Develop a discharge care plan for the case scenario NUR341 Healthy Ageing 2015 Word Limit: 2000 words Assessment purpose Unit objective The assignment will help you to: ? Understand the rationale for use of the ACAT assessments for discharge planning ? Promote independence and quality end of life care through the engagement of community care supports ? Understand the rational for use of palliative care services and advanced care directives ? Prepare appropriate person centred care plan ? Inclusion of family in care plan development ? Develop and identify key factors for handover of care This assessment address unit learning objective 1- 6 Assessment 3 task: Using the case study scenario below, map a person centred care plan and handover summary for the elderly patient being discharged from acute care to home to promote independence and quality end stage life. Scenario Harold is a 68year old Indigenous man due for discharge at the end of the week from an acute medical ward following treatment for exacerbation of congestive heart failure (CHF) including oedema, shortness of breath, reduced appetite, increased pain and lethargy . Harold has a past and current medical history (Mhx) of RHD, CHF, and coronary artery disease with angioplasty, hypertension and type II diabetes. Medications on admission: Digoxin, Metoprolol, Perindopril, Frusemide, Metformin, Novomix 30 and Oxycontin. The medical team visit him on the morning ward rounds with you present. The team have identified the congestive heart failure has deteriorated to end stage and surgical intervention is not possible due to Harold’s medical history, comorbidities and continuous moderate use of tobacco and alcohol. NUR341 Healthy Ageing 2015 Harold, an Elder, lives in a large remote community in the Northern Territory with his wife, Trish, adult children, grandchildren and some nieces and nephews when needed. He has 3 adult children who all work fulltime to help provide food and necessities for the family. Harold and Trish care for the young children whilst the adults are at work all day, but with Harold’s ailing health his wife is caring for both him and the grandchildren. Harold is becoming increasingly frustrated with his hospital admissions and medication regime. He has stated to you he is sick and tired and just wants to die at home in community with his family. Task Now that Harold has been diagnosed with End Stage Congestive Heart Failure you need to prepare for this discharge back to community. To ensure Harold is provided with the best care for this stage in his life you need to map Harold’s care plan using the template attached. In your mapping you should consider Harold’s physical, mental, social and emotional wellbeing. For each problem or issue you identify on the map you need to include a goal, intervention, rationale and evaluation. You will need to develop a summary of care for handover to the community for discharge. This will provide key factors and priorities identified in the care plan to promote Harold’s independence and quality end stage life. You will need to provide justification for your priorities and key factors in your handover summary. Your handover and care plan mapping should include Harold’s cultural identity. NUR341 Healthy Ageing 2015 Preparation – timely completion of study materials – Module 7. Utilise your learning materials, set text and library resources to research the assessment task topics. Presentation – ? NO introduction of topic and statement of intent required ? Completed mapping of care plan on the template provided ? Handover summary (between 500 – 1000 words) priority care needs to ensure quality end stage of life and cultural safety ? NO conclusion necessary ? Font 12pt Arial preferred, 1.5 spacing ? Ensure you have footer with page number and your student name and number ? Please provide a title at the beginning of your essay (no title page required) ? Dot points may be used in the mapping template only Referencing ? References must be presented in CDU APA 6th Referencing Style ? Reference where appropriate in the template and summary ? No reference needed for own words or when referring to the case scenario. ? References should be less than 10 years old. NUR341 Healthy Ageing 2015 Unsatisfactory Limited Satisfactory Good Excellent Marks Mapping of Care Plan: Ability to interpret and address topic (10) Evidence of ability to map care plan for case scenario. Issues/problems identified are holistic and inclusive of cultural identify. Each issue/problem identified has an appropriate rationale, intervention and evaluation clearly mapped. (0-2) Mapping of care plan is poor. Inability to identify holistic care issues/problems. Inability to present clear rationale, intervention and evaluation to support quality end stage life. No inclusion of cultural identity. (3-4) Demonstrated limited ability to identify issues/problems and map a holistic care plan for the case scenario. Mostly descriptive with limited explanation, rationale, interventions or evaluations included. Cultural identity highlighted but not addressed. (5-6 Basic mapping of holistic care plan developed identifying primary issues/problems only. Basic interventions, rationales and evaluations mapped. Some cultural identity elements included. (7-8) Proficient and holistic mapping of care plan inclusive of most issues/problems. Demonstrates ability to critically analyse the case scenario and provide rationales, interventions and evaluations which are achievable. Cultural identity addressed. (9-10) Demonstrates excellence in ability to develop a holistic care plan relevant to case scenario. Plan is inclusive of independence and quality end stage life provisions. Cultural identity is included in all aspects of the plan. Summary for Handover: Ability to interpret and address topic (10) Evidence of ability to develop a summary of information for handover. Summary contains key aspects and priority of nursing care to ensure independence and quality end life care for the case scenario. (0-2) Poor or no summary of care plan for handover provided. (3-4) Summary of care plan is mostly descriptive or repetitive with no justification or priorities provided. (5-6) Basic summary of care plan provided for handover with minimal justification or priorities identified. (7-8) Summary for handover identifies key issues and priorities with a justification for elements in the plan. (9-10) Summary of handover information is clear and concise. Provides insight to case scenarios care pathway with key aspects and priorities clearly identified and justified. Structure, flow of information and written expression (5) Cohesive and logical presentation of information. Mapping presented on template. Ability to express ideas clearly. Quality of grammar, spelling, punctuation and syntax (sentence structure). (0-1) No template used. Poor attention to structure and logical sequencing and flow of information. Poor written expression that lacks clarity of ideas. Frequently incorrect spelling, grammar, punctuation and syntax. (2) Template provided with limited direction, structure or logical sequencing and flow of information. Awkward written expression with limited ability to express ideas clearly. Insufficient attention to correct spelling, grammar, punctuation and syntax. (3) Template provided with generally satisfactory direction, some attention to structure and logical sequencing and flow of information. Written expression and clarity of ideas is generally satisfactory. Spelling, grammar, punctuation and syntax need more consistency. (4) Template used to provide clear direction for the reader including clear structure with logical sequencing and flow of information. Written expression is clear, able to express ideas readily. Consistent attention to correct spelling, grammar, punctuation, and syntax. (5) Template used to provide excellent direction for the reader including excellent structure with logical sequencing and flow of information. Excellence demonstrated in expression of ideas. Excellent attention to correct spelling, grammar, punctuation and syntax. Researching and Referencing (5) Integrates ideas, information and supporting evidence from appropriate resources; makes connections across selected sources that address the assignment task. Use of CDU APA 6th Referencing Style (0-1) No attention to referencing & citation conventions. Sources not relevant or pertinent to the topic. Numerous quotations used rather than interpreting meaning through paraphrasing. (2) Limited attention paid to referencing & citation. Limited evidence of comprehension of resources. Limited connections across selected resources in relation to the assignment task. Reliance on quotations used rather than interpreting meaning through paraphrasing. (3) Generally referencing citation conventions are followed with formatting errors. Developing comprehension of resources. Some connections across selected resources in relation to the assignment task. Some evidence of paraphrasing. (4) Referencing conventions and citations usually correct and consistent with few formatting errors. Proficient comprehension of resources with well-chosen connections across selected resources and the listed assignment task. Demonstrated competence in paraphrasing. (5) Exemplary referencing and citations. All conventions followed with no formatting errors. Insightful, well considered comprehension of resources with insightful connections to address task. Demonstrated excellence in ability to paraphrase. Total out of 30 NUR341 Healthy Ageing 2015