Nu211 Intro To Clinical Practice Care Plan Templates Student ✓ Solved

Nu211 Intro To Clinical Practicecare Plan Templatestudent Name

Develop a comprehensive nursing care plan based on a case study of an 82-year-old female patient presenting with hypothermia. The care plan should include an assessment of the patient's current condition, identification of nursing diagnoses, development of SMART goals and outcomes, detailed nursing interventions related to each goal, rationales supported by evidence-based sources, and evaluation criteria. Ensure all components are supported by credible references formatted in APA style.

Sample Paper For Above instruction

Introduction

The management of hypothermia in elderly patients presents unique challenges due to age-related physiological changes and comorbidities. This paper develops a detailed nursing care plan for an 82-year-old female patient admitted with moderate hypothermia following a fall at home. Through comprehensive assessment, appropriate nursing diagnoses are identified, and evidence-based interventions are proposed to achieve optimal patient outcomes. The plan emphasizes holistic, patient-centered care that incorporates critical thinking and system-based approaches to ensure safety, comfort, and recovery.

Assessment

The patient is an 82-year-old woman presenting with a body temperature of 90.1°F, altered mental status, and fall-related injuries. She has a history of hypertension, COPD, anemia, and prior fall incidents. On assessment, her vital signs showed a blood pressure of 150/90 mmHg, pulse rate of 45 bpm, and oxygen saturation of 95%. She was found with multiple bruises, swelling, redness on her sacrum, dry mucous membranes, and edema in extremities. She was hypothermic and unresponsive initially but responded to intervention by rewarming measures. Her laboratory results indicated anemia, hypocalcemia, and decreased kidney function, consistent with age and her clinical condition.

Identification of Nursing Diagnoses

Based on the assessment, three primary nursing diagnoses were identified:

  1. Impaired thermoregulation related to hypothermia as evidenced by body temperature below 95°F, altered mental status, and cold skin.
  2. Risk for falls related to age-related balance deficits, previous fall incident, and altered mental status.
  3. Impaired skin integrity related to prolonged immobility, pressure from bruises, and hypothermic skin changes.

Goals and Outcomes

For each diagnosis, two SMART goals (one short-term and one long-term) are formulated:

  1. Impaired thermoregulation
    1. Short-term: The patient will have a body temperature within the normal range of 98.6°F within 4 hours of rewarming interventions.
    2. Long-term: The patient will maintain a stable body temperature between 97°F and 99°F during her hospitalization.
  2. Risk for falls
    1. Short-term: The patient will demonstrate understanding of fall prevention measures within 24 hours through patient and family education.
    2. Long-term: The patient will experience no further falls during hospitalization and upon discharge.
  3. Impaired skin integrity
    1. Short-term: The patient’s skin will show no progression of pressure ulcers or skin breakdown within 48 hours.
    2. Long-term: The patient will have intact skin with no new pressure ulcers prior to discharge.

Interventions to Achieve Goals

Each SMART goal is supported by specific, evidence-based nursing interventions. All interventions are aimed at promoting patient safety, comfort, and recovery.

Impaired thermoregulation

  1. Administer warming measures such as heated blankets, warm IV fluids, and environmental temperature control to restore core temperature.
  2. Monitor vital signs and body temperature every 30 minutes to assess response to rewarming efforts.
  3. Assess for shivering, altered mental status, and other signs of hypothermia progression or improvement.

Risk for falls

  1. Implement fall prevention protocols, including bed alarms, ensuring a clutter-free environment, and adequate lighting.
  2. Provide patient education on safety measures, including proper use of assistive devices and caution during mobilization.
  3. Assess patient’s mobility status daily and involve physical therapy for strength and balance training.

Impaired skin integrity

  1. Reposition the patient every two hours to alleviate pressure points and promote circulation.
  2. Use pressure-relieving devices such as specialty mattresses or cushions.
  3. Inspect skin regularly, especially over bony prominences, and document any changes or breakdowns.

Rationale and Evidence-Based Support

The interventions are grounded in current clinical guidelines and research. Rewarming measures such as warmed IV fluids and external heat application are standard practices for moderate hypothermia (Blahd & Husney, 2018). Continuous monitoring enables timely assessment of patient response, reducing risk of cardiac arrhythmias (Mayo Clinic, 2019). Fall prevention strategies are critical for elderly patients, minimizing injury risk (Oliver et al., 2010). Repositioning and pressure-relieving surfaces prevent pressure ulcers, which can develop rapidly in immobilized, hypothermic skin (Debas et al., 2020).

Evaluation

The effectiveness of interventions is measured by the achievement of SMART goals:

  1. The patient’s body temperature stabilized within the target range of 98.6°F within 4 hours, indicating effective rewarming.
  2. The patient demonstrates understanding of fall prevention measures, as evidenced by patient and family feedback, and reports no new falls during hospitalization.
  3. No new pressure ulcers or skin breakdowns are observed prior to discharge, supporting the effectiveness of skin integrity interventions.

Progress is documented in the patient’s chart, and care adjustments are made based on ongoing assessment findings.

Conclusion

A well-structured nursing care plan addressing hypothermia in elderly patients requires comprehensive assessment, prioritized diagnoses, SMART goals, and evidence-based interventions. Continuous evaluation ensures that care remains effective, promoting recovery and preventing complications. This holistic approach integrates clinical best practices and critical thinking, essential for optimizing outcomes in vulnerable populations.

References

  • Blahd, W. H., Jr., & Husney, A. (2018). Hypothermia and cold temperature exposure. Michigan Medicine University of Michigan. Retrieved from https://www.uofmhealth.org
  • Debas, D., et al. (2020). Pressure ulcer prevention in older adults: A clinical practice guideline. Journal of Wound Care, 29(Sup2), S5–S16.
  • Mayo Clinic. (2019). Hypothermia. Mayo Foundation for Medical Education and Research. Retrieved from https://www.mayoclinic.org
  • Oliver, D., et al. (2010). Effective strategies to prevent falls in hospital in-patients and elderly persons in care homes: A systematic review and meta-analysis. Journal of Safety Research, 41(6), 451-461.
  • Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (10th ed.). Mosby Elsevier.
  • Criswell, C. (2009). Creating a clear and compelling vision. Center for Creative Leadership.
  • Hughes, M. (2014). Strategic thinking and planning. In M. M. Roberts (Ed.), The Art of Strategy (pp. 72-85). McGraw-Hill Education.
  • Northwest Earth Institute. (nd). A systems thinking model: The iceberg. Retrieved from https://www.nwei.org
  • Revised National Pressure Ulcer Advisory Panel. (2014). Prevention and treatment of pressure ulcers: Clinical practice guideline. Wound Ostomy Continence Nurses Society.
  • Craven, R. F., & Hirnle, C. J. (2017). Fundamentals of Nursing: Human Health and Function (8th ed.). Pearson.

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