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LBrown2_2361 Care Plan

LBrown2_2361 Care Plan

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Published by: La'shonda Brown on Apr 28, 2011
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11/23/2012

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RNSG 2361 Clinical

Module Assignment:

Care Plan
Student: LerShoniter Brown Date: 4/24/2011 Instructor: Shirley MacNeill

Grading Rubric
3 Appropriate medical terms and/or abbreviations used throughout Highest Priority (according to student) NANDA fully developed Source is documented correctly using APA format 13 Minimum of 3 appropriate NANDA problems identified, properly written, and properly prioritized <13-6 1-2 errors in: Minimum of 3 appropriate NANDA problems identified, properly written, and properly prioritized Either subjective or objective data is missing on care plan or data is not a defining characteristic of developed nursing diagnosis Goals include all but one of criteria: appropriate short term and long term goals; specific, realistic & measurable, a definite time frame for achievement, and consideration of patient s desires & resources <3-2 1 - 2 inappropriate medical term and/or abbreviation used Highest Priority (according to student) NANDA development incomplete <2-0 >2 Inappropriate medical term and/or abbreviation used Developed NANDA not the highest priority without preapproval Source is not indicated or APA format is incorrectly used <6-0 >2 errors in: Minimum of 3 appropriate NANDA problems identified, properly written, and properly prioritized Subjective or objective data is missing on care plan and data is not a defining characteristic of developed nursing diagnosis Goals missing >1 of criteria: appropriate short term and long term goals; specific, realistic & measurable, a definite time frame for achievement, and consideration of patient s desires & resources Points Earned Points Earned

Subjective & objective data included that are defining characteristics of nursing diagnosis

Well written Goals which include: Appropriate short term and long term goals; outcomes that are: specific, realistic & measurable, a definite time frame for achievement, and consideration of patient s desires & resources Interventions: relate to the goals; are specific and clearly stated to include: Who performs, how, when, where, time/frequency, & amount

Interventions include all but one of criteria: relate to the goals; are specific and clearly stated to include: Who performs, how, when, where, time/frequency, & amount

Interventions missing >1 of criteria: relate to the goals; are specific and clearly stated to include: Who performs, how, when, where, time/frequency, & amount

2010 Lamar State College ± Port Arthur

Page 1

2 rationalesare not indentified for each intervention or incorrect source and page number given Inappropriate or incomplete evaluations for 1-2 short term or long term goals is present Comments: Late Penalty: 25 points up to 24 hours Greater than 24 hours will result in a zero for the assignment 2010 Lamar State College ± Port Arthur Page 2 .2 interventionsare not identified as (I) Independentor (C) collaborative or one intervention is incorrectly labeled >2 interventionsare not identified as (I) Independent or (C) collaborative or>1 interventions is incorrectly labeled >2 rationalesare not indentified for each intervention or incorrect source and page number given Inappropriate or incomplete evaluations for >2 short term or long term goals is present Total Points Earned (maximum of 100) Spelling and Grammar Errors Deduction (maximum of 10 points) Late Points Deduction Failure to submit electronically as an attachment in proper format (MS Office Word) with grading rubric as first page of document Points deduction (maximum of 10 points) Final Score Rationale indentified for each intervention and includes source and correct page number Appropriate evaluations are included for short term and long term goals 1 .RNSG 2361 Clinical Interventions are correctly identified as (I) Independent or (C) collaborative 1 .

Problem # 1. Chronic low self-esteem R/T repeated unmet expectations AEB depending on others.RNSG 2361 Clinical Problem List List and prioritize a minimum of 3 problems. frequent lack of success with wound healing. 4/24/2011 2010 Lamar State College ± Port Arthur Page 3 . 3 4/24/2011 Ineffective coping r/t inadequate level of perception of control AEB inability to meet basic and inability to meet role expectations. Type your answers in the space provided. The boxes will expand as you type. Date 4/24/2011 Nursing Diagnosis R/T Etiology AEB Subjective/Objective Data Powerlessness R/T interpersonal interaction and helplessness AEB dependence on others. anger. frustration and dissatisfaction in not being able to participate in decision making and control over her discharge from the hospital 2.

The boxes will expand as you type. 2010 Lamar State College ± Port Arthur Page 4 .RNSG 2361 Clinical Diagnosis by Nanda Type your answers in the space provided.

anger. Posture bent/slouched 4. AEB Patient identified areas in which she can assume more responsibility of her healthby. change in tone as patient speaks about foot restlessness. The nurse and wound care team will assess the patient locus of control to her health. pain. Short term goal #2 met 100% (Mon at 1100). ( C) 1. (page 666) Sad mood. 3. 2010 Lamar State College ± Port Arthur Page 5 . (page 668) 1.RNSG 2361 Clinical DIAGNOSIS BY NANDA NANDA #1: Powerlessness R/T interpersonal interaction and helplessness AEB dependence on others. Patient will Identify factors that are controllable during an eight hour shift. Older adults who engage in control of their health problems had fewer depressive symptoms. 2. Short term goal #4 met 100% (Mon at 1400). Patient will ask question about care and treatment within the shift at 1900 2. For hospitalized patients it was found that lack of staff support in the form on listening to the patient. ³If this wound don¶t heal they going to cut my foot off´. destruction of skin layer. (page 667) LONG TERM: Patient will: 1. ³I can¶t eat what I want and I have a wound on my left foot that has been there for over a year´. The nurse and wound care team will explore the patient¶s feelings of powerless. 4. frustration and dissatisfaction in not being able to participate in decision making and control over her discharge from the hospital AEB Subjective Data: Patient states. sleeps only four hour at night. 4. Short term goal #1 met 100% (Mon at 1000). Patient and family will be referred to additional resources for psychological therapy. (I) 2. nutritionist and physical therapy and for lifestyle changes and recommendations to enhance quality of life. Patient will participate in the care and treatment within the shift at 1900. The nurse will establish a therapeutic relationship by listening and allowing the patient time to question. 1. The nurse will encourage the client to take control of as many ADL¶s as possible. Patient will state feelings of powerless and other feelings related to powerless with the first eight hours of a twelve hour shift. AEBclient allowed to assist in wound care dressing change and sit in wheelchair and complete upper body ADL¶s 3. AEB Patient verbalize that she wasn¶t giving up and she¶s going to do what it takes to heal. (C) 3. diabetic and wounds care. Patient also states. (I) PLAN/GOAL INTERVENTION (Indicate I or C) RATIONALE (Page #) EVALUATION SHORT TERM: Patient will: 1. (Page 667) 2. Patients are more amendable to therapy if they know what to expect. 3. decrease social interaction Changes of skin color at pressure site. An external locus of control can negatively influences patient¶s perception of power over their health. Short term goal #3 met 100% (Mon at 1800). difficulty falling asleep Objective Data: 4. AEB Patient was able to ask all question concerning wound related problems and healing.

MO: Mosby Elsevier Ignatavicious. MO: Elsevier Saunders. Louis. B. M.. Louis.RNSG 2361 Clinical Sources (APA Format): Ackley. (2010). Reviewed & Revised 6/14/2010 2010 Lamar State College ± Port Arthur Page 6 . (6th Ed). B. (2008). D.Medical-Surgical Nursing and Virtual Clinical Excursions 3. L. J. &Ladwig.Nursing Diagnosis Handbook: A guide to planning care (8th Ed. D.). St. & Workman. St. G.0 Package.

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