Unit 4- Assessment And Care Planning Sample

Key nursing care plan models, assessment tools & policies for effective healthcare delivery.

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Unit 4- Assessment And Care Planning

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The informational report is based on an assessment of some tools which are related to the study of the care plan model and the tools needed in a healthcare system. In Task 1 it has been discussed a Care plan which refers to a process by which a patient and healthcare professional discuss, review and agree on a plan of action to achieve several goals and behaviour change which is relevant for the patient. A care plan in a Healthcare organization is defined as a written document which recorded the outcome of the "Care planning process". Also in this report in Task 2, "Care plan policies which are related to delivery and implementation have been discussed to explain defined outcomes as well as the wellbeing of the patient (Doenges et al. 2019). In Task 3 of this report, there have been discussed and reviewed so many processes related to providing care and planning, also to support the discussion few examples are provided too. Also at the end of this report all the nursing care plans, assessment tools, and “Care planning policy” have been discussed thoroughly and reviewed the work accordingly. The aim of the informational report is to gain knowledge about these care plans, and care planning policies and also evaluated their role in the healthcare system.

Task 1: Describing a range of care planning assessment models and tools

“Care planning assessment models” and “Care planning process” has four main phases, which are summarized shortly. The phase of work can be done in a sequential process and also help to create a nursing care plan for all the patients. However, the care plan process also can be developed through the patient's encounter. This nursing care phase has four main phases. These are “Phase 1- Identify”, “Phase 2- Prepare”, “Phase 3- Plan with Patients”, “Phase 4, Manage”.

Phase 1: Identification: Assessment of Patients

The phase of Identify includes some activities which define the patients with whom the care planning has focused and also clarify the goals and care planning to improve the “Coordination of care”, thus also helping to improve patient self-management and improve the identification process. As stated by Nolin et al. (2022), it also helps to determine the specific groups of people where the effort of care planning will be utilised. After selecting the prioritised patients each of the processes of selecting patients will be described, Most of these practices have been developed by their methods which are Opportunistic and Proactive. After all this process a plan of arranging an appointment process has been developed.

Phase 2: Preparation: Preparation of Plans

It is important to plan priorly with the patient about their achieved goals. This plan with the patient can help a nurse or healthcare member to discuss with other team members and also helps to organize their aspects of the patient care planning related to the team, which helps them to think critically and consider all the spiritual, psychological, physical and social aspects of patients (Sobanski et al. 2020). There are a few steps involved in patient care which are assessment, planning, diagnosis, evaluation and implementation.

Phase 3: Planning with Patients

To execute the planning which was discussed with the patient it is needed to maintain a process of gathering patients, and take confirmation from the patient for the upcoming plan. However, some more activities needed to be done to develop and understand the goals and also to prepare for an action plan in a healthcare team. As proposed by Blackwood et al. (2019), developing and understanding a plan for the patient is important in this phase. Creating a plan for suffering patients and also updating the plan is one of the major topics in this phase.

Phase 4: Management of the plans

Taking an action plan for all the above phases and managing everything is important in this phase. Activities in healthcare management depend on the phase where a follow-up plan and medical plan are needed. To manage this phase it needed to follow up with the patient to better management of this situation and some of the activities will help in the process of referrals and to get results (Lin et al. 2020). Also, a follow-up plan with other healthcare members and a revised plan are been done in this phase.

Model of nursing care planning process

Figure 1: Model of nursing care planning process

(Source: Nolin et al., 2022)

Assessment tools in care are used to evaluate and measure some specific aspects of the need for a person’s experiences. As stated by Olaison and Donnelly (2022), assessment tools are a specific technique by which a method of evaluation is done from the information which needs to determine how a person is able to know about the aligned knowledge. Three assessment tools are “diagnostic”, “formative”, and “summative” (Wang et al. 2019). Diagnosis assessment helps to assess the current condition of patients and also utilizes their skills and helps to clear misconceptions about the practice. “Formative assessment” helps to provide information and feedback related to patients' conditions. Summative assessment helps to make progress after all the intervention has been done.

