Reference no: EM133117971

CIC109 Care for individuals in the community - Assessment Writing Service

Implement and monitor care for a person in the primary health care setting

Assessment: Client Consultation and Care Plan

Introduction

Health assessment is an essential nursing function that provides foundation for quality nursing care and intervention. Health assessment is a systematic, deliberative and interactive process by which nurses use critical thinking to collect, validate, analyse and synthesize the collected information, in order to make judgements about the health status and life processes of individuals, families and communities.

Health assessments help to identify the strengths of clients in promoting health. They also help to identify client needs, clinical problems or nursing diagnoses and to evaluate responses of the person to health problems and intervention. An accurate and thorough health assessment reflects the knowledge and skills of a professional nurse.

This assessment provides an opportunity for you to conduct a health assessment on a client, demonstrating your understanding of the activity and how it can be applied in Primary Health Care.

Summary

This assessment has three parts.

1. Part One: Choose ONE of the two health assessment templates provided below and conduct the health assessment on someone you know. You will submit a copy of the completed health assessment.
2. Part Two: Respond to a number of questions as they apply to the health assessment you conducted in Part One. You will submit the answers to these questions in the format of a written report.
3. Part Three: Review your plan of care for the client chosen in Part One to suggest any updated needs after a period of time.

Task Instructions

Two items must be submitted for this assessment.
1. Part One is to be submitted in the form of a PDF or Word document based on the PDF health assessment template below.
2. Parts Two and Three are to be submitted on the Primary Healthcare Report Template provided.

Part One:
Choose ONE of the following health assessments below and undertake it with someone that you know in the relevant age group. This requires you to download the chosen document from the link below, conduct the assessment and upload the completed form as your response. Alternatively, you may create a Word document based on your chosen assessment and upload it.

You will not be able to complete all tests and provide all results. However, any results that the individuals have recently had, and are aware of, can be included. Please ensure that you do not identify the person, their carer or doctor as follows:
• Only provide a first name or a pseudonym
• Leave the address fields blank aside from a suburb/town
• Leave the phone contact field blank
• Leave the Carers details blank (in the case of the 75 years and older assessment)
• Leave all details regarding the Doctor and appointments with the Doctor blank.

You will not be able to complete all tests and provide all results. However, any results that the individuals have recently had, and are aware of, can be included.
The Health assessment documents are in PDF file when you locate them. To save as Word, do the following: Save as PDF on your PC
Close it.

Go to where you have saved it. Right click.
Open as ‘Word' document and now you can type in it.

Option 1: Health assessment for people aged 75 years and older
This is an in-depth assessment of a patient aged 75 years and over. It provides a structured way of identifying health issues and conditions that are potentially preventable or amenable to interventions in order to improve health and/or quality of life.

The purpose of this health assessment is to help identify any risk factors exhibited by an elderly patient that may require further health management. In addition to assessing a person's health status, a health assessment is used to identify a broad range of factors that influence a person's physical, psychological and social functioning.

Option 2: Health assessment for people aged 45 to 49 years who are at risk of developing chronic disease Assessment for a person who is aged 45 to 49 years (inclusive) with a chronic disease risk factor, and based on the identification of this specific risk factor, is at risk of developing a chronic disease. A health assessment at this stage of life can assist patients to make the necessary lifestyle changes to prevent or delay the onset of chronic disease.

Part Two:

Once you have completed the health assessment, you need to report on the support you can provide this client in relation to their primary healthcare needs. This requires you to download the Primary Healthcare Report Template, and complete the sections on it.

You do not need to provide an introduction, body or conclusion. Instead respond to each section heading, providing the information required. A suggested word count is provided for each question.

Part Three:

For Part Three, you need to assume that it is 12 months after your initial assessment. Now, the client has attended the preventative, curative and rehabilitative services that you referred them to in Item 5 Part Two. Their health condition/s have improved significantly.

After conducting an assessment and completing your report, you must review the client's situation and update their plan of care by providing follow-up advice and recommendations for future health management.

Specify how you would:
• Follow up on the advice you provided
• Update the information on their health plan, in consultation with the client
• Ensure they remain connected with the community support services relevant to their situation
• Make recommendations for continued monitoring of their health.

Note: Need Only Assessment 2: Client Consultation and Care Plan

Attachment:- Care for individuals in the community.rar