Care planning Resources

The purpose of this article is to present a scenario of a typical patient at risk of developing pressure damage and demonstrate how to complete the assessment and implement a prevention plan using the aSSKINg framework (Healthcare Improvement Scotland, 2020).  By following these recommendations, healthcare professionals can demonstrate good preventative care, reduce the risk of patients developing pressure damage, and protect their organisation against any future litigation claims (Downie, 2014).

Palliative care of the elderly patient who wishes to die at home is an integral part of the role of community nurses. Historically, it has been found that this area is at risk of mismanagement, with poor symptom control, a breakdown in home care services and
lack of support for carers; aspects which can lead to admission to hospice or hospital. As such, this article examines the essential role of the community nurse in both practical  ways of assessment, planning and reviewing care of the patient and the family; as well
as psychological ways of supporting, guiding and listening. The article uses a case study to illustrate an example of the process of planning palliative care in the community, while acknowledging that each situation is individual to each patient, resulting in a variety of challenges. It can be seen that the community nurse is the mainstay in the whole process of palliative care of the elderly patient; providing a bespoke package of care in collaboration with the wider multidisciplinary team and thus enabling the patient to
remain at home in their final days.

Several crucial documents have identified the need for integrated care to meet patient requirements in the current financial climate, developed from the concepts of self-care and joining up care to improve health outcomes. These include the Five Year Forward View (2014), Next Steps on the Five Year Forward View (2017), NHS Long Term Plan (2019) and now the introduction of the Health and Care Act (2022) — all of which provide a contextualised approach to care. Integrated care is aimed at the way that organisations work together to support self-care (which incorporates the principles of holistic care considering physical, emotional, social, spirtual and ecomonc health [Mills, 2017]), with a commitment to improve patient outcomes by avoiding confusion and repetition. It  enhances comprehensive care planning by listening to patients — perhaps best summed up by the phrase, ‘No decision about me, without me’ (Department of Health [DH], 2012).