Care Plan Assignment Essay
Care Plan Assignment Essay
Care Plan Assignment
This assignment will utilize your nursing analysis skills with the nursing process.
Individually, you will complete a comprehensive care plan on a patient that you will create. You will select a topic from a list provided, and create a case study, comprehensive assessment document, care plan document, and reference page.
You will use the case study and care plan templates provided to enter your information and build your case study patient. The templates will detail the laboratory, testing, medications, and patient history, as well as the care plan.
You will use APA format for your reference page and citations. You will include your case study data and care plan template in your submission.
Description:
The Care Plan is a comprehensive overview of a patient in their current state, including the experience of a complex condition. It is a way for nurses and patients collectively to design an evidence-based plan for the treatment/support or management of a complex condition. This assignment is designed to take you through all phases of the assessment, nursing analysis/diagnosis/priority problem, treatment/management and evaluation of a patient’s complex condition.
Topics:
You will choose one of the topics below on which to develop a care plan. Please note, you may not choose the same topic as your critical analysis assignment. Remember, this is an original case study that you are developing and you cannot use the case studies provided in the critical analysis assignment.
1. Alterations in oxygenation/ventilation such as asthma, COPD
2. Alteration in oxygenation/perfusion, such as coronary artery disease, vascular disorders; and dysrhythmias
3. Alterations in sensory input (integumentary, visual, and auditory systems)
4. Alterations in ingestion, digestion, absorption, and elimination
5. Alterations in problems to regulatory mechanisms, including the endocrine system such as diabetes and thyroid
6. Alterations in movement and coordination, including the musculoskeletal system, such as arthritis; joint replacement; and amputation.
7. The surgical experience, including pre-op and post-op care
8. Pain management – Acute
9. Pain management – Chronic
10. Pain management – Acute on Chronic
Please note, you may not choose the same topic as your critical analysis assignment.
Part 1
Patient case study:
Completed patient case study that includes appropriate data to support the assessment findings, priority problem, goals, interventions, and evaluations.
Biographical Data:
Description of current problem/presenting problem or chief concern
Demographics including name, age, identified gender.
Allergies
Residence/Living Situation
Social Supports
History of past medical diagnoses
Current medications and treatments
Laboratory, imaging, testing data and results
Part 2
Nursing Process care plan:
Assessment
Completed patient assessment
Areas of concern and/or symptoms identified
Similar areas of concern grouped/clustered together
Areas of concern are prioritized, highest to lowest
Actual or potential problem indicated and listed
Nursing Diagnosis/Analysis
One priority problem identified that shows evidence of critical thinking and that there is an understanding of the client’s condition
Defining characteristics and assessment data relevant to identified nursing diagnosis/priority problems.
Planning/Outcomes/Goals
One priority goal written relating to primary problem and specific to the patient’s needs. Goal must focus on short-term.
Goal written as an action (SMART)
Goal is focused on resolving symptoms
Interventions and Rationales
One intervention identified for goal/outcome
Intervention must be pharmacological
Intervention is appropriate for the specific patient and outcome/goal and show evidence that client’s condition and developmental level are understood
Rationales provided for intervention and supported by nursing theory and scientific evidence (Referenced)
Evidence of critical thinking
References are appropriate and scholarly
Evaluation
Evaluation statement indicates when and how the clients’ goal/outcome will be evaluated as met or unmet for the specified timelines
Format
APA, word-processed
Care plan flows, is organized
No significant spelling or grammatical errors
Please note above, I will only mark the number of items required (e.g., problem identified, diagnosis, goals, intervention). If more are submitted, I will only mark the first of those required.