Analysis And Care Plan Creation

Analysis And Care Plan Creation
Analysis And Care Plan Creation
Assignment 2: Case Study Analysis and Care Plan Creation
Click (I COPIED AND PAST IT ON BELOW) to download and analyze the case study for this week. Create a holistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
CASE STUDY
Week 2: Respiratory Clinical Case
Patient Setting:
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy.
PMH
History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.
Past Surgical History
None
Family/Social History
Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.
Medication History
Theophylline SR Capsules 300 mg PO BID
Albuterol inhaler, PRN
Phenytoin SR capsules 300 mg PO QHS
HTCZ 50 mg PO BID
Enalapril 5 mg PO BID
Allergies
NKDA
ROS
Care plans enable nurses to focus on patients in a holistic, big-picture manner, allowing them to provide evidence-based, patient-centered care.
Care plans also assist hospitals in ensuring continuity of care across nurse shifts, promoting inter-professional teamwork by getting everyone on the same page, and meeting documentation requirements for insurers and regulatory authorities.
Even if your hospital demands care plans, unless it’s a stringent necessity, chances are your nurses aren’t preparing one for each and every patient since they’re too busy.
Depending on the unit, they may only be able to treat patients for a number of days before becoming swamped with unnecessary paperwork.
Given that the majority of the information in a nursing care plan is already required in numerous parts of each patient’s electronic health record (EHR), nurses may question the value of creating an official plan of care.
Nurses are unlikely to create care plans unless they are required.
And, unless care plans are useful, preparing them will be regarded as more “busywork,” which is every nurse’s nightmare.
What are the advantages of a hospital nursing care plan?
How can you ensure that care plans are a helpful tool that nurses will want to use?
Why Does Your Hospital Require a Nursing Care Plan?
Care plans are used to teach nursing students how to individualize patient care, think critically about what is required to accomplish desired goals, and move toward those outcomes through the nursing process.
Experienced nurses already know how to accomplish this without documenting it and, in many cases, without even realizing it.
Nonetheless, a written nursing care plan can be a useful tool for efficient nursing communication.
Long-term care providers, such as nursing homes, mental health facilities, and home health nurses, frequently employ formal care plans, and are frequently obliged to do so by governing organizations such as the Joint Commission.
Care plans, on the other hand, frequently fall by the wayside in hospitals.
There are numerous advantages for hospitals that successfully implement care plans, including:
Continuity of care: Nursing care plans guarantee that nurses from different shifts or floors have access to the same patient data, are aware of the patient’s nursing diagnoses, exchange their observations, and collaborate toward the same goals.
Nurses are the core of the care team, but they are not the only ones.
Physicians, social workers, nursing assistants, physical therapists, and other caregivers must also be aware of the patient’s health issues, goals, and progress.
A nursing care plan consolidates all of this information, offering a clear path to the desired results.
Patient-centered care: Treatment plans assist in ensuring that patients receive evidence-based, comprehensive care.
Nursing diagnoses are standardized to provide excellent care, but nursing interventions are adapted to the individual patient’s physical, psychological, and social needs.
Engaged patients: Setting attainable goals for and with patients aids in the direction and measurement of nursing care.
Goals also encourage patients to get more involved in their recovery since they can see exactly what they need to do to obtain the desired results.
Compliance: The care plan acts as proof of receipt and assists payers in determining how much treatment they should reimburse.
What Exactly Is a Nursing Care Plan?
A nursing care plan is the written manifestation of the nursing process, which is defined by the American Nurses Association as “the common thread uniting different types of nurses who work in diverse areas… the essential core of practice for the registered nurse to deliver holistic, patient-focused care.”
The nursing process consists of five major steps:
Assessment is gathering and analyzing data in order to acquire a comprehensive picture of the patient’s needs and risk factors.
Diagnosis: Forming nursing diagnoses based on data, patient feedback, and clinical judgment.
Outcomes/Planning:
Setting short- and long-term goals based on the nurse’s examination and diagnosis, ideally with patient input.
Choosing nursing interventions to achieve such objectives.
Implementation entails carrying out nursing care in accordance with the care plan, which is based on the patient’s health status and the nursing diagnosis.
Documenting the care provided by the nurse.
Monitoring (and documenting) the patient’s state and progress toward goals, as well as changing the treatment plan as necessary.
A nursing care plan is official record of this procedure, and most care plans are divided into four columns that roughly reflect the nursing process’s steps.
Care plans include the following:
Diagnoses in nursing
wished-for outcomes/goals
Evaluation of nursing interventions
According to NurseLabs, some healthcare professionals utilize only three columns, integrating “desired outcomes/goals” and “evaluation” into a single column, but others use five columns, including one for “assessment cues.”
Nursing students’ care plans usually contain a column for “rationale/scientific explanation,” in which they are required to describe the logic behind their recommended nursing actions.