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CASE STUDY
Please read this case study below and think about all of the content we have read and discussed. There is a care plan template that you are to fill out addressing each topic on the care plan. There has to be 3 care plan in total, with nursing diagnoses in three different templates, the first template needs to have the priority nursing diagnosis, the second template needs to have the long term nursing diagnosis and the last template needs to have the educational nursing diagnosis, all related to the case study. Below you will find a rubric you must use that will guide you in completing this exam.
NUR 422: Case Study and Care Plan
Using the following case study, develop a care plan to meet the needs of this client. Follow the rubric, you may use your Townsend book and other resources and are required to cite in APA.
Mr. X, a 68-year-old married Chinese man comes to the office for a follow up appointment. Mr. X is a retired cook who lives at home with his wife, MRS. X, who does not speak English.
Today, Mr. X complains of difficulty falling asleep, and irritability for the past 6 months. He states he has frequent headaches, dizziness, and a sensation of tightness in the chest and palpitations. Three weeks before this visit, he had several episodes of chest pain and called 911 each time. Mr. X was admitted for a medical evaluation. Results of all lab work, EKGs, a cardiac ultrasound, and a stress test were all negative. Due to ongoing complaints, Mr. X was referred for a psychiatric consultation. Despite sensitive probing by the psychiatrist, Mr. X denies symptoms of depression. He has no history of psychiatric or physical illness and is not prescribed medications. He does endorse feeling on edge and being nervous all day.
When asked about his family, Mr. X reports that his wife had worked for many years as a nanny in a distant town and they were accustomed to living apart. She retired 6 months ago and returned to live with him. He became agitated when talking about his wife and described her as “a headstrong woman who always did things her way”. The psychiatrist pointed out to him that his symptoms could be related to his recent life changes because they started when his wife rejoined him. Mr. X was able to articulate that his symptoms got worse when his wife aggravated him. They fought frequently about everything from how to set up a monthly budget to arranging their furniture, to what gifts to send to their children. He remembered that before he went to the emergency department at the hospital, he was angry with his wife because “she put wet dishes in the wrong place and messed up the kitchen.” Mr. X stated that he could not stop the worrying about the dishes and declined the offer to start Sertraline 25 mg daily.
Grading Rubric
Content Unacceptable (-3 points each) Acceptable (-2 points each) Exemplary Score
Data Cluster
Subjective (Patients’ words” and
Objective (Assessment data)
10%
Does not recognize the data cluster applicable to the nursing diagnosis. Recognizes some of the data cluster supporting the development of an appropriate nursing diagnosis based on the case.
Recognizes and reports the critical data elements representing the factual basis for the development of a priority nursing diagnosis.
Nursing Diagnoses
15%
Does not recognize the priority major nursing diagnosis; does not identify long term diagnosis or educational diagnosis; diagnostic statement are not in PES format
Recognizes a nursing diagnosis, may or may not be able to target appropriate priority diagnosis; includes long term diagnosis and educational nursing diagnosis related to case information. Diagnostic statements are presented in PES format.
Recognizes 3 pertinent nursing diagnosis, to include;
priority diagnosis
long term diagnosis
educational nursing diagnosis
related to case information.
Diagnostic statements are presented in PES format utilizing NANDA resource. Nursing diagnoses are synthesized from assessment data, and accurately reflect the client’s care needs.
Patient Centered Goals
10%
Does not recognize a goal or mentions goals that are not based on the nursing diagnosis. Goals not measurable or time specific. Recognizes one or more goals in the case; may not always be related to the nursing diagnosis or may not all be measurable. . Recognizes 1 appropriate and measureable goal for each nursing diagnosis. Goals are appropriately stated as short term or long term and measurable.
Implementation
20%
Does not select and apply 2 appropriate nursing interventions for each goal identified; interventions are not related to the goal statement; interventions are not cited.
Identifies < 2 appropriate interventions; interventions are somewhat based on the nursing goals identified; interventions are cited. Identifies 2 interventions for each goal; each intervention relates specifically to the goal; and the need of the client. Each intervention is cited Rationales 5% Rationales for selected interventions are not provided or are not appropriate. Rationales for some selected interventions are provided and somewhat appropriate to the identified intervention. Rationales are provided for all identified nursing interventions; rationales are appropriate, patient centered, and logical. Evaluation 10% Evaluation statements do not match the identified goal. Evaluation statements are closely related to the identified goals. Goal is identified as having been "met," "not met," or "partially met." Evaluation statements are aligned with identified goals. There is one evaluation statement for each identified goal. Organization 10% The writing is not logically organized. Frequently, ideas fail to make sense together. The reader cannot identify a line of reasoning. The writing is generally logical, although occasionally ideas fail to make sense together. The reader is fairly clear about what the writer intends. The ideas are arranged logically to support the central purpose of care plan development. They flow smoothly to one another and are clearly linked to one another. The reader can easily follow the line of reasoning Sentence Structure and word choice 5% Errors in sentence structure are frequent enough to be a distraction to the reader. Many words are used inappropriately. Some sentences are awkwardly constructed causing occasional distraction; word choice is merely adequate. Sentences are well phrased. They flow smoothly from one to the other. Word choice is consistently precise and accurate medical terminology is used Grammar, spelling and writing mechanics 5% There are so many errors that meaning is obscured. The reader is confused and stops reading. There are occasional errors but they do not represent a major distraction or obscure meaning. The document is free or almost free of all errors. Comments Total Score Date: _____________ Client Initials: _____ NURSING DIAGNOSIS: ­­­­­­­­­­­­­­­­­­­­­____________________________ RT: ___________________________________________ AEB: __________________________________________ NURSING CARE PLAN PRIORITY AIRWAY BREATHING CIRCULATION SAFETY OTHER: ______________ NURSING CONCEPT COGNITION COMMUNICATION COMFORT GRIEF INTERPERSONAL VIOLENCE MOOD & AFFECT PAIN SAFETY SEXUALITY SPIRITUALITY STRESS & COPING ASSESSMENT PLANNING GOAL Desired Outcome Specific & Measurable IMPLEMENTATION RATIONALE Reason for the interventions EVALUATION GOAL MET Patient Data Patient Will Nurse will: Why? What happened? Y/N ASSESSMENT PLANNING GOAL Desired Outcome Specific & Measurable IMPLEMENTATION RATIONALE Reason for the interventions EVALUATION Patient Data Patient Will Nurse will: Why? What happened? ASSESSMENT PLANNING GOAL Desired Outcome Specific & Measurable IMPLEMENTATION RATIONALE Reason for the interventions EVALUATION Patient Data Patient Will Nurse will: Why? What happened?

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