Reference no: EM134045490

Preparing to Care

You are being asked to develop a care plan based on a mock client situation. You will complete this with a partner of your choosing. The following are the guidelines, instructions and case study for the Care Plan Assignment.

Format: The assignment must be completed using Microsoft Word, adhering to APA formatting guidelines. This includes a title page, in-text citations within your care plan, a reference page, and an appendix. Single spacing and the use of bullets are permitted within the templates.

Assignment Instructions:

Using the Nursing Care Plan template and the guidelines below, create a care plan based on the provided case study, including:

Nursing Diagnoses: Identify two nursing diagnoses that algin with the NANDA-I criteria - 1 actual and 1 potential. Provide a 1 sentence rationale explaining why this diagnosis is appropriate for this client.

Cues: List 3-5 priority cues from the assessment data that support the nursing diagnosis.

Goal Statements: Develop one goal statement for each nursing diagnosis, applicable to this client situation, ensuring each goal follows the SMART criteria.

Nursing Interventions: Identify 3 nursing interventions for each goal, applicable to this client situation. Each intervention must meet the SMART criteria and include an in-text citation from a credible source to demonstrate evidence-based practice.

Student Contract: Attach the completed Student Contract as an Appendix, the final page of your document.

Scholarly Writing: Use APA guidelines for the title page, in-text citations and reference list. Ensure clear & concise nursing language and appropriate grammar and spelling.

Formatting & Submission: Submit your work using the provided template, and include a title page, reference page and appendix.

Grading: Refer to the assignment rubric for further expectations and grading criteria.

Mock Client Case Study

Ria Santos is a 78 year old woman admitted to the medical unit from the Emergency Department. Ria lives alone in an apartment. Her husband passed away two years ago, and her daughter lives three hours away. Ria receives occasional assistance from a neighbour but reports that she often spends several days alone. She reports feeling lonely and says, "Most days I watch television and don't see anyone."

Over the past week, Ria has experienced an increasing cough, fatigue, poor appetite, and difficulty completing daily activities. She states, "I have been too tired to cook and haven't felt like eating much." Ria reports drinking mostly tea and has consumed very little water over the past several days. Ria mentions that she sometimes coughs when drinking and that she does not always use the thickening powder recommended by her doctor because she dislikes the texture. These concerns are relevant to Nutrition And Its Mode.

Ria has become increasingly weak and reports using her furniture for support when walking around her apartment. Two days before admission, Ria felt dizzy when getting out of bed and nearly fell.

Ria has a history of hypertension, osteoarthritis and mild dysphagia following a stroke 3 years ago. Her age and related considerations can be considered in the context of Ageing Gerontology Biology.

Admission Findings:

Ria is admitted to a semi-private room. The healthcare team has initiated droplet/contact precautions until further testing results are available. A precaution sign is posted outside the room.

On assessment, Ria appears fatigued and has mild dyspnea when speaking. She has a productive cough with yellow sputum, and you hear crackles in both lower lung lobes when you auscultate. You note that her oral mucous membranes are dry. The nurse from the previous shift notes that Ria remained in bed and required assistance to change her position overnight.

Vital Signs: T 38.4C, P 108, R 24, BP 96/58, O2Sats 92% on room air

Admitting Diagnosis: Community acquired pneumonia, dehydration, generalized weakness

Doctor's Orders:

Vital Signs q4h
Encourage oral fluids
Intake and output q8h
Regular diet with thickened fluids to nectar consistency
Ambulate with assistance
Sputum sample to lab for C&S

Consults:

Speech-language pathologist
Dietician
Physiotherapist
Social Worker