Develop one (1) Goal Statement and a supporting Objective.
Read scenario; underline or highlight related data; develop lists of related data. (See #8 for Hint)
Identify 3 priority (most urgent) NURSING issues and write a NANDA nursing diagnosis label for each; can be “at risk” or “actual” diagnosis
· HINT: Use the NANDA list in your book
Number the 3 NANDA diagnostic labels you identified in order of priority.
· HINT: Consider Maslow’s hierarchy of need; think about what needs to be addressed immediately
Pick the NANDA diagnostic label that is HIGHEST priority and develop the NANDA diagnostic label into a complete Nursing Diagnosis, correctly incorporating all components
· If you use an “At risk” diagnostic label, the Nursing Diagnosis will have 2 parts: NANDA Label and Related factor
· If you use an “Actual” diagnostic label, the Nursing Diagnosis will have 3 parts: NANDA Label, Related factor and Defining characteristics.
Using the Nursing Diagnosis completed,
Develop one (1) Goal Statement and a supporting Objective.
The goal is a general statement, but the objectives MUST include all of the following components:
· SMART (Learn this acronym and how to use it!)
· S: Specific
· Must be patient centered; start with “the client will…”
· M: Measurable
· A: Attainable
· R: Realistic
· T: Timed
· HINT: Your GOAL and OBJECTIVES MUST be based on the PRIORITY Nursing Diagnosis you completed in # 4.
· DO NOT write goals and objectives based on a different diagnostic label. When you write complete Care Plans for future clients, each diagnostic label will be developed into a Nursing Diagnosis and have its own goals, objectives and interventions. For this assignment, use your 1st priority diagnosis
Based on your nursing diagnosis and goal, write appropriate nursing interventions.
· HINT: The Interventions MUST directly relate to the Nursing Diagnosis, Goal and Objective you have developed. DO NOT list interventions for other diagnoses. Note that sometimes the same intervention may apply to more than one diagnosis, but do not include unrelated interventions.
· When identifying INTERVENTIONs, use your text to locate appropriate interventions. You may also use the internet as a resource for interventions; many examples of Care Plans are available, but DO NOT copy a care plan directly from the internet; your Care Plan must be specific to this scenario and this patient.
· Using the Care Plan completed in class as an example, complete the Care Plan assignment as above and submit.
· A “rough draft” of your care plan MUST be submitted in Week 9; this counts as a Quiz grade
· Final grading based on the RUBRIC provided
· Care Plan assignment is due WEEK 10 and is 4% of your Grade. (Nonobjective)
Developing your Critical Thinking Skills:
· Hints for grouping like data and developing “Issues”
a) Are any of the vital signs abnormal? Are there other factors in the scenario that could have caused the abnormal vital signs?
b) G. C. has fallen 3 times. Is there any other data that makes her at risk for falling again?
c) Based on the scenario, what else is G.C. at risk for?
d) Why has her pain increased today? What data supports this?
e) Why was she admitted to a Rehab facility instead of going directly home when discharged from the hospital?
f) Why do her orders include a high protein drink supplement?
Developing Nursing Interventions
· Should be based on the 1st Priority, fully developed Nursing Diagnosis, Goal and Outcome statement
· Should be a nursing action; use action verbs such as assess, administer, monitor, teach, assist, instruct etc.
· Ask yourself: “Does this intervention help to meet the Goal and Objective statement?” Will these interventions accomplish the desired outcome?
Gillian Chickory is a 72-year-old retired bus driver admitted yesterday from Fortis Hospital to Fortis Rehab and Care Manor. Prior to admission, she lived alone in her own home. She has a daughter who lives out of state. She does not have any Advance Directives.
She has fallen three times in the past month; and has large bruises in various stages of healing on her right hip, shoulder and cheek. Her most recent fall, 3 days ago, resulted in a 2 inch laceration below the right eye. She has 6 sutures in place and the eye socket is a deep purple color.
She is oriented x 4; her vital signs are: T 99.9, P88, R16, BP 106/54; Pain 7/10, right cheek.
During the initial assessment in the morning, Ms. Chickory tells the nurse she is having much more pain in the right cheek today. The nurse notes a small gap opening between 2 of the sutures, and a small amount of yellow pus oozing from the wound. The surrounding area is red, hot to the touch and edematous.
Ms. Chickory has lost 15 pounds over the past month. She is 5’ 6” and now weighs 118 pounds. Her appetite is poor, and she states she “has not felt much like eating.”
Although her orders are for ambulation, she is fearful of falling again and seldom gets out of bed. Her right side is painful; it is difficult for her to turn and prefers to lie on her left side. She often refuses assistance to reposition.
Ms. Chickory was diagnosed with hypertension 2 months ago and started on both an antihypertensive and a diuretic. Since starting these medications, she is often incontinent of urine. She is very embarrassed about this and does not call for help to “clean up” when she is wet. She states she “pees on the floor a little” on the way to the bathroom.
Medical Admitting Diagnoses:
· Physical decline; Hypertension; Unexplained weight loss; Congestive Heart Failure
· Labetalol 100 mg by mouth twice a day. Hold for systolic BP <100; diastolic <60
· Bumex (bumetanide) 1 mg by mouth once a day
· Klor-Con® M20 extended-release (potassium chloride) Take 1 tablet daily by mouth
· Milk of magnesia 30 ml once day as needed for constipation
· Boost high protein dietary supplement, 8 ounces 3 times a day between meals
· Acetaminophen 325 mg, tabs 2 every 4-6 hours as needed for mild to moderate pain
Diet: Regular diet; Calorie count for 3 days; Dietary referral for weight loss
Activity: Following PT consult, assist out of bed daily; may ambulate as tolerated
Physical Therapy: PT consult for evaluation of gait; evaluate activity tolerance