Please help me Mrs. Hope is an

Please help me Mrs. Hope is an 86 year-old widowed female who was admitted to a nursing home 3 months ago. She is ambulatory, and able to perform self-care but transitioned to the nursing home after several falls in her apartment, with the latest one resulting in a fractured hip. Mrs. Hope does require the use of a walker since her surgical procedure. Her past medical history includes osteoarthritis, type II diabetes mellitus, hypercholesterolemia, and hypertension. She has three daughters and 7 grandchildren that visit on a regular basis. Today, Mrs. Hope’s daughter approaches you and states “I have some concerns about my mom. She doesn’t seem to have a lot of energy, and she is falling asleep during our conversations. I am very concerned about this change.” During your shift yesterday, you noted that Mrs. Hope did not each much of her dinner (only 25%) and she left the dining room early asking for her bedtime pills because she was very tired and wanted to go to bed. Given your observations, and the information provided by the daughter you make the decision to conduct a sleep assessment. During the sleep assessment Mrs. Hope provides the following information: she likes to go to bed around 8 pm, 9 at the latest she finds that she is able to fall asleep quickly, but wakes up several times during the night due to noise, having to urinate, and feeling cold (despite using multiple blankets) it takes hours for her to fall asleep after she has waken up she complains that her room is too bright, she likes to keep the bathroom light so she can easily locate it when she wakes up and needs to urinate Upon review of the chart, you not that several PSWs and nurses have documented that Mrs. Hope falls asleep during her meals, struggles with maintaining a conversation, and frequently states “I am just so tired”. It is noted that Mrs. Hope does not take any medications to assist with sleep, but frequently has a coffee with her nighttime snack. She does not participate in group activities, due to low energy and fatigue. Use the nursing process to identify the following from the information provided in the case study. Assessment: Assessment Data for the patient Diagnosis & Analysis: What is the priority problem being experienced by the patient? This is your diagnosis. Planning: How and When does this need to be fixed? What are the priorities? Intervention: What nursing interventions both pharmacological and non-pharmacological can you use to support this patient’s care needs that DIRECTLY will impact the priority problem? How do you know this is an important intervention? Evaluation: This is your outcome! What do you expect will happen after the intervention is implemented? What is the timeline that it should be completed within? Your care plan must include: 1) Diagnosis – choose ONE that pertains to the client 2) 2 goals related to the above diagnosis 3) For EACH goal you are required to have two interventions; one related to social determinants of health the other anatomical/physiological 4) Each intervention needs an outcome statement please ensure you include a TIMELINE Rubric: Care Plan Assignment Requirement Grade Comments Template Completed /2 Assessment Complete patient assessment by systems Areas of concern and/or symptoms identified Similar areas of concern and/or symptoms grouped/clustered together Areas of concern and/or symptoms are prioritized, highest to lowest Actual or potential problem indicated and listed /5 Nursing Analysis & Diagnosis One priority problem identified that shows evidence of critical thinking and that there is an understanding of the client’s condition PES statement Nursing diagnosis identified and supported by defining characteristics and related findings Defining characteristics and assessment data relevant to identified nursing diagnosis transferred to Assessment column of NCP template /10 Outcomes/Goal Two goals written relating to nursing diagnosis and specific to the patient’s needs Each goal written as an action (SMART) Goal is focused on resolving symptoms /10 Interventions and Rationales Interventions are appropriate for the specific patient and outcome/goal and show evidence that client’s condition and developmental level is understood Rationales provided for each intervention and supported by nursing theory and scientific evidence (Referenced) Evidence of critical thinking References are appropriate and scholarly Two interventions identified for each outcome/goal /10 Evaluation Evaluation statement indicates when and how the client outcome/goal will be evaluated as met or unmet for the specified timelines /5 TOTAL GRADE /42 CARE PLAN TEMPLATE Nursing Diagnosis/Priority Problem: Goal 1 Form Assessment Data/ Defining Characteristics (Signs and symptoms supporting the chosen nursing diagnosis) Client Outcomes (SMART: specific, measurable, achievable, realistic and time specific) Nursing Interventions (Nursing initiated actions based on the medical plan of care and client outcomes) Rationale/Evidence Based (Reasons why each intervention is expected to work; connect to nursing theory, pathophysiology, APA cited) Evaluation (Expected Outcomes achieved? Not achieved? What is next? Future plan)

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