Posted: October 27th, 2022

Care of Adults

  

Hello, please are two tasks.

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Task # 1

is a Care Plan, below I attach two forms in words that must be completed. Please below I attach a document with an example of a Nursing Care Plan that will serve as a guide to make mine. 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

Care Plan 

Medical Diagnosis: Arthritis

Arthritis is inflammation of one or more of your joints. The main symptoms of arthritis are joint pain and stiffness, which typically worsen with age. The two most common types of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis is usually caused by normal wear and tear, while rheumatoid arthritis is an autoimmune disorder. Other types of arthritis can be caused by uric acid crystals, infections or even an underlying disease, such as psoriasis or lupus.

Task # 2 

Case Study 

Case Study: Health Care of the Older Adult

2.The nurse is completing the admission assessment for a patient scheduled for cataract surgery in the outpatient center. Because the patient is over the age of 70 and has several chronic conditions, including hypertension and congestive heart failure, the nurse focuses on completing a thorough medication history. (Learning Objective 4)

a. What questions should the nurse include in the medication history?

b. The patient states that she stopped taking one of her medications due to cost, since her health insurance would not reimburse for the medication. What are other reasons that older adults may be non-compliant with ordered medications?

c. How does aging affect drug absorption, metabolism, distribution, and excretion?

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

Student Name

Date

Patient (initials only)

Patient Medical Diagnosis

Nursing Diagnosis (use PES/PE format)

1.

2.

3.

1.

2.

3.

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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