Process paper/Care Plan: 40%
A client care plan will be created according to the attached guidelines on an assigned patient/ client is to be submitted to the clinical instructor on or before the designated deadline. Work presented after the designated deadline will receive a deduction of 20 points on the final paper grade. Work presented after one week will obtain a grade of zero (0). The professor will deduct (10) points from the grade for a Care Plan that is deemed a “redo”
Care Plan Instructions
Choose a client you are caring for in the clinical area (in your student role) who has multiple nursing problems or co-morbidities. Write a detailed analysis of the patient’s health care problems using the outline presented below. Develop a detailed plan of care for the patient individualized to the client’s specific needs. Obtain data from the patient, the chart and other organizational documents, members of the health care organization staff, and the patient’s significant others/family members.
Appropriate completion of this exercise facilitates your basic knowledge and enhances your analytic skills through a thorough investigation of: physical assessment, psychosocial/cultural assessment, pathophysiology, laboratory and diagnostic studies, medications, and patient health promotion and teaching needs. Use the headings and subheadings provided in this outline for ease of organization and reading.
This document must be typed in APA (current edition) format including grammar. There is a minimum page limit of 10 pages and a maximum of 15 pages not inclusive of title page, reference page or attachments. In addition the paper should show clarity and logical flow.
- Demographic Data
Provide demographic data (5%) about the patient: age, gender, initials, we must protect the confidentiality of our patients—do not use any full names in this document), birthplace, ethnicity, race, religious preference and current place of residence (no actual addresses). Include patient’s presenting symptoms and primary diagnosis or diagnoses and any concurrent diagnoses ( i.e. diabetes mellitus type I or II [insulin non-insulin dependent], hypertension, lupus, etc.).
Complete a pathophysiology section (8%) addressing the primary diagnosis. Other disease processes (i.e. chronic conditions, diabetes mellitus, etc. must be included in the discussion as they effect the patient’s current condition.
Describe the patient’s primary disease process in your own words. Do not include a large quantity of information quoted directly from a textbook. Re-think and paraphrase the description of the disease process in your own words to reflect your analysis and synthesis of the information as it affects the care of your patient. (Note: Some direct quotes are acceptable and even desirable. Be sure to properly cite quotations in APA 6th Ed format.) Identify this section as follows:
a. Name and description of the disease
- Risk factors for the disease
- Presenting symptoms and clinical manifestations
- Physiological changes the disease produces
- Disease progression
- Chronic major body systems changes that the disease process causes
- Usual treatment for the disease; treatments that your client is receiving. Include maintenance (general and specific medications) that your patient is taking; labs, tests, procedures that are mentioned in your reference and the labs, tests, procedures that your patient is getting.
- Brief summary of secondary (concurrent) disease processes and their
predicted impact on primary diagnosis
Use at least one pathophysiology textbook and one peer-reviewed nursing journal (within 2-3 years) article in addition to your nursing textbook.
- Lab work and Diagnostic Studies
Complete the “Lab work and Diagnostic Studies” worksheet. Include all labs and studies that have been performed on your patient—both within appropriate parameters and abnormal. (Note: If your patient has been hospitalized for an extended length of time, include all procedures and treatments that have been done during the hospitalization but only the last two or three days’ labs unless there are specific labs of interest over the entire hospitalization.)
On any of your patient’s labs or studies that have had abnormal results, discuss the purpose of each test and what the abnormal results of each test indicate in relation to the pathophysiology of your specific patient. State the trend of these abnormal results (is your client progressively improving or progressively getting worse or has the lab been somewhat chaotic?).
Provide a “Pharmacology Table”. Include all medications the patient is receiving. This should only be 1-2 pages with the medication that are scheduled. You can include PRN medications if the patient is receiving them on a regular schedule.
- Clinical Workup: The clinical workup involves two sections—history and physical assessment. It is essential that you separate the two by using the headings “History” and “Physical.” This portion of the paper is best written in outline form.
Use the Functional Health Pattern Format found in your Health Assessment text for obtaining the patient history. Include a Genogram (as an attachment, see APA current edition). The genogram is required and is a part of your grade.
Use an organized style of performing and reporting the physical assessment also found in your Health Assessment text.
Use headings and subheadings for this section of your paper for ease of organization and ease of reading.
6. Developmental stage should be written as a narrative using a well-known developmental theorist (i.e. Erikson). Give supporting data to validate whether you believe the patient is accomplishing the developmental tasks or not.
7. Create the plan of care:
a.. Assessment: Include pertinent assessment data that support the specific nursing diagnosis for each individual diagnosis. Identify all data according to whether it is subjective or objective.
- Diagnosis: Develop three (3) priority nursing diagnoses—two (2) physiological and one (1) psychosocial. Use NANDA diagnoses. (Note: NANDA does not recognize “knowledge deficit” as a psychosocial diagnosis.) If you find that your goals and interventions on two diagnoses are very similar, combine those diagnoses and develop another diagnosis that addresses other patient problems. Pick one (1) of the above diagnoses and complete c-f.
*Remember the following guidelines:
Human response r/t physiological or psychological cause of the response
You may use “secondary to” and include the manifestations of the disease process or procedure to clarify the patient’s status.
- Client Goals: Develop two short-term and one long-term goal for each nursing diagnosis. Goals must be realistic, measurable, and have a stated time frame. Goals should begin with: “The patient/family will…..”
- Nursing Interventions: List all appropriate interventions that you will (or did) perform to assist the patient to accomplish the goals. *Remember you plan of care is multidisciplinary (inclusive of other healthcare disciplines) therefore do not start all interventions with “The nurse will”
- Rationales: Provide appropriate scientific rationales for each intervention. Be sure to cite your source of rationales appropriately (see APA 6th Ed). Rationales are the physiological or psychological reason why an intervention would benefit a patient. You can find rationales in nursing journals as well as in the textbooks.
- Evaluation: Describe a short summary of whether the patient goals were or were not met on each diagnosis. If you are reporting actual outcomes of patient care during the time you cared for the patient state data that support the outcome. Typical terms that describe goal evaluation are: “Goal met, discontinue goal.” “Goal met, continue goal for duration of hospitalization.” “Goal not met, reassess and modify goal.”
Example: “Goal met. Patient’s temperature remained below 100.5 ® during the shift. No increase in drainage from the incision site; no increased redness or edema at the site.”
If you are unable to assess the outcome because of time limitations—state what you would have assessed for:
Example: “Unable to assess due to time limitations; would have assessed for successful ambulation from client room to nurses desk and back with patient experiencing no dizziness or shortness of breath.”
- Health Promotion: Provide at least (2) health promotions for your patient. These could be community related.
- Teaching: Teaching should include those things specific to the disease process as well as general wellness and health promotion knowledge deficit that you have identified.
- References and Style: You must have at least five references. One of your references must be a pathophysiology book other than your nursing text. Another reference must be from a nursing journal. You may include as many references as you wish. All references cited in the body of the paper must appear on the reference page. Do not include sources on the reference page if they have not been cited in the body of the paper. Everything that you quote from another author must be appropriately cited and referenced. Citations must be provided throughout the paper. Failure to do so is a serious legal and ethical violation and constituents plagiarism, which is grounds for dismissal from the program.
Use APA 7th Ed headings and subheadings to help organize your material is mandatory. Papers which are grossly inappropriate in terms of grammar, punctuation, and spelling errors will receive additional penalty or be returned for corrections to make them readable. If a paper is returned for this purpose, the student will incur a 10 points deduction penalty applied to the new grade.