Hello, please are two tasks.
Task # 1
is a Care Plan, below I attach two forms in words that must be completed.
Task # 2
is a Case Study that has three items a, b, and c, which must be answered independently.
Required Textbooks and Reading Material:
Touhy, Theris DNP and Jett, Kathleen, (2018). Ebersole and Hess’ Gerontological Nursing & Healthy Aging, 5th Edition. Elsevier. ISBN: 9780323401678
Task # 1
1. Care Plan
What is a nursing care plan?
A nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. Care plans also provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, quality and consistency in patient care would be lost.
Medical Diagnosis: Alzheimer’s disease
Alzheimer’s disease is a progressive disease that destroys memory and other important mental functions. It’s the most common cause of dementia – a group of brain disorders that results in the loss of intellectual and social skills. These changes are severe enough to interfere with day-to-day life. In Alzheimer’s disease, the connections between brain cells and the brain cells themselves degenerate and die, causing a steady decline in memory and mental function.
Task # 2
2. Case Study
What is a nursing case study?
A nursing case study is an in-depth study of a patient that is encountered during the student’s daily practice in a practicum. They are important learning experiences because the student can apply classroom/theoretical learning to an actual situation and perhaps make some conclusions and recommendations.
Case Study, Critical Thinking, Ethical Decision Making, and the Nursing Process
1. Mrs. Elle, 80 years of age, is a female patient who is diagnosed with end-stage cancer of the small intestine. She is currently receiving comfort measures only in hospice. She has gangrene of her right foot and has a history of diabetes controlled with oral agents. She is confused and the physician has determined that she is unable to make her own informed decisions. The hospice nurse, not realizing that the weekly order for CBC and renal profile had been discontinued, obtained the labs and sent them to the nearby laboratory for processing. The abnormal lab results obtained later that day revealed that the patient needed a blood transfusion. The hospice nurse updated the patient’s medical power of attorney who was distressed at the report. The patient’s wishes were to die peacefully and to not have to undergo an amputation of her right foot. But if the patient receives the blood transfusion, she may live long enough to need the amputation. The patient’s physician had previously informed the medical power of attorney that the patient would most likely not be able to survive the amputation. The patient’s medical power of attorney had made the request to cease all labs so that the patient would receive comfort measures until she died. The patient has no complaint of shortness of breath or discomfort. (Learning Objective 4)
a. What ethical dilemma exists?
b. Who are the stakeholders and what gains or losses do each have?
c. What strategies should the hospice nurse take to resolve the ethical dilemma?
Medication Preparation Log (MPL)
Student Name_________________________________________________
Clinical Rotation Date__________________________________________
|
Patient Initials Room # Code Status Allergies |
Diagnosis Relevant Medical/Surgical History |
||||
|
Drug |
Dose/Range |
Route |
Time |
Reason for RX |
Top 4 Side Effects |
NursingCare Plan Form
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Student Name |
Date |
|
Patient (initials only) |
Patient Medical Diagnosis |
|
Nursing Diagnosis (use PES/PE format) |
|
Assessment Data
(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis) |
Goals & Outcome
(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.) |
Nursing Interventions
(List at least three nursing or collaborative interventions with rationale for each goal & outcome.) |
Rationale
(Provide reason why intervention is indicated / therapeutic; provide references.) |
Outcome Evaluation & Re-planning (Was goal met? How would you revise the plan of care according the patient’s response to current plan?) |
|
1. 2. 3. |
Statement #1 Statement #2 |
1.
2. 3. 1. 2. 3. |
Outcome #1 Outcome #2 |
EVALUATION CRITERIA FOR NURSING CARE PLANS (NCP)
At least one nursing care plan (or update of care plan) will be evaluated per week on a pass-fail basis –
fails will be required to revise until final care plan is adequate
DAY 1 CARE PLAN IS A DRAFT – FACULTY TO REVIEW FOR SUGGESTIONS TOWARD FINAL PRODUCT – PASS-FAIL EVALUATION WILL BE ON DAY 2 CARE PLAN
Patient Profile Database Form (30%)
______Assessment: All subjective and objective data are documented on form (10%)
______Pathophysiology: Should be based on the medical diagnosis (10%)
______Laboratory Data: Noted as normal or abnormal and reason abnormal (10%)
Medication Preparation Log (10%)
______ Medications:
Nursing Care Plan Forms (60%)
______Nursing Diagnosis Statements: (15% points possible-see breakdown below)
_____Three statements are written
(1 %/statement for a total of 3 possible points)
_____Only NANDA-approved nursing diagnoses are used (1 %/statement for
a total of 3 % possible)
_____ Statements are written in PES (for actual diagnoses) or PE (for potential or “at risk”
diagnoses) format (1%/statement for a total of 3% possible)
_____Diagnosis is supported by assessment data (1%/statement for a total of 3% possible)
_____ Nursing diagnoses are listed from highest to lowest priority. Life threatening
diagnoses (e.g. ABCs, infection, etc.) come first, then safety, then all others.
