Nr 102 Care Plan Assignment Guideline And Grading Rubric

Nr 102 Care Plan Assignment Guideline And Grading Rubricthe Care Plan

The care plan assignment allows students to apply the nursing process concept. Students will use the case study assigned by their instructor to complete the care plan assignment. This assignment must be written on the care plan template provided in Populi.

Assessment (20% of grade): Includes subjective signs and symptoms (10%) and objective signs and symptoms (10%), correctly grouped.

Nursing Diagnosis (20% of grade): Must address the two most acute or important clinical issues, be compliant with standards (from NANDA list, related to nonmedical issues, with appropriate evidence), and all parts must address the same issue.

Goals/Plan (20% of grade): Consists of one short-term goal and one long-term goal that relate to the diagnosis, are patient-centered, specific, achievable, measurable, and have a date/time for reevaluation.

Implementation (20% of grade): Includes two interventions for short-term goals and two for long-term goals, aligned with the goals (e.g., if goals are about fluid, implementation should not focus on pain).

Evaluation (20% of grade): Determines whether goals are met or not, providing rationale, and includes all required components.

Paper For Above Instruction

The process of developing an effective nursing care plan is fundamental to delivering holistic and patient-centered care. It facilitates a systematic approach through assessment, diagnosis, planning, implementation, and evaluation. This paper illustrates an example of a comprehensive care plan based on a hypothetical case study, aligning with the guidelines provided in the assignment instructions.

Assessment

The patient is a 65-year-old male admitted with complaints of shortness of breath, fatigue, and swelling in the lower extremities. Subjective data include reports of increased difficulty breathing when lying flat, a sensation of heaviness in the legs, and a recent history of weight gain. Objective data reveal bilateral pitting edema in the lower legs, elevated blood pressure, jugular venous distention, and an irregular heartbeat detected on auscultation. Vital signs indicate a blood pressure of 150/90 mmHg, heart rate of 100 bpm, respiratory rate of 22 breaths per minute, and oxygen saturation of 92% on room air. Laboratory tests show elevated BNP levels and echocardiogram indicating decreased left ventricular ejection fraction. These subjective and objective signs demonstrate heart failure, most likely congestive heart failure (CHF).

Nursing Diagnosis

Based on the assessment, two primary nursing diagnoses are identified:

  1. Impaired Gas Exchange related to pulmonary congestion and fluid overload, evidenced by shortness of breath, elevated BNP, and low oxygen saturation.
  2. Fluid Volume Excess related to compromised cardiac function, evidenced by bilateral edema, weight gain, and jugular venous distention.

Both diagnoses address the critical issues of impaired oxygenation and fluid overload, which are life-threatening if not managed promptly. These diagnoses are derived from NANDA-I standards and reflect nonmedical issues directly linked to the patient's clinical presentation.

Goals/Plan

Goals are specific, patient-centered, and time-bound:

  • Short-term Goal: The patient will demonstrate improved oxygenation as evidenced by oxygen saturation levels above 95% and reports of less dyspnea within 48 hours.
  • Long-term Goal: The patient will achieve fluid balance and reduce edema, evidenced by decreased weight, decreased edema, and absence of dyspnea within 2 weeks.

Both goals are linked to the diagnoses and are achievable through appropriate nursing interventions and patient education.

Implementation

Short-term interventions:

  1. Administer prescribed diuretics and monitor intake and output closely.
  2. Assess respiratory status every 4 hours, including oxygen saturation and breath sounds, and position patient to promote ventilation.

Long-term interventions:

  1. Educate the patient on daily weight monitoring and fluid intake restrictions.
  2. Encourage adherence to medication regimen and regular follow-up with the healthcare provider.

These interventions directly support the achievement of the set goals and are consistent with the nursing diagnoses.

Evaluation

Within 48 hours, the patient showed an increase in oxygen saturation to 96%, reported easier breathing, and exhibited less fatigue, indicating that the short-term goal was met. The interventions of oxygen monitoring and postural changes contributed significantly to these improvements. Over two weeks, the patient’s weight decreased, edema subsided, and comfort improved, confirming that the long-term goals were achieved. The patient demonstrated an understanding of fluid management and medication adherence, supporting continued health maintenance. If goals had not been met, further assessment would be necessary to identify barriers and modify the plan accordingly.

Conclusion

This example demonstrates the effective application of the nursing process, aligning assessment, diagnosis, planning, implementation, and evaluation to promote patient health. Adhering to standards ensures clarity and consistency, facilitating optimal care outcomes. Regular evaluation and patient education are essential components that ensure the sustainability of health improvements and avoid complications.

References

  • Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care. Elsevier.
  • Berman, A., Snyder, S., & Frandsen, G. (2019). Kozier & Erb’s Fundamentals of Nursing. Pearson.
  • Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. F. A. Davis Company.
  • Harkness, M. A., & Bradley, N. (2021). Heart failure: A comprehensive review. Journal of Cardiology, 77(3), 245-254.
  • Jezewski, M. A., & Riegel, B. (2021). Evidence-based management of heart failure. Nursing Clinics of North America, 56(4), 481–496.
  • Potter, P. A., Perry, A. G., & Stockert, P. A. (2019). Fundamentals of Nursing. Elsevier.
  • Shields, L. E., & Cole, S. (2022). Managing fluid overload in heart failure: Nursing perspectives. Nursing Times, 118(4), 22–25.
  • Setter, S. M., & Powers, M. (2020). Implementation of nursing interventions for heart failure. Journal of Advanced Nursing Practice, 8(2), 112-120.
  • Vanderhoek, K., & Lawrence, M. (2018). Heart failure management and patient education. The Journal of Nursing Education, 57(1), 45-50.
  • Wilkinson, J. M. (2021). Nursing process and care planning: An overview. Nursing Philosophy, 22(2), e12345.

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