Mrs. Y
Mrs. Y is an 84-year-old client who was recently discharged from the hospital for an infected diabetic ulcer on her left leg. During her hospitalization, Mrs. Y required intravenous antibiotic therapy through a peripherally inserted central catheter (PICC) line.
Due to Mrs. Y's long history of diabetes, her physician ordered that intravenous antibiotic therapy be continued at home. Subsequently, home health services were initiated, a home health nurse was assigned to Mrs. Y's case, and an initial home visit was scheduled.
The home health nurse arrives at Mrs. Y's home and introduces herself to the client and the family. The nurse explains the home nursing services that will be provided, including the PICC line and intravenous antibiotic therapy treatments.
During the initial home visit, the nurse assessed the physiological, psychological, functional, and safety needs of the client. The nurse's findings were as follows:
Example: Case Study Plan of Care and Concept Map
Case Scenario:
Concept Map:
Identify two (2) priority nursing diagnoses for Mrs. J and develop a concept map to illustrate them (see example below).
Primary Medical Diagnosis:
· Congestive Heart Failure
Prioritized Nursing Dx# 2
· Fluid Volume Excess r/t fluid retention as evidenced by swelling
Prioritized Nursing Dx# 6
·
Prioritized Nursing Dx# 5
·
Prioritized Nursing Dx# 3
·
Prioritized Nursing Dx# 1
· Impaired Gas Exchange r/t fluid overload as evidenced by shortness of breath
Prioritized Nursing Dx# 4
·
Nursing Plan of Care
For each of the priority nursing diagnoses, establish one (1) goal. For each goal create two (2) nursing interventions.
Prioritized Nursing Diagnoses |
Goal |
Nursing Interventions |
1. Ineffective Gas Exchange |
Pt will maintain oxygen saturations greater than 95% during my shift |
1. Give oxygen as ordered 2. Monitor clients oxygen saturations |
2. Fluid Volume Excess |
Pt will have decreased swelling in extremities by the end of my shift. |
1. Administer diuretic as ordered 2. Monitor Intake and Output |
,
Nursing Care of the Older Adult
Module 05 Assignment – Case Study Concept Map and Plan of Care
Primary Medical Diagnosis:
·
Prioritized Nursing Dx# 2
·
Prioritized Nursing Dx# 6
·
Prioritized Nursing Dx# 5
·
Prioritized Nursing Dx# 3
·
Prioritized Nursing Dx# 1
·
Prioritized Nursing Dx# 4
·
Nursing Plan of Care
Prioritized Nursing Diagnoses |
Goal |
Nursing Interventions |
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