Assignment Guidelines:
- Format: must be word processed, double-spaced with cover page and reference page.
- If not word processed, your paper will not be graded and a mark of “0” will be assigned.
- Must be submitted in the Nursing Care Plan Assignment drop box
- Please note: In – text referencing following APA format is required for the Interventions in your Care Plan, including page numbers.
- Please note: marks are assigned specifically for scholarly writing. (Spelling, grammar, referencing, clarity, style and format etc.)
- This assignment is to be completed in pairs.
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 with a rationale for each intervention.
These must be referenced using APA format. 4 marks
2. Complete assignment using understandable and correct wording, spelling, and grammar and sentence structure. Submit assignment 2 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: # 4362-12
Mary Smith is a 29 year old divorced mother of 2 young children aged 4 and 6. She has no family living in Ontario. She was diagnosed with Multiple Sclerosis about 5 years ago and the disease has progressed quite rapidly. She now depends on a walker for ambulation and has experienced episodes of dysphagia recently. She had colon surgery 1 year ago due to bowel adhesions from her 2 C-Sections. She now has an ileostomy that has been producing large amounts of foul smelling, watery effluent. She tells you that she’s embarrassed to go out due to leakage around her appliance and the odour. When you ask her about her diet she tells you that she’s on a fixed income and basically eats whatever she can afford. Most of her money goes towards food and clothing for her children. She has been off work since her surgery and relies on Welfare and child support to get by. Mary tells you that she has lost about 10 kg. since her surgery and she appears weak and cachectic. She has a productive cough and tells you that it hurts to take a deep breath. Her children are currently being cared for by a close friend.
The Diagnosis
The client’s admitting diagnosis is: ?Pneumonia, generalized weakness, dehydration, malnourishment and dysphagia.
History:
Ms. Smith moved to Ontario from Nova Scotia about 8 years ago after she got married to her former husband. After she was diagnosed with MS, her husband filed for divorce. He’s been making regular child support payments and sees the kids a couple of times a week. Mary has a cordial relationship with him but he has remarried and is not providing much help to her. In addition to generalized weakness, Mary has been experiencing vision loss and bladder control issues as her MS has progressed. Mary used to be very active in the community and coached women’s soccer for a number of years. She loves to read but is having difficulty with this as her vision loss progresses. She has never been a religious person but states “only God can help me get out of this mess”. She’s quite worried that she will never be able to go home and be a “family” again. Mary had no health issues until she was diagnosed with MS. She lives in an accessible apartment and has great neighbours and friends who are “there for her” but she really hates to ask others for help.
Admission Findings:
On admission you find a frail, young lady who is very quiet in her demeanour and does not want to bother anyone. She appears sad and somewhat depressed. Her ostomy appliance has been leaking stool and appears to be badly in need of changing. Upon inspection, the periostomal edges are red and inflamed and she has a 3 cm ulceration on the posterior aspect of her stoma. She needs a shower and hair wash badly and has a very unpleasant body odour. Her clothing are soiled with stool leaking from her stoma. Her vital signs are: T – 38.5 P – 92 BP – 146/80 R – 24 She wears glasses to read and has excellent hearing.
Doctor’s Orders:
bed rest with bathroom privileges – A1 Stomahesive powder and skin prep to edges of stoma
contact precautions Stool for C&S ASAP
Urine for Culture and sensitivity Enterostomal therapist to see
DAT – push fluids dietician to see
Vital signs q8h Chest x-ray today
Opthalmologist to see intake and output q8h
Oxygen at 2L/min via NP PRN Deep breathing and coughing exercises q4h
Care Plan
Student Name ________________________ Date_____________________________
| Nursing Diagnosis | Assessment data that supports the nursing diagnosis | Plan/Goal(s) | Interventions |
| 1. _________________________ 2. | ___________________________________________ | _________________________ | ________________________________ |
