Assignment: CARE PLAN
Create a wholistic 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.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
USE care plan template to help you design a holistic patient care plan. The care plan example provided here is just a reference for you to build your care plan. You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.
Week 4: Genitourinary Clinical Case
A 60-year-old Hispanic male presents with the chief complaint of decreased urinary flow. The patient has been experiencing this over the past two years, but for the past two weeks, the symptoms have increased significantly. The current symptoms are similar to what he experienced in the past. However, for the past two weeks, he has had increased nocturia, with decreased strength of urinary flow and slight terminal dysuria. Patient has had no treatment in the past. The nocturia has been very troublesome over the past two weeks. Yesterday he had significant difficulty in starting his urine flow and this is interfering with daily activities. He needs to pass urine four to five times every night. He has been urinating frequently and always needs to know if there are bathrooms around.
Patient does not complain of any other radiating pain. He has had no treatment or diagnostic work up in the past, but now the symptoms have been increasing in severity. He believes he had a low- grade fever yesterday. The patient is not sure what is going on but thinks he may have cancer. He had significant obstructive symptoms two days ago. Gradual worsening of symptoms has compelled him to seek medical help now.
Patient has not sought any medical care for this problem to date. He is being treated for hypertension and hypercholesterolemia. There is no known history of heart disease, but he was hospitalized five years ago as a suspected case of angina. He was diagnosed with chest wall syndrome for which he was treated and then released. There are no recent hospitalizations and no surgeries.
Denies any other positive review of systems. Denies abdominal pain, nausea or vomiting. No blood in the stool. No gross hematuria.
Cardizem 240mg daily
Zocor 20mg daily
Patient is compliant with the prescribed regimen and knows why he is being treated.
No known drug allergies
|Grading Criteria||Maximum Points|
|Care plan demonstrated involvement of the client in the process of recognition, planning, and resolution of the problem.||15|
|Care plan included effective nursing interventions that were customized for the client and appropriate to the goal.||15|
|Care plan included diagnostic workup, medications, conservative measures, and a follow-up plan.||15|
|Care plan provided rationale for choosing a particular treatment modality.||15|
|Care plan demonstrated logical diagnosis, which was substantiated with relevant evidence.||10|
|Care plan focused on patient education, maintained a fine balance between major and minor health issues of the patient.||10|
|Care plan included nursing interventions that are specific, appropriate, and free of essential omissions.||10|
|Used APA standards consistently and accurately.||10|