71 year old female who is admitted to hospital yesterday via ambulance. She had a fall at home, she is a previously healthy woman who loves in a condo with her husband in the city. She has two kids and a couple of grandchildren who also live in the city and are supportive.
Plese help me. Mrs. Rose centers is a 71 year old female who is…
Plese help me.
| Mrs. Rose centers is a 71 year old female who is admitted to hospital yesterday via ambulance. She had a fall at home, she is a previously healthy woman who loves in a condo with her husband in the city. She has two kids and a couple of grandchildren who also live in the city and are supportive. She has a history of hypertension for which she is on medications and suffers from insomnia. So she fell at her condo states. She did not hit her head. She slipped in some water on the kitchen floor and she was on the floor for about three hours or so. Her husband came home called the ambulance right away. She is alert and oriented to person, place and time. Her purpils are reactive light and she has minimal pain at this time. Vital signs are normal, BP98/75, P85, RR22, SPO2 98% on RA. Pulses are palpable, she has a bruise to her right knee and side of her leg. She says she is not in any pain at this time, also the nurse checked her head for any sort of injury or laceration and there’s none at this time.
During the pain assessment Mrs. Rose provides the following information: She has allergies to penicillin She’s complaining 3 out of 10 for pain in her right leg where she had fallen in hurt herself. This is the new onset of pain from the fall that is progressively getting worse and jurts more with movement. she describes the pain as a throbbing adult ache. it is localized to her right leg where she has the bruising and a bit of swelling. the skin is intact. she has not had andthing for pain yet but I think we do need to give her something to help relieve her of the pain. And the patient told the nurse. It hurts quite a bit it right there and I don’t think it’s spreading but it hurts to move and it hurts everywhere. It started when I fell and it has it gets worse when I move ecery in bed like when I move it hurts, it’s getting worse. There’s a lot of pain right side, I’d say three pain.
After assessment the nurse wants to give her 650mg of Tylenol. Because while she rated at three out of ten for pain and has not received anything as of yet. Normally we should start with a non-opioid analgestic for mild pain. |
Use the nursing process to identify the following from the information provided in the case study.
Assessment: Assessment Data for the patient
Diagnosis & Analysis: What is the priority problem being experienced by the patient? This is your diagnosis.
Planning: How and When does this need to be fixed? What are the priorities?
Intervention: What nursing interventions both pharmacological and non-pharmacological can you use to support this patient’s care needs that DIRECTLY will impact the priority problem? How do you know this is an important intervention?
Evaluation: This is your outcome! What do you expect will happen after the intervention is implemented? What is the timeline that it should be completed within?
Your care plan must include:
1) Diagnosis – choose ONE that pertains to the client
2) 2 goals related to the above diagnosis
3) For EACH goal you are required to have two interventions; one related to social determinants of health the other anatomical/physiological
4) Each intervention needs an outcome statement please ensure you include a TIMELINE
Rubric: Care Plan Assignment
| Requirement | Grade | Comments |
| Template Completed | /2 | |
| Assessment
Complete patient assessment by systems
|
/5 |
|
Nursing Analysis & Diagnosis
|
/10 |
|
Outcomes/Goal
|
/10 |
|
Interventions and Rationales
|
/10 |
|
Evaluation
|
/5
|
|
| TOTAL GRADE | /42 |
CARE PLAN TEMPLATE
| Nursing Diagnosis/Priority Problem: |
Goal 1 Form
| Assessment Data/
Defining Characteristics (Signs and symptoms supporting the chosen nursing diagnosis) |
Client Outcomes
(SMART: specific, measurable, achievable, realistic and time specific)
|
Nursing Interventions
(Nursing initiated actions based on the medical plan of care and client outcomes)
|
Rationale/Evidence Based
(Reasons why each intervention is expected to work; connect to nursing theory, pathophysiology, APA cited) |
Evaluation
(Expected Outcomes achieved? Not achieved? What is next? Future plan) |
Goal 2 Form
| Assessment Data/
Defining Characteristics (Signs and symptoms supporting the chosen nursing diagnosis) |
Client Outcomes
(SMART: specific, measurable, achievable, realistic and time specific)
|
Nursing Interventions
(Nursing initiated actions based on the medical plan of care and client outcomes)
|
Rationale/Evidence Based
(Reasons why each intervention is expected to work; connect to nursing theory, pathophysiology, APA cited) |
Evaluation
(Expected Outcomes achieved? Not achieved? What is next? Future plan) |
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