Usually existing problems come before “risk for” problems (1%/ statement for a
total of 3% possible)
______Plan: Goals and Outcomes Statements: (12 % possible-see breakdown below)
_____Two statements are required for each nursing diagnosis statement
(2 %/ statement for a total of 6% possible)
_____Statements are prioritized (1%/set of goals for a total of 3% possible)
_____Statements are written in SMART format (1 %/ statement for a total of 3% possible)
______ Nursing Interventions with Rationale: (24 % possible-see breakdown below)
_____ Each goal has two interventions (1%/goal for a total of 8% possible)
_____ Each intervention has a rationale with a reference (1%/goal for a total of 8% possible)
_____ Statements are specific (what, when, how much, how often) (1% per goal for total of 8% possible)
______Evaluation:
(9 %)
State if goal has been met; if not met or partially met, discuss whether will continue or modify plan
(9%)
Final Grade: ___________ Date:____________ Instructor signature: __________________________
Evaluation minimum 85% required for a rating of ‘pass’, if not, student must rewrite care plan by end of clinical rotation. After that, it may consider as “fail”.
SampleNursing Care Plan
Student Name: Sally Jones Date: 1/17/12
Patient (initials only): R. N. Patient Medical Diagnosis: Stroke
Nursing Diagnosis (use PES format): Impaired physical immobility related to motor track dysfunction as evidenced by weakness and lack of coordination
|
Assessment Data (Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis) |
Goals & Outcome (Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.) |
Nursing Interventions (List at least two nursing or collaborative interventions with rationale for each goal & outcome.) |
Rationale (Provide reason why intervention is indicated/therapeutic; provide references.) |
Outcome Evaluation & Replanning (Was goal(s) met? How would you revise the plan of care according the patient’s response to current plan of care?) |
|
1. +2 weakness on left upper and lower extremity 2. Inability to walk without assistance (patient shuffles when walks and gets confused as to which leg needs to move to propel forward) |
Statement #1: Patient will perform ROM exercises each hour during the shift. Statement #2: Patient will ambulate from bed to door twice by the end of shift. |
1. Educate pt about importance of ROM exercises. Rationale: If pt understands the importance of ROM exercises (to maintain and hopefully increase strength), the pt is more likely to participate in exercises (Potter & Perry, p. 4). 2. Assist pt w/ ROM exercises while teaching him how to perform ROM exercises. 3. Consult with physical therapist for strength training and development of a mobility plan 1. Determine amount of assistance needed to get patient out of bed and ambulate. 2. Clear walkway of hazards. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3). |
1. If patient understands the important of ROM exercises (to maintain and hopefully increase strength), the patient is more likely to participate in exercises (Potter & Perry, p. 4). 2. Pt needs to be instructed on how to perform ROM exercises, and performing the exercises while instructing the patient will solidify his understanding so he can perform exercises on his own (Potter & Perry, p. 5). 3. Techniques such as gait training, strength training, and exercise to improve balance and coordination can be very helpful for rehabilitation patients (Tempin, Tempkin, & Goodman, 1997) 1. Weakness and lack of coordination can cause the pt to be off balance which would put him at risk for a fall. Determining level if assistance needed before trying to assist out of bed and ambulate will prevent a fall for the patient (Potter & Perry, p. 2). 2. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3). |
Outcome #1: Pt partially met goals. He was open to and understanding of the need to perform ROM exercises, but he still needs guidance in how to perform. Will continue to with current plan. Outcome #2: Patient exceeded goal: he walked 4 times. Wil modify plan to increase distance (to nurses’ station). |
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