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Care Plan Assignment Client Case: A 72-year-old client presented to…
Care Plan Assignment
Client Case: A 72-year-old client presented to the emergency room after a fall at home.
Chief Complaint: “I fell in the middle of the night when I was getting up out of bed to use the bathroom.”
Past Medical History:
? Gall bladder removed at the age of 45
? Mild chronic pain related to arthritis; client reports taking Tylenol on rare occasions
Vital Signs:
? T: 99.8 F, RR 20 bpm, O2 sat 98% on room air
? In lying position: BP 110/80, HR 76
? Immediately after standing: BP 88/70, HR 88
? After 1 minute standing, BP 90/76, HR 82
Assessment:
? Head: a 0.5 cm x 5 cm laceration that is not currently bleeding over the right eye
? Extremities: a purple hematoma over the right wrist, which is swollen
? Pain: 3/10 to the right wrist with movement; facial grimacing noticed when moving the right wrist
? Skin: turgor is poor with notable 2+ (moderate) tenting to skin on the forearm
? Gastrointestinal/Genitourinary: eats two regular meals a day; last bowel movement was 2 days ago; reports urine being darker yellow than usual and slightly cloudy; denies any dysuria but reports having urinary urgency
? Social: client reports living home alone and does not have any living family members; spouse died 3 months ago and had no children. Client reports having some friends at a local senior center, where the client goes to on a weekly basis. Client considers to be Catholic and attended mass weekly until spouse passed away.
Diagnostic exam: X-Ray shows a hairline fracture to the right wrist
1. Review the Daily Holistic Assessment Tool (DHAT). Based on this case study and the DHAT, list three questions you would like to ask this client?
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2. Highlight phrases in the case study that are important information to follow up on for this client.
3. List three nursing diagnoses that are a priority based on your holistic assessment of this client:
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4. Choose one of your nursing diagnoses listed above and complete a care plan for this client utilizing the care plan template (on the next page). Please make sure to cite resources using APA 7th Edition. Thank you.
Nursing Diagnosis: Focus on one priority problem. Assessment: Distinguish subjective and objective data that support your priority nursing diagnosis Planning: In SMART terms, write 1 short-term goal and 1 long-term goal for the Client. Intervention: Identify 2 nursing interventions that would assist in accomplishing the goals AND include the rationale with the source (may utilize Yoder & Wise or Doenges books). Evaluation: Use specific terms to determine how the short-term and long-term goals were met.
Nursing Diagnosis:
Subjective Data:
Short-Term Goal:
First Intervention:
Rationale:
Short-Term Goal Evaluation:
Objective Data:
Long-Term Goal: Second Intervention:
Rationale: Long-Term Goal Evaluation:
