Nursing Scenario Michelle Mason is a 62-year-old African American female who lives at home alone. She has been under the care of her PCP for hypertension

Nursing Scenario
Michelle Mason is a 62-year-old African American female who lives at home alone. She has been under the care of her PCP for hypertension

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Scenario

Michelle Mason is a 62-year-old African American female who lives at home alone. She has been under the care of her PCP for hypertension and diabetes. Recently she has not been feeling well, she complains of dizziness and fatigue. The dizziness has caused her to be afraid to leave the house. The fatigue has caused her to lose interest in her ADLs. She has been sleeping throughout the night and most of the day, in addition she has not been in contact with her friends or her family.

Instructions:

Develop a Care Pan for Michelle Mason with:

1. Three priority nursing diagnoses

2. One goal for each nursing diagnosis

3. Three interventions for each goal

4. A rationale for each intervention

5. One evaluation for each goal


CLINICAL APPLICATION OF THE NURSING PROCESS TOOL

Name _________________________

Course _________________________

Instructor _________________________

Client’s initials:__________ Actual Developmental Stage: _________________________

Gender: _____ Age: _____ Perceived Developmental Stage: _______________________

Reason for admission (if applicable) _____________________________________________

Analysis (nsg.dx)

Expected Outcomes

(client goals)

Implementation

(nursing interventions)

Rationales

(Why? w/ references)

Evaluation

(of goals)


Scoring Code Key Student Name: _____________________

S – Satisfactory

NI – Needs Improvement

U – Unsatisfactory

Please submit this scoring criterion with the Care Plan.

Area to be scored

Scoring code

1. Analysis

0. Determined basic needs of the client which are threatened

0. Nursing Diagnosis are in priority order based on Maslow’s Hierarchy of Needs, and ABC’s (airway, breathing, circulation)

All parts of the nursing diagnoses present and appropriate (Diagnosis statement, Related to (R/T) factors, patient specific – as evidenced by (AEB) subjective and objective (S / O) data)

1. Plan

1. Goals are appropriate (time specific, measurable, focused, realistic) and related to the Nursing Diagnosis

1. Measures to accomplish goal are appropriate

1. Rationale

2. Uses scientific principles

2. Reference sources are noted

1. Implementation

3. Nursing actions carried out are specific and appropriate for goal attainment

1. Evaluation

4. Describes clients responses to nursing interventions

1. Determines the extent to which goals have been met

(States goal attained, not attained or partially attained)

COMMENTS:

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