NUR2115 Module 10 Comprehensive Plan of Care

In this third and final submission of your Course Project, you will be completing a comprehensive care plan. This written assignment should include the following:

Comprehensive Plan of Care

Develop a comprehensive plan of care/treatment with short and long term goals and include safety needs, special considerations regarding personal needs, cultural/spiritual implications, and needed health restoration, maintenance, and promotion.

SAMPLE COMPREHENSIVE PLAN OF CARE PAPER

The patient that I have been working with at Rennes health and rehab center does have an extensive medical history. The patient’s medical history includes anemia, acute cystitis, acute kidney injury, coagulopathy, elevated IRN, falls, hypertension, lipedema, atrial fibrillation, cerebral artery occlusion with cerebral infarction, arthritis, dementia with delusions, neuropathy, bilateral lower extremity edema and overweight.

The patient had reduced bodily function which results in urinary incontinence, impaired dentition, impaired memory, decreased physical mobility, & impaired transferability (Doenges, Murr, & Moorhouse, NUR2115 Module 10 Comprehensive Plan of Care 2016). The patient was put on a soft food diet and thickened liquids to prevent aspiration. Upon assessment, the student nurse concluded the main concern for this patient is self-care deficit and ineffective health management evidenced by the reduced bodily functions mentioned above (Doenges, Murr, & Moorhouse, 2016). This was all obtained through the chart in the medical history section due to patient being a poor historian.

The patient was unable to tell any family history and there was nothing in the chart about family members other than she was widowed. The summary of the patient’s lab results are as follows: INR 1.1, Potassium 15.7, Iron 23, Hemoglobin 9.8, White blood cells 9.8, Platelets 3.6. The patients INR is low and should be between 2 and 3 to prevent any more clots from happening. The INR is important to have because of the stroke that the patient had this past January. NUR2115 Module 10 Comprehensive Plan of Care

The patient’s hemoglobin is important because of her past history of anemia. The patient’s hemoglobin is with in normal limits as of the patient’s last blood draw.

The patient has a decline in musculoskeletal mobility and cognitive functions; the patient is at risk for falls. Clients who are at risk for falls need attentiveness toward their living environments. NUR2115 Module 10 Comprehensive Plan of Care During transferring, health care personnel need to make sure the patient’s bed, wheelchair, or other assistive device is locked and grounded. The patient should be encouraged and demonstrate understanding to call for aid before attempting to ambulate out of the bed or chair.

This patient is at risk for aspirations and needs to be on thickened liquids. When eating, the client should be sitting up in a high fowler’s position to reduce the risk for aspiration. Because of the patient’s cognitive ability, the client should not be left alone during feedings. When sleeping in bed the patient should have a safety mat on the ground lateral to his mattress and the bed needs to be in the lowest position.

The patient is no longer able to accomplish all activities of daily living (ADL’s) by himself. The patient will needs around the clock care with the majority of his health management. It is essential for the healthcare staff to collaborate to promote the patient’s health in the best way possible. Short-term goals included a vocalization understanding by the patient in recognizing his strengths and weaknesses in ADL activities to allow for room and assistance. NUR2115 Module 10 Comprehensive Plan of Care

This goal will be measured by how well the client adheres to the healthcare plan on a daily basis (Doenges, Murr, & Moorhouse, 2016). The long term goal for this patient is to maintain or improve his health by executing self-care activities to his utmost capability (Doenges, Murr, & Moorhouse, 2016). To measure this, an evaluation will be conducted every month to demonstrate an improvement in ADL activities and to make adjustment if needed for continual enhancing of the plan. NUR2115 Module 10 Comprehensive Plan of Care

When providing care to clients, personal needs like cultural and spiritual implications should be incorporated into their care to provide the client with a sense of customized care. NUR2115 Module 10 Comprehensive Plan of Care This not only promotes patient-centered care, but also encourages the patient to adhere to the health maintenance and promotion that healthcare team is implementing. This patient is a devout Mormon who values his time with the local pastor and fellowship with other clients and his family.

Allowing the patient time to visit when possible promotes the nursing competency of holistic care. Personal needs of the client should be met when possible. The patient should be given opportunities to socialize with other residents through group activities and meal times. Encouragement of family visits should be implemented to promote social interaction and prevent risk of social impairment and depression (Doenges, Murr, & Moorhouse, 2016).

Strategy is important when implanting a care plan. Chronically ill patients like the patient need an ongoing effort to promote and maintain health. To effectively accomplish all the goals in the care plan, the health care team needs to work together to ensure adherence and continuation collaboratively. Competent and open communication and open communication will encourage improvement and point out flaws in the plan. NUR2115 Module 10 Comprehensive Plan of Care

This also allows for smooth implementation of new strategies, medications, therapies, and so on. Continual improvement and evidence based practice promotes patient safety, a critical point in all nursing care plans. To ensure proper adherence and promote client autonomy, involvement by the client should be allowed when possible with ADLs. (Doenges, Murr, & Moorhouse, NUR2115 Module 10 Comprehensive Plan of Care 2016). Regular checks should be implemented on a small and large scale to determine if all critical components of the plan are working effortlessly to improve the patient’s health condition.

NUR2115 Module 10 Comprehensive Plan of Care References

Jarvis, C. (2016). Physical examination and health assessment (7th ed.). St. Louis, MO: Elsevier.

Doenges, M. E., A. C., & Moorhouse, M. F. (2016). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales. Philadelphia, PA:F.S. Davis

NUR2115 Module 10 Comprehensive Plan of Care