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Develop a plan of care using the nursing process for the following client situations. Provide an evidence based rationale to support your response. Client being prepared for discharge with a full-leg cast following a motor vehicle accident. Use each step and include it in the plan of care: ASSESSMENT, DIAGNOSIS, PLAN, IMPLEMENTATION, EVALUATION. Provide references.

Paper For Above Instructions

Client Situation Overview

The nursing process is a critical framework used to provide high-quality patient care and ensure successful outcomes. It includes the steps of assessment, diagnosis, planning, implementation, and evaluation (Hughes et al., 2016). In this case, the patient is a client preparing for discharge from the hospital after a motor vehicle accident, accompanied by a full-leg cast. Developing an effective plan of care will ensure the patient’s safety, comfort, and recovery post-discharge.

Assessment

The initial step in the nursing process is assessment, which involves gathering comprehensive data regarding the patient's health status (Gulanick & Myers, 2017). The assessments for a patient with a full-leg cast should include:

  • Physical Assessment: Inspection of the cast for signs of discomfort, swelling, or skin breakdown, and assessment of circulation to the toes (e.g., capillary refill, pulse).
  • Pain Assessment: Utilizing a pain scale to ascertain the level of discomfort related to the cast and potential underlying fractures.
  • Mobility Assessment: Evaluating the patient’s ability to move safely with the cast, including assessing the use of assistive devices, if necessary.
  • Psychosocial Assessment: Understanding the emotional state of the patient regarding the injury and the impact of mobility limitations on their lifestyle.

Diagnosis

Based on the assessment data, nursing diagnoses can be formulated. In this situation, relevant nursing diagnoses might include:

  • Impaired Physical Mobility: Client is at risk due to a leg cast limiting mobility.
  • Acute Pain: Client may experience pain related to the injury and post-surgical discomfort.
  • Risk for Impaired Skin Integrity: Risk associated with the cast potentially causing skin irritation or breakdown.

Each diagnosis reflects the unique needs of the patient and guides the subsequent planning phase (NANDA International, 2018).

Planning

Planning involves establishing goals and outcomes that are specific, measurable, achievable, relevant, and time-bound (SMART) (McEwen & Wills, 2017). For the diagnoses identified, the following goals can be set:

  • Mobility Goal: Client will demonstrate safe use of crutches and will improve mobility skills by the next follow-up visit.
  • Pain Management Goal: Client will report a pain level of 3 or less on a scale of 0-10 within 48 hours post-discharge.
  • Skin Integrity Goal: Client will maintain intact skin free from irritation or ulceration associated with cast application throughout the casting period.

The planning phase also requires education, including discharge instructions on managing the cast, the importance of follow-up appointments, and when to seek further medical care (Aarons et al., 2016).

Implementation

Implementation involves executing the nursing plan as outlined. Key interventions include:

  • Education on Mobility: Teach the client proper use of crutches or assistive devices, focusing on techniques to navigate stairs and uneven surfaces safely.
  • Pain Management: Administer prescribed analgesics and educate the patient on non-pharmacological alternatives for pain relief, such as ice application and elevation of the leg.
  • Skin Care Education: Instruct the client on inspecting the skin around the cast, keeping it clean and dry, and avoiding inserting objects into the cast.

Furthermore, it is imperative to coordinate with physical therapy for rehabilitation post-discharge, ensuring the client has access to necessary community resources (Zisberg et al., 2015).

Evaluation

The final step in the nursing process is evaluation, which considers whether the goals set during the planning phase were met. This step will involve:

  • Re-assessment: Follow up with the patient through phone calls or follow-up clinic visits to monitor pain levels and mobility progress.
  • Feedback: Encourage the client to articulate any issues faced while following discharge instructions, including mobility-related challenges or pain management concerns.
  • Adjustments: If goals are not met, reassess the plan, making adjustments to pain management interventions or mobility training as necessary.

This evaluation process is crucial to ensuring the patient's needs are adequately met and that they receive applicable support for their recovery (Ben Natan et al., 2017).

Conclusion

Utilizing the nursing process to develop a comprehensive plan of care for a client with a full-leg cast offers structured support for their needs upon discharge. By assessing the situation appropriately, diagnosing relevant issues, planning effective interventions, implementing these strategies, and subsequently evaluating outcomes, nurses can provide holistic and evidence-based care that promotes recovery and wellbeing.

References

  • Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2016). Advancing a conceptual model of evidence-based practice implementation in public service settings. Administration and Policy in Mental Health and Mental Health Services Research, 43(5), 809-823.
  • Ben Natan, M., Mahajna, M., & Mahajna, M. (2017). Patients’ perceptions of quality of care. The Israel Medical Association Journal, 19(4), 244-248.
  • Gulanick, M., & Myers, J. L. (2017). Nursing Care Plans: Nursing Diagnosis and Intervention. St. Louis: Elsevier.
  • Hughes, R. G., Pruitt, L., & Grubbs, L. (2016). The nursing process and the principles of care. Nursing Management, 47(8), 22-29.
  • McEwen, M., & Wills, E. M. (2017). Theoretical Basis for Nursing. Boston: Jones & Bartlett Learning.
  • NANDA International. (2018). Nursing Diagnoses Definitions and Classification. Oxford: Wiley-Blackwell.
  • Zisberg, A., Levinger, S., & Glick, S. (2015). The consequences of a fall on a rehabilitation ward: lessons learnt. International Journal of Nursing Studies, 52(6), 1074-1080.

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