Please help me. I need 2 care plan. Because I need 2 goals with SMART goals. So finally I need 2 care plan. Please help me
Please help me. I need 2 care plan. Because I need 2 goals with SMART goals. So finally I need 2 care plan. Please help me.
Mrs. Hope is an 86 year-old widowed female who was admitted to a nursing home 3 months ago. She is ambulatory, and able to perform self-care but transitioned to the nursing home after several falls in her apartment, with the latest one resulting in a fractured hip. Mrs. Hope does require the use of a walker since her surgical procedure. Her past medical history includes osteoarthritis, type II diabetes mellitus, hypercholesterolemia, and hypertension. She has three daughters and 7 grandchildren that visit on a regular basis. Today, Mrs. Hope’s daughter approaches you and states “I have some concerns about my mom. She doesn’t seem to have a lot of energy, and she is falling asleep during our conversations. I am very concerned about this change.” During your shift yesterday, you noted that Mrs. Hope did not each much of her dinner (only 25%) and she left the dining room early asking for her bedtime pills because she was very tired and wanted to go to bed. Given your observations, and the information provided by the daughter you make the decision to conduct a sleep assessment.
During the sleep assessment Mrs. Hope provides the following information:
she likes to go to bed around 8 pm, 9 at the latest
she finds that she is able to fall asleep quickly, but wakes up several times during the night due to noise, having to urinate, and feeling cold (despite using multiple blankets)
it takes hours for her to fall asleep after she has waken up
she complains that her room is too bright, she likes to keep the bathroom light so she can easily locate it when she wakes up and needs to urinate
Upon review of the chart, you not that several PSWs and nurses have documented that Mrs. Hope falls asleep during her meals, struggles with maintaining a conversation, and frequently states “I am just so tired”. It is noted that Mrs. Hope does not take any medications to assist with sleep, but frequently has a coffee with her nighttime snack. She does not participate in group activities, due to low energy and fatigue.
Using this templates
Refer this example
Diagnosis: Patient is at risk for increased susceptibility to falling related to a prosthesis on his left leg
Outcome/Goal #1: Patient and caregivers will implement strategies to increase safety and prevent falls in the home.
Outcome/Goal # 2:Patient will relate the intent to use safety measures to prevent falls. Remember your goals are SMART. A timeline must be included
Since each of the Goals/Outcomes are different, then what interventions etc will you use for each?
CARE PLAN TEMPLATE
Nursing Diagnosis/Priority Problem: Please write down about diagnosis
Goal 1 Form
Assessment Data/
Defining Characteristics
(Signs and symptoms supporting the chosen nursing diagnosis)
Client Outcomes
(SMART: specific, measurable, achievable, realistic and time specific)
Nursing Interventions
(Nursing initiated actions based on the medical plan of care and client outcomes)
Rationale/Evidence Based
(Reasons why each intervention is expected to work; connect to nursing theory, pathophysiology
Evaluation
(Expected Outcomes achieved? Not achieved?
What is next? Future plan)
I need 1 goals, and
SMART goals like this.
S.
M.
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Goal 2 Form
Assessment Data/
Defining Characteristics
(Signs and symptoms supporting the chosen nursing diagnosis)
Client Outcomes
(SMART: specific, measurable, achievable, realistic and time specific)
Nursing Interventions
(Nursing initiated actions based on the medical plan of care and client outcomes)
Rationale/Evidence Based
(Reasons why each intervention is expected to work; connect to nursing theory, pathophysiology
Evaluation
(Expected Outcomes achieved? Not achieved?
What is next? Future plan)
I need another 1 goals, and
SMART goals like this.
S.
M.
A.
R.
T.
Rubric: Care Plan Assignment
Requirement Grade Comments
Template Completed /2
Assessment
Complete patient assessment by systems
Areas of concern and/or symptoms identified
Similar areas of concern and/or symptoms grouped/clustered together
Areas of concern and/or symptoms are prioritized, highest to lowest
Actual or potential problem indicated and listed
/5
Nursing Analysis & Diagnosis
One priority problem identified that shows evidence of critical thinking and that there is an understanding of the client’s condition
PES statement
Nursing diagnosis identified and supported by defining characteristics and related findings
Defining characteristics and assessment data relevant to identified nursing diagnosis transferred to Assessment column of NCP template
/10
Outcomes/Goal
Two goals written relating to nursing diagnosis and specific to the patient’s needs
Each goal written as an action (SMART)
Goal is focused on resolving symptoms
/10
Interventions and Rationales
Interventions are appropriate for the specific patient and outcome/goal and show evidence that client’s condition and developmental level is understood
Rationales provided for each intervention and supported by nursing theory and scientific evidence (Referenced)
Evidence of critical thinking
References are appropriate and scholarly
Two interventions identified for each outcome/goal
/10
Evaluation
Evaluation statement indicates when and how the client outcome/goal will be evaluated as met or unmet for the specified timelines
/5
TOTAL GRADE
Complete Answer:
