Nurse Life Care Plan for (Client) - Table of Contents
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NURSE LIFE CARE PLAN for (Client) ©2011, Shelene Giles Methodology The American Nurses Association (ANA) defines nursing as the protection, promotion, and optimization of health and abilities; prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. The human response includes the response of the individual and family to actual or potential health problems. ANA notes “…Nurses are educated to be attuned to the whole person, not just the unique presenting health problem. While a medical diagnosis of an illness may be fairly circumscribed, the human response to a health problem may be much more fluid and variable and may have a great effect on the individual’s ability to overcome the initial medical problem. In what some describe as a blend of physiology and psychology, nurses build on their understanding of the disease and illness process to promote the restoration and maintenance of health in their clients…Nursing is a key element in patient survival as well as in the maintenance, rehabilitation, and preventive aspects of healthcare.." (ANA Nursing's Social Policy Statement, Second Edition, 2003). The American Association of Nurse Life Care Planners (AANLCP) defines nurse life care planning as utilizing the nursing process in the collection and analysis of comprehensive client specific data in the preparation of a dynamic document. This document provides an organized, concise plan of estimated reasonable and necessary, current and future healthcare needs with the associated costs and frequencies of goods and services. The Nurse Life Care Plan is developed for individuals who have experienced an injury or have chronic healthcare issues. Nurse life care planners function within their individual professional scope of practice and, when applicable, incorporate opinions arrived at collaboratively with various health care providers. The Nurse Life Care Plan is considered a flexible document and is evaluated and updated as needed. The Nurse Life Care Plan is based on the assessment of the health status, establishing goals, and planning care as defined in the Nurse Practice Act specific to the state of RN licensure. (AANLCP Membership Guide, 2008) The nursing process is the foundation of developing the nursing care plan. The nursing process includes an assessment, nursing diagnosis, plan of care, and implementation as well as evaluation of the plan of care. Nurse Life Care Planners also use the nursing process as the foundation to formulate a plan of care entitled a Nurse Life Care Plan. The Nurse Life Care Planner initiates the nursing process with reviewing medical records to understand the course of medical treatment/complications/outcomes, and conducts a nursing assessment using a holistic approach with the client/family/ caregiver to understand present symptoms/limitations/activities of daily living/psychosocial aspects/family dynamics. The Nurse Life Care Planner then identifies an appropriate nursing diagnosis to describe the client’s individual needs. When applicable, a collaborative approach is used with other health care providers when determining these needs. Research is also performed to determine long term outcomes/complications, costs, and maintenance/replacement frequency of recommended medical and non-medical needs. Nurse life care planning is an extension of case management where the nurse has learned to perform an assessment, formulate a plan of care in collaboration with the health care team members, facilitate medical needs, and negotiate costs related to care. A Nurse Case Manager can be introduced to implement the Nurse Life Care Plan recommendations and evaluate the response to complete the nursing process. The Nurse Life Care Plan is specific to the individual and is intended to follow the client throughout his/her lifetime to ensure funds will be available to properly care for the client. Costs for medical care are obtained through actual/potential healthcare providers and national databases with a geographical zip code modifier. Other costs are obtained through research with suppliers, facilities, pharmacies, and other resources. Where applicable, costs are obtained from various vendors and the median cost is listed in the Nurse Life Care Plan. The costs included in the Nurse Life Care Plan are based on today's dollars. No provision has been made for future inflation and an economist should be considered. Costs have been rounded to the nearest dollar. The Nurse Life Care Plan should be reviewed/updated when there are significant changes to the medical condition. ©2011, Shelene Giles Nurse Life Care Plan for (client) - Table of Contents Section One Introduction 1 Records Reviewed 2 Records Requested 2 Medical Timeline 3 Current Medical Providers & Treatment 16 Medications 18 Relevant Past Medical History 18 Symptoms/Limitations 18 Psychosocial Information 22 Educational/Vocational Information 22 Summary and Treatment Recommendations 22 Complications 22 Conclusion 23 Resources 24 Section Two – Nurse Life Care Plan Tables Medical Care 25 Surgeries/Procedures 26 Therapeutic Evaluations/Modalities 27 Diagnostics 28 Lab Work 29 Medications 30 Scar Management 31 Medical Supplies 32 Durable Medical Equipment/Aids for Independent Function 33 Orthosis/Prosthesis 34 Mobility 35 Home Care/Living Arrangements 36 Home Modifications 37 Transportation 38 Educational/Vocational 39 Other 40 Lifetime Cost Projection 41 Section Three – Enclosures Authorization to Release Medical Information Curriculum Vitae ©2011, Shelene Giles .