Plan Of Care
Winter 2018 Professional Practice I – Assignment
Date Due: March 30, 2018.
Assignment Guidelines:
1. Format: must be word processed, double-spaced with cover page and reference page.
2. If not word processed, your paper will not be graded and a mark of “0” will be assigned.
3. Must be submitted in the two assigned drop boxes. 1) Nursing Care Plan and 2) Self-Assessment and Learning Plan
4. In – text referencing following APA format is required for the Interventions in your Care Plan, including page numbers.
5. Please note: marks are assigned specifically for scholarly writing. (Spelling, grammar, referencing, clarity, style and format etc.)
Your Assignment:
1. Use the Nursing Care Plan template below to complete a care plan for the patient below as follows:
Identify 2 nursing diagnosis – 1 actual and 1 potential 4 marks
List all of the assessment data that supports each of your diagnosis. 2 marks
Identify 1 goal/plan statement for EACH nursing diagnosis. 2 marks
Identify 4 nursing interventions for each goal/plan statement. These must be referenced using APA format. 4 marks
2. Using the 5 Practice Concepts and associated Practice Components attached and based on the care needs of this client
complete a Self- Assessment using the table below. Identify 4 of your strengths and 4 areas for improvement. Please be specific. 4 marks
3. Based on your self-assessment AND the care needs of your client complete 2 learning plans using the approved format. 8 marks
4. Complete assignment using understandable and correct wording, spelling, grammar and sentence structure. Submit assignment 4 marks
following format requirements (Nursing Care, Self-Assessment and Learning Plan charts). Accurately follow APA guidelines for in-text
citations and reference page.
Please ensure that you include a cover page and reference page. DO NOT submit this assignment outline with your submission.
The Client: #35467
GH is an 82 year old male widow with three grown children. One daughter lives nearby, the other two live in different provinces. Mr. H is Japanese and has only lived in Canada for the past two years. He is financially stable and has a close relationship with his children. This is his first experience with the Canadian health care system.
The Diagnosis
The client’s admitting diagnosis is: exacerbation of COPD (chronic obstructive pulmonary disease), CAD (coronary artery disease), diabetes and possible small bowel obstruction.
History:
Mr. H has been diabetic for 15 years and has been reasonably well managed with diet and Insulin although meeting his dietary needs has been a challenge since arriving in Canada. He has had COPD for the past 5 years and CAD for 10 years. He smokes 1 package of cigarettes per day and has done so for the past 65 years. He has had frequent problems with constipation over the last 2 years and has been treated with suppositories and Fleet Enema’s PRN. He has significant vision loss due to diabetic retinopathy. He has never had surgery before and is quite concerned about this possibility. He speaks English very poorly and cannot read English at all. His daughter acts as his translator on a regular basis but does not have Power of Attorney for personal care.
Admission Findings:
When he arrives from the emergency department you find a frail, elderly man who is short of breath and repeatedly pointing to his abdomen and grimacing. He walks with a pronounced limp on the left side. He appears anxious and is unable to answer most of your questions due to the language barrier. He appears to be in considerable physical and emotional distress. His vital signs are: T – 38.6 P – 102 BP – 186/98 R – 24 O2 sat 88 on room air. He is well groomed but appears reluctant to allow you to remove his clothing so that you can get him settled in bed. He keeps pointing to the phone but can’t explain what he wants you to do. He attempts to light a cigarette and doesn’t seem to understand that he can’t smoke in hospital. When you remove his shoes you find that his great left toe appears gangrenous and his nails are badly ingrown on both feet.
Doctor’s Orders:
Bed rest with bathroom privileges – A1 Deep breathing and coughing exercises q4h
Foot care nurse to see Abdominal ultrasound today
Stool for Culture and sensitivity Fleet enema PRN
NPO Dietician to see
Vital signs q4h Abdominal x-ray today
Diabetic Clinic nurse to see Intake and output q8h
Oxygen at 2L/min via NP PRN Contact Translation Services to see asap
Bedside glucometer ac and hs 1500 calorie diabetic diet
Care Plan
Student Name ________________________ Date_____________________________
Nursing Diagnosis
Assessment data that supports the nursing diagnosis
Plan/Goal(s)
Interventions
1.
_________________________
2.
___________________________________________
_________________________
________________________________
PRACTICE CONCEPTS
The practice caring concepts represent a framework for professional practice. Each concept reflects a theme in nursing practice. Topics relating to each practice concept have been identified and are referred to as components. The practice concepts help to link the caring curriculum to the standards of nursing practice.
PRACTICE CONCEPTS
COMPONENTS
CARING AND COMPETENCY
· Psychomotor Skills ( Documentation
· Reporting ( Technology
CARING AND CONNECTEDNESS
· Therapeutic Relationships ( Cultural Diversity
· Team Building ( Collaboration
· Caring Relationships ( Client Confidentiality
CARING AND HEALING AND HEALTH PROMOTION
· Advocacy ( Healing Environment
· Client Autonomy ( Teaching and Learning
CARING AND PRACTICE JUDGEMENT
· Critical Thinking ( Consultation
· Prioritizing ( Preparation
· Standards ( Legislation
· Policies ( Expectations
· Assessment ( Nursing Care
· Evaluation
CARING AND PROFESSIONALISM
· Punctuality ( Attendance
· Comportment ( Self-Assessment
· Leadership ( Role Socialization
· Accountability ( Assignments
Self- Assessment
Areas of Strength
Practice Concept
Practice Component
1.
2.
3.
4.
Areas for Improvement
1.
2.
3.
4.
Student Name: ____________________________________________________Date:__________________________________
Learning Plan
Name:
Learning Needs: What learning needs did I identify through practice reflection and peer input etc.? Identify a minimum of 3 learning needs.
1.
2.
3.
Learning Goal #1 (goal must be based on your learning needs) Practice Concept:
Activities and Timeframes How am I going to achieve my goal? Identify a minimum of 3 learning activities with timeframes for each.
Evaluation of changes/outcomes to my practice: How can I demonstrate to my teacher that I have achieved my goal? Identify 3 ways that you can demonstrate you have achieved your goal.
Learning Goal #2 (goal must be based on your learning needs) Practice Concept:
Activities and Timeframes How am I going to achieve my goal? Identify a minimum of 3 learning activities with timeframes for each.
Evaluation of changes/outcomes to my practice: How can I demonstrate to my teacher that I have achieved my goal? Identify 3 ways that you can demonstrate you have achieved your goal.
