Lippincott Client Cases for Clinical Judgment


Choose a client over the age of 65 from Lippincott Client Cases for Clinical Judgment to use as an example for this activity. Read through the client’s EHR and listen to report as if you were taking care of this client at the bedside. Once completed, reflect on these questions and submit a word document with one paragraph for each of these questions. Ensure you use APA format.

Describe in detail the basic care and comfort needs of this client, utilize the nursing process to describe how you would meet these needs.
What are the nutritional and sensory/perception needs of this client? Describe how you would meet those needs using the nursing process.
What are the integumentary and musculoskeletal needs of this client? Describe how you would meet those needs using the nursing process.
What are the immunity, infectious, and inflammatory needs of this client? Describe how you would meet those needs using the nursing process.
Grading Rubric for Reflection Assignment (10 Points Total)

1. Basic Care and Comfort Needs (2 points)

2 points: Thoroughly describes the client’s basic care and comfort needs, clearly utilizing the nursing process (assessment, diagnosis, planning, implementation, evaluation) to explain how these needs will be met.
1 point: Describes the client’s basic care and comfort needs with some detail but only partially applies the nursing process.
0 points: Fails to describe the client’s basic care and comfort needs or does not apply the nursing process.
2. Nutritional and Sensory/Perception Needs (2 points)

2 points: Provides a comprehensive explanation of the client’s nutritional and sensory/perception needs, clearly integrating the nursing process to describe interventions and outcomes.
1 point: Addresses the client’s nutritional and sensory/perception needs but lacks depth or only partially incorporates the nursing process.
0 points: Does not address the client’s nutritional or sensory/perception needs or fails to use the nursing process.
3. Integumentary and Musculoskeletal Needs (2 points)

2 points: Fully identifies the client’s integumentary and musculoskeletal needs, using the nursing process to outline appropriate care.
1 point: Discusses integumentary and musculoskeletal needs with limited detail or only partially applies the nursing process.
0 points: Does not describe the integumentary or musculoskeletal needs, or neglects the nursing process.
4. Immunity, Infectious, and Inflammatory Needs (2 points)

 

Sample Answer

 

 

 

 

 

 

 

Client Care Reflection (Hypothetical Case): Mr. Samuel Jenkins

Basic Care and Comfort Needs

Mr. Jenkins, due to his acute CHF exacerbation, requires significant assistance with basic care and is at high risk for discomfort related to dyspnea and the infected Stage 3 pressure injury (PI). The nursing process begins with Assessment of his pain level (PQRST) and subjective reports of fatigue and anxiety, and objective vital signs. The Diagnosis is Impaired Comfort related to physical symptoms and impaired mobility, and Self-Care Deficit related to physical weakness. Planning involves setting a goal for the client to report pain at a manageable level ($\le 3$) and complete ADLs with minimal assistance. Implementation includes administering scheduled and PRN analgesics, utilizing non-pharmacological methods such as guided imagery, and assisting with hygiene activities while providing frequent rest periods to manage activity intolerance. Evaluation is conducted 30 minutes after intervention and periodically throughout the shift, observing for relaxed demeanor, reports of reduced pain, and tolerance for ADLs (Dougherty & Lister, 2021).

Nutritional and Sensory/Perception Needs

The client’s diabetes, CHF, and non-healing Stage 3 PI create complex nutritional needs, while the geriatric status risks sensory decline. Assessment includes monitoring daily weights, strict intake and output (I/O) for fluid restriction compliance, lab work (albumin, prealbumin, glucose), and screening vision and hearing, noting any signs of disorientation. The resulting Diagnosis is Imbalanced Nutrition: Less than Body Requirements related to restrictive diet and hypermetabolic state (wound healing), and Risk for Acute Confusion related to fluid and electrolyte imbalance. The Planning goal is for the client to maintain current body weight and demonstrate orientation. Implementation involves providing a low-sodium, fluid-restricted, diabetic-appropriate diet, offering small, frequent meals to maximize intake, and ensuring the environment is well-lit and quiet with assistive sensory devices (glasses, hearing aids) in place to aid orientation and perception. Evaluation tracks whether his blood glucose remains within target range and if his weight is stable, and verifies orientation status every four hours (Ackley et al., 2021).