Case Study 27-Home work care plan - Sean is a 21-year-old male who was admitted

The care plan should have:

 Number of case study for a reference

 Assessment including objective and subjective symptoms

 1 nursing diagnosis

 1 short term goal

 3 interventions for the short term goal, with rationales for each intervention.

 Evaluation method for short term goal.

 1 long term goal

 3 interventions for the long term goal, with rationales for each intervention.

 Evaluation method for long term goal.

 Initial post 1%: post your care plan based on the case study individually distributed to you following the guidelines.

2 peer responds EACH AT LEAST 50 WORDS required 3%: comment on 2 care plans of your peers, give your peers constructive suggestions for improvement (if you think something needs changing offer options, do not just point out the flaws) or talk about positive aspects of your peer’s care plan. Please be polite, mindful of your peers’ feelings and if you do have any constructive criticism give it in a form of a suggestion.

 

More detailed rubric attached.

 

Grading Rubric for discussion 2

Initial post 1%: you will be distributed a case study, post your care plan based on the case study individually distributed to you following the guidelines. It must include 1 nursing diagnosis, relevant assessment findings, 1 short and one long term goal/outcome, at least 2 implementations per goal/outcome (total of 4).

 2 peer responds required 3%: comment on 2 care plans of your peers, give your peers constructive suggestions for improvement (if you think something needs changing offer options, do not just merely point out the flaws) or talk about positive aspects of your peer’s care plan. Please be polite, mindful of your peers’ feelings and if you do have any constructive criticism give it in a form of a suggestion.

Care plan rubric

Assessment

Includes subjective, objective and historical data that support actual or risk for nursing diagnosis.

Includes all pertinent data related to nursing diagnosis and does not include data that is not related to nursing diagnosis.

Diagnosis

Includes the most appropriate diagnosis written within the guidelines and NANDA approved.

Planning (Outcome identification)

Includes 2 patient or family goals, one short and one long term that are most appropriate for the patient/family and the nursing diagnosis. Goal should be measurable and have a target date or time.

Implementation (Interventions)

Includes interventions or nursing actions that directly relate to the patient's goal, that are specific in action and frequency, are labeled "I" for independent and "C" for collaborative. At least 2 intervention per goal should be listed. The interventions should be appropriate to help patient or family meet their goal.

Evaluation

Includes data that is listed as criteria in goal statement. Based on this data, goal is determined to be met, partially met, or not met. If goal was not met or partially met, plan of care is revised or continued and a new evaluation date/time is set.

 

 

Care plan checklist

1. ASSESEMENT (20% of grade)

?Are objective and subjective grouped correctly? 6.6%

?Subjective (what patent Self reports) 6.6%

?Objective (What you can Observe) 6.6%

2. NURSING DIAGNOSIS (20% of grade)

?Is nursing diagnosis addressing most acute/important clinical issue? 6.6%

?Is it written within standards? 6.6%

      -Diagnosis comes from NANDA list

      -Has related to part that addresses nonmedical issue (medical diagnosis has to be    

Rewritten into nursing terms)

     - Has as evidenced by part that sums up symptoms made you lead to conclusion

?All parts of nursing diagnosis address the same issue 6.6%

3. GOALS/PLAN (20% of grade)

?Have one short term goal 4%

?Have one long term goal 4%

?Goals relate to diagnosis 4%

?Goals are patient centered (start with patient will... for example) 4%

?Goals are measurable and have a date/time for reevaluation 4%

4. IMPLEMENTATION (20% of grade)

?2 for short term 6.6%

?2 for long term 6.6%

?Has to follow the goals (if your goals are about fluid, do not have implementation about

Pain) 6.6%

5. EVALUATION (20% of grade)

?Basically your goals restated

 

 

Case study 27: for Vashtie Sirleaf

Sean is a 21-year-old male who was admitted to the emergency department after being involved in a

Motor vehicle accident with his sister Anna. Anna was pronounced dead on scene and Sean suffered

Mild loss of consciousness. Upon arrival to the emergency department, Sean was confused and

Complained of left upper quadrant pain, which radiated to his left arm. During physical examination,

Sean’s vital signs were: BP 123/85 mmHg, HR 95 beats/min., RR 22 breaths/min, Temp, 98.6°F, and an

Oxygen Saturation of 97%. Sean’s orders included strict spinal immobilization protocols, EKG, IV fluid

Bolus, morphine and Zofran, ultrasound (FAST), and a CT scan. After the CT scan, Sean lost consciousness

And vital signs significantly changed from baseline. Sean’s vital signs were: BP 93/56 mmHg, HR 132

beats/ min, RR 34 breaths/min. Temp, 95.6°F, and an Oxygen Saturation of 89%. The trauma team

Performed resuscitation interventions and then the patient was transferred to the operating room to

Treat the cause of bleeding. Sean was hemodynamically stabilized and transferred to the intensive care

Unit for further monitoring.