. Patient Patient/Family Strengths This considers the abilities and capabilities of the patient even in the state of illness The strengths must cover all aspect of the persons being. For instance; Physiologic and physical functioning. - Breathing - elimination - Circulation etc. Ability to perform activities of daily living. e. g: Walking, eating, talking, brushing and bathing Emotional Adjustment: -Ability to exhibit appropriate reaction or contain situations. -That is laugh, cry etc appropriately Cognitive: - Logical reasoning - Mental Orientation - Understanding of situations - Analyzing of issues Spiritual -Confidence in belief systems Presence of support persons - Friends - Family members Adequate finance e.g. NHIS Health Problem Problems should be written on daily bases The health problems are not clinical features of diseases but what problems the clinical features cause. However, some clinical features as they may occur can be health problems provided their cause can be explicitly observed in the patient. Prioritize the health problems of each day Consider the use of; - A B C of life - Maslow’s hierarchy of needs Problems should be consistent with the 1st part of the Nursing diagnosis Example of health problem; Patient can not eat well to meet his nutritional needs - Client has loss of appetite CHAPTER 3 Nursing Diagnosis This is a technical statement by the nurse of the patient problem that the nurse can solve. The nursing Diagnosis should be made of the health problem and the cause linked with the “related to” phrase. Note that for every problem mentioned, it should form the first part of the nursing diagnosis which is then joined to the cause by the related to ‘’phrase’’. Examples: ❑ 1. Deficient fluid volume related to abnormal fluid loss [urine or vomiting] evidenced by poor skin turgor, dry skin cracked lips, sunken eye. ❑ Excess fluid volume related to compromised regulatory mechanism evidenced by oedema of the feet, increase BP. ❑ Imbalance nutrition [less than body requirement] related to anorexia, nausea, restricted diet evidenced by weight loss. ❑ Activity intolerance related to muscle weakness evidence by patient inability to walk, maintain personal hygiene. ❑ Deficient knowledge on disease condition (causes, s/s, treatment and prevention) related to lack of exposure / lack of information evidenced by patient’s inability to respond correctly to simple questions. Objective/Out Criteria Specific-targeting a particular health issue - Measurable-It should be able to be assessed in quantity and quality. Students should describe the outcome criteria specifically and not with words like verbalization and observation. Should show a degree of or amount of something. Achievable—It should be within the means of solving. Realistic-----It should be something that is possible Time bound.---It must have a time frame within which it should be achieved - Must meet one Nursing diagnosis and target health problem instead of cause. - The time on the objective should be a fix time not a range - The objective is stated addressing 1st part of the diagnosis (problem) Orders Make the order with the rationale attached. - If a particular drug is to be administer, please state the name of drug and its dosage and time. - State exactly what was carried out Evaluation - State the state of the outcome criteria - State the time of evaluation and ensure that it is in congruence with the time stated in the objective. - Students should try to amend goals that were unmet CHAPTER 4 Narrative Summary of Day to Day activities or care – good Construction of sentences - Spelling - Weekly if it exceeds a week - The report should be in third person singular or plural (neutral) Daily Care - A summary of the care plan state an assessment & problem, interventions & evaluation - Drs Reviews - Maintenance of personal/environment hygiene Preparation for Discharge/Rehabilitate - Information on discharge - Education throughout admission on condition, done Care at home, Treatment Regimen and it effects, all relevant current health issues. - Home visit to assess home condition - Mention the possibility of care given - Teach clients on some procedures - Working with supporting groups Follow up/ Home issue 1st - Assess home environment - Housing - Environmental Refuse disposal source of H2O - Style of rooms - Community support systems - Readiness of Patient relatives to receive patient home. 2nd Evaluate - Patient state of condition eg drugs systems - The education on 1st resist - Review - Reinforce education - Introduce to community nurse for mention that she may come 3rd - Handover to community health nurse - Reinforce education and terminate care CHAPTER 5 Evaluation Statement of Evaluation - Pick each goal as a heading - State the outcome criteria - The intervention and state the of patient or a paragraph each disable each goal. Amendment - State the health problem, the diagnosis goal initially, unmet as in the care plan, then draw the amended care plan Termination: - Informed patient of the discharge - Home visits/Education of patient - The frequency of contact with patient be reduce - Handing over of patient to CHN for continuity of care Summaries the salient points for day of admission to discharge - Some particulars Name of health facility - Medical Diagnosis - Health problems - Some objectives - intervention and results - Preparation before and date of discharge - Duration of stay - When care ended Conclusion - Feeling about care study and nursing process, make recommendations Bibliography -Use the A P A system - Minimum of 10 authors WRITING STYLE Font size 12 Double spacing Centre chapter number and style Use only page numbers no other numbering Do not use titles that capture name of client No diagrams on cover page No comb binding Centre the main subheadings in each write up except sub-subheading THANK YOU