Care planning assessment tools

Figure 2: Care planning assessment tools

(Source: Olaison and Donnelly, 2022)

Task 2: Evaluation of care planning policy related to practice implementation and delivery

The nursing care plan is a process to identify the existing needs correctly and also recognise the client's potential or risks. Care plans help to provide one type of communication with the nurses, patients and all the healthcare providers. Evaluating a "Care planning policy" needs to require collecting of data and analyzing the information obtained from various sources and also including the patient's feedback in this process. As proposed by Nekhlyudov et al. (2019), the nursing care plan can be both formal and informal. “Informal nursing care plan” is generated in the nurse’s mind and “Formal nursing care plan” is a written document on the computer. These are policies and again divided into “standardised care plans” and “Individualize care plans”. “Standardized care plans” help to develop guides by the nursing staff in a healthcare organization to ensure the well-being of the patients (Chan et al. 2019). These plans also ensure the criteria and promote the efficiency of a nurse and develop basic activities between nursing units.

An "individualized plan" helps to involve in the "standardized care plan" to meet some goals and needs approached by the client and this also helps to be more holistic and personalized in a better needs. "Individual care plan" also needs to develop and improve patient's care satisfaction and it is more likely to be evaluated and valid, this increases the nursing care. This is also very important in the current healthcare environment because patient satisfaction and well-being are necessary and specific quality helps to measure their needs in a healthcare organization. Through this care treatment patient outcomes can measure relating these to empowerment and well-being.

The objective and goal of these nursing care policies are to promote more “Evidence-based nursing care” and also help in familiar and pleasant conditions in the healthcare sector and hospital centre (Kokorelias et al. 2019). Also, these policies help in the holistic care of suffering patients and this involves a process including physical, social, spiritual and psychological care of the patients to prevent disease. These policies also help to develop such programmes which lead to the care bundles and care pathway. This care pathway involves the effort of the team and this is related to the well-being of the patients which is related to the standard care of the patient and also it helps to provide outcomes for the patients, these policies help in the concerning care of the specific disease. As stated by Muth et al. (2019), it also helps to distinguish and identify the expected outcomes and also helps to provide expected outcomes from healthcare organizations. This also helps in reviewing communication as well as documentation of the nursing care plan. This policy also helps to measure nursing care which further needs to measure to verify specific outcomes (Kroenke et al. 2019). This policy also helps to provide individual care to the patient and allows the nurse to think critically as it directly develops the condition between the interventions which is related to every individual patient.

Care plan and evaluation process of nursing

Figure 3: Care plan and evaluation process of nursing

(Source: Kokorelias et al. 2019)

Task 3: Monitoring and Review processes related to Care Planning

The nursing care plan needed an approach of step-by-step order which helps to complete the nursing care plan correctly. A nursing care plan refers to a process which helps to identify the previous needs of the risk related to the client. To keep track of the progress of patient care it is necessary to make a care plan related to patients with the health status of the change. This process is also beneficial to the nurse and the clients who needed the care and treatment.

Monitoring, Reassessment, evaluation and progressive review are very important in the process of clinical care which further performs with the beginning of the care and further continues to provide some means which further lead to determining the “Progress of the disease” as well as it determines the effects of different types to interventions which included treatment and invasive investigations. As stated by Fan et al. (2019), monitoring the process of treatment plays an important role in documentation and performing chances to plan for serial management which helps in regular intervals. “Monitoring” also helps to play a better role in the Monitoring process to get better observation. However, it is important for a process to measure and record data.

Similarly, it is also stated by McMahan et al. (2019), Progressive review is a role to play in intervals by the team of care providers which is to provide certain aspects of nursing. This process correlated with the available information. Progressive review also included the "monitoring parameters" and also helps to take information related to these events. This also helps to build a patient's experience in this period. Evaluation is a specific process of integrating information. As proposed by Doenges et al. (2019), by following up on this evaluation process it can be determined the entire conformance to provide a care plan for nursing. This nursing plan is also more effective in the treatment. There are some potential risks associated with this alternative treatment which is followed by the consideration of the alternatives. It also requires the healthcare providers to derive a conclusion from this evaluation plan and also make any change decision if it is necessary to change in the nursing care plan. The process of evaluation is important to set an evaluation process in the nursing care process.

Monitoring in care planning plays an important role to plan some of the serial measurement which needs certain parameters in the regulation of intervals. The values and results obtained from the documentation help to monitor the disease and which care is more considerably have discussed. The determinants of those parameters depend on the critical aspects of this method. As said by Nekhlyudov et al. (2019), reviews of care plans from given feedback from the patients as well as healthcare provider also provide some information which is functional and helps to review and clinical indicators which helps to guide and that has been made through the implementations that made on the next step.


