Unit 3.3: Care Planning and Evidence-Based Practice

• Topic 01

  Nursing Care Plan Structure — SMART Goals

  45 questions
• Topic 02

  Evidence-Based Practice and Clinical Guidelines

  48 questions
• Topic 03

  Discharge Planning and Continuity of Care

  45 questions
• Topic 04

  Patient and Carer Involvement in Care Planning

  42 questions

A few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.

1. A pre-operative assessment nurse identifies that a 76-year-old patient scheduled for elective bowel surgery has a carer who is themselves being treated for cancer. The patient lives in a one-storey house with a downstairs toilet. Which of the following actions BEST demonstrates comprehensive pre-operative discharge planning?

   • A
     Refer to the physiotherapy team pre-operatively to assess the patient's ability to manage stairs in a property that has no lift access
   • B
     Refer only to community nursing for post-operative wound care, as social care needs and home adaptations can be more accurately assessed following discharge
   • C
     Refer for occupational therapy (home assessment), social work (social care assessment as the usual carer has reduced capacity), and community nursing (post-operative wound care); document all referrals and expected community arrangements in the care plan before admission
     Correct answer
   • D
     Inform the patient that their usual carer will need to resume full caring responsibilities as soon as the patient is discharged from hospital after surgery
   Explanation

   A 76-year-old patient undergoing major bowel surgery faces:

   1. Reduced post-operative mobility requiring an occupational therapy home assessment
   2. A compromised carer situation requiring a formal social care assessment under the Care Act 2014, including a carer's assessment for the partner
   3. Post-operative wound care needs requiring community nursing referral

   All three referrals should be made pre-operatively and documented in the care plan. The one-storey home with a downstairs toilet is a positive factor. This reflects NHS England's expectation that discharge planning begins before admission for elective cases.

2. A colleague justifies a clinical practice by saying 'we've always done it this way on this ward.' Which of the following BEST identifies why this is an insufficient basis for clinical practice?

   • A
     The colleague is correct; accumulated ward experience is equivalent to a cohort study in the evidence hierarchy
   • B
     Tradition and custom are at the lowest level of the evidence hierarchy and are not a valid basis for clinical decision-making; nurses are professionally accountable for ensuring their practice is evidence-based under the NMC Code
     Correct answer
   • C
     Tradition is acceptable if the practice has not resulted in any documented patient complaints
   • D
     Tradition is only problematic if a NICE guideline exists that explicitly contradicts the practice
   Explanation

   Tradition, custom, and anecdote occupy the lowest position in the evidence hierarchy. The NMC Code (Section 6) explicitly requires nurses to always practise in line with the best available evidence. 'We've always done it this way' is not a defence under professional standards. The Francis Report (2013) identified entrenched culture and resistance to evidence-based change as contributors to patient harm at Mid Staffordshire NHS Trust.

3. A nurse is completing a care plan for a patient who is mobile but has been assessed as having a Waterlow score of 18, indicating a high risk of pressure ulcer development. Which type of problem should be documented, and what type of goal is required?

   • A
     A potential (at-risk) problem should be documented, and the goal should be preventative — such as 'Patient's skin will remain intact over all bony prominences throughout admission'
     Correct answer
   • B
     An actual problem should be documented because the patient's Waterlow score is already high
   • C
     An actual problem should be documented because high Waterlow scores indicate existing skin damage
   • D
     The nurse should document the Waterlow score but defer goal-setting to the tissue viability nurse
   Explanation

   A Waterlow score of 18 indicates high risk but does not mean a pressure ulcer is present. This is a potential (at-risk) problem. Potential problems require preventative goals — the aim is to prevent the problem occurring, not to treat it. An appropriate goal would focus on maintaining skin integrity. Failing to document and plan for at-risk problems is a professional standard failure under the NMC Code and is clinically unsafe.