Please help me, I need care plan.

Please help me, I need care plan. 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 S: Rose Senters, age 71-year-old female B: She is a previously healthy woman who lives in a condo with her husband in Winnipeg, she has 2 kids and grandchildren who are supportive. She has a history of hypertension for which she is on medications and suffers from insomnia. She fell at her condo and states she slipped in some water on the kitchen floor and that she did not hit her head. She was on the floor for about 3 hours or so, her husband came home and called the ambulance. A: She is alert and orientated to person, place, and time Her pupils are reactive to light and she has minimal pain at this time. Vital signs are normal, BP 98/75, P 85, RR 22, SPO2 98 % on RA. Pulses are palpable, she has a bruise to her right knee and side of her leg. She says she is not in any pain at this time. R: We should follow through with a complete pain assessment. During the pain assessment Mrs. Rose provides the following information(after watching the simulation video, I wrote) She has allergies to penicillin She’s complaining 3 out of 10 for pain in her right leg where she had fallen in hurt herself. This is the new onset of pain from the fall that is progressively getting worse and jurts more with movement. she describes the pain as a throbbing adult ache. it is localized to her right leg where she has the bruising and a bit of swelling. the skin is intact. she has not had andthing for pain yet but I think we do need to give her something to help relieve her of the pain. After assessment (after watching the simulation video, I wrote it) the nurse wants to give her 650mg of Tylenol. Because while she rated at three out of ten for pain and has not received anything as of yet. Normally we should start with a non-opioid analgestic for mild pain. CARE PLAN TEMPLATE Nursing Diagnosis/Priority Problem: Please include “as evidenced by ” 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) Goal 2 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) SCIENCE HEALTH SCIENCE NURSING PNUR 2020

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