From the above report, it can be concluded that there has been a clear assessment of the range of nursing care assessment models which helps to smooth out the process of nursing. Also, it's been critically analysed the evaluation process of the “Nursing care plan” which helps to determine the outcomes and the well-being of the process related to the patients. This report thoroughly helps to determine the value of nursing care plans and processes which is related to planning and all the provisions of a healthcare system and this also has been discussed by giving supporting decisions.


Blackwood, D.H., Walker, D., Mythen, M.G., Taylor, R.M. and Vindrola?Padros, C., 2019. Barriers to advance care planning with patients as perceived by nurses and other healthcare professionals: a systematic review. Journal of clinical nursing, 28(23-24), pp.4276-4297.

Chan, C.W.H., Ng, N.H.Y., Chan, H.Y., Wong, M.M. and Chow, K.M., 2019. A systematic review of the effects of advance care planning facilitators training programs. BMC health services research, 19(1), pp.1-14.

Doenges, M.E., Moorhouse, M.F. and Murr, A.C., 2019. Nursing care plans: Guidelines for individualizing client care across the life span. FA Davis.

Doenges, M.E., Moorhouse, M.F. and Murr, A.C., 2019. Nursing care plans: Guidelines for individualizing client care across the life span. FA Davis.

Fan, S.Y., Sung, H.C. and Wang, S.C., 2019. The experience of advance care planning discussion among older residents in a long?term care institution: A qualitative study. Journal of Clinical Nursing, 28(19-20), pp.3451-3458.

Kokorelias, K.M., Gignac, M.A., Naglie, G. and Cameron, J.I., 2019. Towards a universal model of family centered care: a scoping review. BMC health services research, 19, pp.1-11.

Kroenke, K., Alford, D.P., Argoff, C., Canlas, B., Covington, E., Frank, J.W., Haake, K.J., Hanling, S., Hooten, W.M., Kertesz, S.G. and Kravitz, R.L., 2019. Challenges with implementing the centers for disease control and prevention opioid guideline: a consensus panel report. Pain Medicine, 20(4), pp.724-735.

Lin, C.P., Evans, C.J., Koffman, J., Chen, P.J., Hou, M.F. and Harding, R., 2020. Feasibility and acceptability of a culturally adapted advance care planning intervention for people living with advanced cancer and their families: A mixed methods study. Palliative Medicine, 34(5), pp.651-666.

McMahan, R.D., Tellez, I. and Sudore, R.L., 2021. Deconstructing the complexities of advance care planning outcomes: what do we know and where do we go? A scoping review. Journal of the American Geriatrics Society, 69(1), pp.234-244.

Muth, C., Blom, J.W., Smith, S.M., Johnell, K., Gonzalez?Gonzalez, A.I., Nguyen, T.S., Brueckle, M.S., Cesari, M., Tinetti, M.E. and Valderas, J.M., 2019. Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus. Journal of internal medicine, 285(3), pp.272-288.

Nekhlyudov, L., Mollica, M.A., Jacobsen, P.B., Mayer, D.K., Shulman, L.N. and Geiger, A.M., 2019. Developing a quality of cancer survivorship care framework: implications for clinical care, research, and policy. JNCI: Journal of the National Cancer Institute, 111(11), pp.1120-1130.

Nekhlyudov, L., Mollica, M.A., Jacobsen, P.B., Mayer, D.K., Shulman, L.N. and Geiger, A.M., 2019. Developing a quality of cancer survivorship care framework: implications for clinical care, research, and policy. JNCI: Journal of the National Cancer Institute, 111(11), pp.1120-1130.

Nolin, A., Tian, C., Hamilton, C., Chan, J., Casablanca, Y., Powell, M., Shriver, C., Bateman, N., Conrads, T., Maxwell, G. and Darcy, K., 2022. Tools for survivorship care planning in uterine serous carcinoma (497). Gynecologic Oncology, 166, pp.S245-S246.

Olaison, A. and Donnelly, S., 2022. Assessment, care planning and decision making. In Critical Gerontology for Social Workers (pp. 115-129). Policy Press.

Sobanski, P.Z., Alt-Epping, B., Currow, D.C., Goodlin, S.J., Grodzicki, T., Hogg, K., Janssen, D.J., Johnson, M.J., Krajnik, M., Leget, C. and Martínez-Sellés, M., 2020. Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement. Cardiovascular research, 116(1), pp.12-27.

Wang, C., Zhu, X., Hong, J.C. and Zheng, D., 2019. Artificial intelligence in radiotherapy treatment planning: present and future. Technology in cancer research & treatment, 18, p.1533033819873922.

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