Select a case from your clinical practice, where you have been involved in the treatment and care of an individual. Drawing from this experience and reflection, develop an academic paper outlining the case and considerations care. Within this paper you will need to include the case formulation and a brief initial care plan that addresses the individuals needs, strengths and recovery goals (for both personal and clinical recovery).
You may wish to focus on a period (i.e. seclusion event) for the individual, or the entire pathway. The plan of care must detail the following:
- Mental State Examination and Risk Assessment
- A clear unambiguous nursing diagnosis
- Goals which are clear, specific, observable and measurable – based on a model/framework which you identify and rationalise;
- Interventions/strategies which are evidence-based (include rationales)
- Psychopharmacological aspects of care;
- Prioritised problems;
- Psychosocial aspects relating to the individual and the situation
- It is imperative that you always maintain confidentiality, of the individual, the family and supporters, as well as the healthcare service and clinicians involved in the care of the individual, and that you obtain consent from the individual and clinical facilitator prior to commencing the assessment task.
The paper must draw from academic literature to develop and critique the care plan and rationales behind to plan of care included
A formulation is a summary of the client’s presentation, gained from the thorough assessment, which draws together important features to facilitate the development of a treatment plan. Information gained from the initial assessment is utilised in the formulation. The main areas a formulation should cover areas such as :
Summary of the presenting problem/s (might include a problem list). As a complete case formulation includes all of the following elements and ties them together into a coherent whole: all of the patient’s symptoms, disorders, and problems; the mechanisms causing the symptoms, disorders, and problems; the precipitants of the symptoms, disorders, and problems; and the origins of the mechanisms.