Mrs. Y is an 84-year-old client who was recently discharged from the hospital for an infected diabetic ulcer on her left leg. During her hospitalization, Mrs. Y required intravenous antibiotic therapy through a peripherally inserted central catheter (PICC) line.
Due to Mrs. Y’s long history of diabetes, her physician ordered that intravenous antibiotic therapy be continued at home. Subsequently, home health services were initiated, a home health nurse was assigned to Mrs. Y’s case, and an initial home visit was scheduled.
The home health nurse arrives at Mrs. Y’s home and introduces herself to the client and the family. The nurse explains the home nursing services that will be provided, including the PICC line and intravenous antibiotic therapy treatments.
During the initial home visit, the nurse assessed the physiological, psychological, functional, and safety needs of the client. The nurse’s findings were as follows:
- Mrs. Y lives alone; however, her daughter checks on her frequently throughout the day.
- The client is noted to have moderate functional issues and ambulates with a cane.
- The client has several throw rugs in the main walking quarters and minimal lighting throughout the hallways.
- Mrs. Y states “I used to get around my house with ease, but now I get a little tired and have to sit down and rest frequently.”
- Identify three (3) priority nursing diagnoses for Mrs. Y. Consider using the resource below to assist you.
- eBook: Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care – Chapter 5 Nursing Diagnoses in Alphabetical Order
- Create a visual representation of the three (3) priority nursing diagnoses by incorporating them into the Concept Map (template in the worksheet). Be sure each nursing diagnosis includes the following elements:
- “related to (r/t)” — description of the client’s problem
- “as evidenced by” — description of the client’s symptoms
- Complete the Nursing Plan of Care (table in the worksheet) describing what should be implemented for Mrs. Y.
- Goals: Establish at least one (1) goal for each of the nursing diagnoses you identified (for a total of 3 goals). Goals should be patient-specific, measurable, actionable, realistic, and time-limited.
- Nursing Interventions: Describe at least three (3) nursing interventions for each of the goals (for a total of 9 nursing interventions). Each intervention should be in alignment with the goal it is supporting.
- Complete the assignment using proper spelling, grammar