Care+Plan+Example - herzing university PDF

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Herzing University Brookfield/ Kenosha Adult Health Care Plan Template Student Name: _Test Student_______________ Unit: __Med-Surg________________

Date: ___3/9/2018__________

Patient initials: __J.P._ List of three Nursing Diagnosis you identified for your patient: 1. Impaired physical mobility related to loss of integrity of bone structures, soft tissue injury and prescribed movement restrictions as evidenced by limited joint range of motion, inability to purposely move, and inability to bear weight 2. Risk for peripheral neurovascular dysfunction related to vascular insufficiency and nerve compression secondary to edema and mechanical compression by splints 3. Acute pain related to edema, movement of bone fragments and muscle spasms as evidenced by pain descriptors such as grimacing 4. Ineffective self-health management related to lack of knowledge regarding muscle atrophy, exercise program and care of external immobilizers as evidenced by questions about long term effect of immobilization, devices, activity restrictions

Assessment

Subjective: -states “I’m afraid to try and move my arm. -does not want to try and wiggle fingers -sling in use on the left arm

Objective: -recent reattachment of left shoulder surgery. Bed rest per M.D. order. Received dressing changed, pain is 4/10

Priority Nursing Diagnose

IMPAIRED PHYSICAL MOBILITY

Goals/Outcomes List at least 2 (must be time-sensitive, measurable, & realistic)

1. Client will experience uncomplicated bone healing and return of skeletal function by next M.D. appointment 2. Client will use assistive devices as necessary to increase physical mobility by discharge 3. Client will experience no complications of immobility by discharge 4. Client will demonstrate optimal independence in positioning, exercising, and performing

Interventions to Implement-relate to numbered Outcome At least 3-5

Rationale Must use APA references and have at least two different sources

Evaluation-relate to numbered Goal/Outcome (if not completely med, what might you do differently)

~support the affected body part ~ move the injured extremity as little as possible ~ monitor for bleeding at injury site ~ monitor circulation in the affected part ~ recognize and actively prevent complications associated with immobility ~ allow clients to do as many bed activities as they can, help with light manual guidance and verbal cues as needed ~use memory aids/strategies such as written schedules, directions, sketches, and timers for bed mobility exercises

-to avoid fracture displacement and soft tissue injury (Lewis, Dirksen, Heitkemper, Bucher and Camera, 2011) -to avoid additional injury (Lewis et al., 2011) -to plan appropriate intervention (Lewis et al., 2011) -to detect possible nerve or vascular damage (Lewis et al., 2011) -the inability to be upright disturbs many body systems(Metzler & Harr, 1996) -Clients need the opportunity to feel more normal tone and postures so they do not relearn abnormal patterns (Ackley & Ladwig, 2008) -this helps them function as independently as possible (Ackley & Ladwig, 2008)

Client repositioned self in bed without moving the affected arm. Client return demonstrated keeping the left arm immobile while the right arm/hand did most of the task for the client. Sling is in use and in proper alignment without causing too much discomfort for the client. Client was instructed to use pain medication as needed per M.D. order in order to minimize the anxiety of immobility of the affected side. Goal Met but will continue to monitor until discharge

functional activities in bed by discharge

~consult with physical therapist for further evaluation, strength training, gait training, and development of a mobility plan

-techniques such as gait training, strength training and exercises to improve balance and coordination can be very helpful for rehabilitating clients (Taylor & Sparks,2006 )

References Ackley, B. J., & Ladwig, G. B. (2008). Nursing diagnosis handbook: an evidence-based guide to planning care (8th ed.). St. Louis, Mo.: Mosby Elsevier. Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medicalsurgical nursing: assessment and management of clinical problems. (8th ed.). St. Louis, Mo.: Elsevier/Mosby. Metzler, D., & Harr, J. (n.d.). Positioning your patient properly. [Am J Nurs. 1996] - PubMed NCBI. National Center for Biotechnology Information. Retrieved March 21, 2013, from http://www.ncbi.nlm.nih.gov/pubmed/8607544 Taylor, C. M., & Ralph, S. (2006). Sparks and Taylor's nursing diagnosis cards (11th ed.). Philadelphia.: Lippincott Williams & Wilkins.

Grading Rubric for Care Plans (100 points each) Your Points 10

Excellent to Very Good

Moderate

10 pts: Appropriate for patient & contains 3 parts of nursing diagnosis statement

5 pts: Appropriate diagnosis but missing 1 part of the nursing diagnosis

10

10 pts: Selected priority nursing diagnosis; enough assessment data to support diagnosis

Outcome (one short-term and one long-term outcome needs to be identified)

20

20 pts: Outcome is SMART and appropriate for patient

Intervention (3 interventions for each outcome which equals 6 interventions total)

20

20 pts: 3 SMART interventions are utilized for patient

Rationale for interventions (need rationale for each intervention, including APA formatted references) Evaluation (how do you know your intervention worked? If met that is good. If not met, how might you change your interventions?)

20

20 pts: Clearly and concisely explains the rationale for each of the 3 interventions with source referenced

20

20 pts: clearly and concisely explains how you know your interventions worked; states whether outcome was met/unmet; if unmet, explain what you might have done differently

5-9 pts: Did not select priority diagnosis; some data to support diagnosis but not complete 10-19 pts: Missing 1-2 aspects of a SMART outcome; outcome moderately appropriate for patient 10-19: missing 1-2 aspects of a SMART intervention; 1 intervention may not be appropriate for patient 10-19 pts: Rationale for interventions vague; inappropriate reference used; missing 1 rationale 10-19 pts: vague statements regarding how you would evaluate interventions; lacking statement regarding whether outcome was met/unmet

Nursing Diagnosis (Identify 3 nursing diagnoses but only select the highest priority one to work up) Assessment Data/Priority Diagnosis

100/100

Slightly/Needs Improvement 0 pts: Inappropriate diagnosis for patient; lacks 2 parts of nursing diagnosis

0-4 pts: Selected least important nursing diagnosis; not enough data to support the diagnosis 0-9 pts: Missing 3 or more aspects of a SMART outcome; inappropriate outcome for patient

0-9 pts: Missing 3 or more aspects of SMART intervention; 2 interventions not appropriate

0-9 pts: Missing rationales for each intervention; lacks references; missing 2 rationale

0-9 pts: states whether outcome was met/unmet but doesn’t explain how evaluated interventions

Comments:

Maria, You did a great job on this care plan. I feel that the nursing diagnosis you picked was very appropriate, but remember that if a patient is having pain they may not be able to achieve mobility. Always look at Maslow’s and what hierarchy would come first. Physiological needs for the patient take priority number one....