Develop a basic patient care plan based on a hypothetical patient scenario encountered during your nursing fundamental clinical rotation. This assignment will help you apply theoretical knowledge to practical clinical situations and enhance your critical thinking and decision-making skills.
Instructions
Part 1: Patient Scenario
Review the patient scenario, including relevant patient information (compliant with HIPAA laws), medical history, and current health status.
Part 2: Nursing Diagnosis
Identify two nursing diagnoses based on the patient scenario. Consider the patient's presenting problems, health needs, and potential risks.
Part 3: Nursing Interventions
Develop nursing interventions for each nursing diagnosis identified. Include both independent nursing actions and collaborative interventions involving other healthcare team members.
Part 4: Evaluation
Outline how you would evaluate the effectiveness of the nursing interventions implemented. Consider measurable outcomes and criteria for success.
Reflect on the process of developing the patient care plan. Consider the challenges you encountered, the rationale behind your nursing interventions, and any insights gained from this experience.
This assignment must be in APA 7 Format and your sources cannot be older than 5 years old.
Assignment must include the following:
Identification of Nursing Diagnoses
Development of Nursing Interventions
Evaluation of Nursing Interventions
Reflection on the Process
Organization and Clarity
Full Answer Section
Patient Scenario
Patient: Mrs. Emily Carter, a 72-year-old female admitted to the medical-surgical unit with complaints of shortness of breath, fatigue, and ankle swelling for the past two weeks. Medical history includes hypertension, type 2 diabetes mellitus, and osteoarthritis. Physical examination reveals decreased oxygen saturation, crackles in lung bases, and pitting edema in lower extremities.
Part 1: Nursing Diagnosis
Based on the patient's presentation, two primary nursing diagnoses are:
- Impaired gas exchange related to alveolar-capillary changes as evidenced by shortness of breath, decreased oxygen saturation, and crackles in lung bases.
- Activity intolerance related to decreased cardiac output and generalized weakness as evidenced by fatigue and ankle swelling.
Part 2: Nursing Interventions
Nursing Diagnosis: Impaired gas exchange
- Independent interventions:
- Monitor respiratory rate, rhythm, and depth.
- Assess breath sounds every 2-4 hours.
- Elevate head of bed to facilitate breathing.
- Encourage deep breathing and coughing exercises.
- Administer oxygen therapy as ordered.
- Collaborative interventions:
- Collaborate with respiratory therapy for pulmonary function tests and inhaled bronchodilators.
- Consult with the physician for diuretic therapy or other appropriate interventions.
Nursing Diagnosis: Activity intolerance
- Independent interventions:
- Assist with activities of daily living as needed.
- Educate patient on energy conservation techniques.
- Encourage gradual increase in activity level as tolerated.
- Monitor vital signs during activity.
- Collaborative interventions:
- Collaborate with physical therapy for mobility assessment and exercise prescription.
- Consult with dietitian for nutritional counseling to promote energy levels.
Part 3: Evaluation
Evaluation of the effectiveness of nursing interventions will be based on the following:
- Impaired gas exchange:
- Improvement in oxygen saturation levels.
- Decreased shortness of breath.
- Reduced crackles in lung bases.
- Activity intolerance:
- Increased ability to perform activities of daily living.
- Improved tolerance to activity.
- Decreased fatigue.
Part 4: Reflection
Developing this patient care plan highlighted the importance of critical thinking and clinical reasoning in nursing practice. It emphasized the need for comprehensive assessment, accurate diagnosis, and individualized care planning. Challenges included prioritizing nursing diagnoses and selecting appropriate interventions. This experience reinforced the significance of collaboration with other healthcare professionals in providing optimal patient care.
Note: This is a basic example of a patient care plan and would require further elaboration in a real-world setting. The specific interventions and evaluation criteria may vary depending on the patient's individual circumstances and the healthcare setting.