The care plan assignment allows students to apply the nursing process concept. Students will use the case study assigned by their instructor to complete the care plan assignment. Please n

STANDARD COLLEGE CARE PLAN ASSIGNMENT    Student Name: Case study number:

Assessment

Subjective and

objective

signs and symptoms

Nursing Diagnosis

(Minimum of 2; PRIORITIZE your nursing diagnosis)

Goals

2 goals per nursing diagnosis

Interventions

2 nursing interventions per goal

Evaluation

Relating directly back to your patient as to; Goal met, Goal partially met, Goal not met. Give the reason why a goal was

not met.

Subjective:

Objective:

Priority nursing diagnosis:

Goal #1:

Goal #2:

Interventions for goal 1: 1. 2.

Interventions for goal 2: 1. 2.

1.

2.

Created on 3/5/2023 1

Subjective:

Objective:

Secondary nursing diagnosis:

Goal #1:

Goal #2:

Interventions for goal 1: 1. 2.

Interventions for goal 2: 1. 2.

1.

2.

Created on 3/5/2023 2

NONgraded Practice care plan group work

Please develop 1 priority nursing diagnosis, 1 goal and 2 interventions per goal

Group 1:

16 y.o. female patient is seen in primary care office. She appears pale, wears a thick sweater and complains of fatigue and constantly feeling cold. She states her periods are irregular and very heavy and she has difficulty participating in after school activities and sports. On assessment hep pulse is 105, resp 26, b/p 110/70, t 97.8F. Pale conjunctiva. She states she doesn’t like meat and mostly eats vegan foods. She is diagnosed with iron deficiency anemia.

Group 2: Heart failure

75 y.o. patient diagnosed with heart failure is seen in cardiac office for worsening of shortness of breath. He has difficulty completing sentences and has productive cough. He has increased difficulty in self-care. On assessment noted bilateral crackles, +3 pedal edema, jugular vein distention. He states he takes his medications but struggles with fluid restrictions.

Group 3: MI

Patient is seen in ER for chest pain. He complains of episode of chest pain after shoveling snow on his driveway. He is pale and clammy, rates pain as 8/10. His pulse ox is 90% and he is started on 2 liters of oxygen. He received 1 sublingual nitroglycerin but the pain is not resolved and radiates to left arm and jaw. Pt describes it as constant pressure.

Group 4: Peripheral arterial disease

65 y.o. patient is seen in primary care office for complaints of cramping in the left leg while walking the dog. Pain resolves with rest. His legs are pale and hairless, left pedal pulse is nonpalpable. He reports forty-year smoking history. He states pain is limiting his activities.

Group 5: COPD

50 year old patient is admitted for pulmonary rehab. He has a 30-year

history of smoking, but quit last year. He has severe shortness of breath and

dyspnea, he has to take frequent breaks when getting dressed in the

morning. He is very thin and has visible use of accessory muscles. He says “I

am so afraid to die”.

Group 6: asthma

A 10 year old newly diagnosed with asthma is seen in pediatric office. He is wheezing, coughing and appears pale. His pulse ox is 90% and he is receiving in office albuterol treatment. Mom states she didn’t have time to pick up prescribed inhaler from the drug store.

Group 7: pneumonia

70 y.o. patient is admitted to med surg floor for community acquired pneumonia. She is oriented to self only. VS: b/p 100/70, p 110, r 25, pulse ox 91%. Bilateral crackles in lower lung fields and dry, non-productive cough. She is prescribed IV antibiotics.

Group 8: confusion

75 y.o. patient is seen at primary care office, brought by the daughter. The daughter is complaining about increased confusion and aggressive behaviors started last week. Patient is oriented to self only, and constantly asks to repeat what is being said. Daughter is concerned about patient’s safety at home.

Group 9: gallbladder

40 y.o. female is seen in ER for sever RUQ pain aggravated by french fires she ate for dinner. Pain radiates to the back and is rated as 9/10. Patient is sweaty and pale. She complains of nausea and vomited at home 3 times in the last 2 hours. Her abdomen is tender to palpation and her admitting diagnosis is acute cholecystitis.

Group 10: fracture

85 y.o. female is seen in ER for possible fracture. She has history of osteoporosis and hypertension. She tripped over an area rug at home and fell on her left side. Her left arm is bruised and has limited mobility. Pt has ice pack on the site and rates pain as 5/10. Her extremity is put in a fiberglass cast and orthpedic consult is scheduled outpatient.

Select one of the following case studies to complete care plan assignment:

Case study 1: John Doe, approximately 50 years old, is admitted to your unit for observation from the emergency department (ED) with the diagnosis of rule out hepatic encephalopathy with acute alcohol (ETOH) intoxication. This man was sent to the ED by local police, who found him lying unresponsive along a rural road. Examination and x-ray studies are negative for any injury, and you are awaiting the results of the blood alcohol level and toxicology tests. He has no identification and is not awake or coherent enough to give any history or to answer questions. He is lethargic, has a cachectic appearance, does not follow commands consistently, and is mildly combative when aroused. He smells strongly of ETOH and has a notably distended abdomen and edematous lower extremities. He has a Foley catheter and an IV of D5½NS with 20 mEq KCl and 1 ampule of multivitamins infusing at 75

mL/hr.

Case study 2: You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is 70-year-old J.M., a patient who has been coming to the clinic for several years for management of coronary artery disease (CAD) and hypertension (HTN). He has had episodes of dizziness for the past 6 months and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months. On his last clinic visit 3 weeks ago, a chest x-ray (CXR) showed cardiomegaly, and a 12-lead electrocardiogram (ECG) showed sinus tachycardia with left bundle branch block (LBBB)

Case study 3: D.M., a 25-year-old man, hops into the emergency department (ED) with complaints of right ankle pain. He states that he was playing basketball and stepped on another player's foot, inverting his ankle. You note swelling over the lateral malleolus down to the area of the fourth and fifth metatarsals, and pedal pulses are 3+ bilaterally. His vital signs are 124/76, 82, 18. He has no allergies and takes no medication. He states he has had no prior surgeries or medical problems: