Care map

    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
The post Care map first appeared on COMPLIANT PAPERS.

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:
Mrs. Y lives alone; however, her daughter checks on her frequently throughout the day.
The client is noted to have moderate functional issues and ambulates with a cane.
The client has several throw rugs in the main walking quarters and minimal lighting throughout the hallways.
Mrs. Y states “I used to get around my house with ease, but now I get a little tired and have to sit down and
rest frequently.”
Consider Mrs. Y’s current health status and functional decline, then address the following:
Download the Concept Map and Plan of Care worksheet below. An example is also provided for your
reference.
Identify three (3) priority nursing diagnoses for Mrs. Y.
Create a visual representation of the three (3) priority nursing diagnoses by incorporating them into the
Concept Map (template in the worksheet). Be sure each nursing diagnosis includes the following elements:
“related to (r/t)” — description of the client’s problem
“as evidenced by” — description of the client’s symptoms
Complete the Nursing Plan of Care (table in the worksheet) describing what should be implemented for Mrs. Y.
Goals: Establish at least one (1) goal for each of the nursing diagnoses you identified (for a total of 3 goals).
Goals should be: patient specific, measurable, actionable, realistic, and time limited.
Nursing Interventions: Describe at least three (3) nursing interventions for each of the goals (for a total of 9
nursing interventions). Each intervention should be in alignment with the goal it is supporting.

The post Care map first appeared on COMPLIANT PAPERS.

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