I Hate CBT's

View Original

shadow health patricia young care plan

Guest User

Focused Exam: Infection Results | Completed Gerontology - Fall 2021, RNSG 1261

Return to Assignment

Note: Shadow Health will be undergoing scheduled maintenance on September 13th, 2021 between 07:00 AM ET and 07:30 AM ET. Attempts will be disabled during this time period. Once the maintenance window concludes, assignments will be available again.

Care Plan: 6.5 of 8.5 (76.5%)

Nursing Diagnoses: Definitions & Classifications 2018-2020 © NANDA-International, 2017 used by arrangement with Thieme Medical Publishers, Inc., a division of the Thieme Group. All rights reserved. Authorized translation from the English language edition published by Thieme Medican Publishers Inc. No part of this material may be reproduced in any form without the written permission of the agent of the copyright holder, NANDA-International. Direct inquires to nanda-i@thieme.com. Link for more information: http://www.nanda.org/.

Status

  • Student Response: exhibits

  • Model Answer: exhibits

  • Explanation: The correct status for the nursing diagnosis is "exhibits" because Ms. Young has shown clear signs of acute pain, rather than a potential to develop the condition.

  • Points Earned: 0.5 out of 0.

Diagnosis

  • Student Response: Impaired Skin Integrity

  • Model Answer: Acute Pain

  • Explanation: Per Ms. Young’s self-report of pain on a standardized pain scale, agitation, and appetite change, the Acute Pain diagnosis is most correct. While Ms. Young is likely to be less active given her recent pain, an Activity Intolerance diagnosis would not take priority over an Acute Pain diagnosis. Similarly, Ms. Young’s age and medical history do put her at risk for Impaired Skin Integrity, but the patient’s potential to develop this condition is not more pressing than the patient’s current, quantifiable experience of pain.

  • Points Earned: 0 out of 0.5

Your Results

  • Turn In

  • Reopen

  • Lab Pass

Overview

  • Transcript

  • Subjective Data Collection

  • Objective Data Collection

  • Education & Empathy

  • QSEN Competencies

  • Documentation

  • Care Plan

  • Reflections

**Nursing Diagnosis: 1.5 out of

Etiologies

  • Student Response: infection

  • Model Answer: infection

  • Explanation: Ms. Young’s acute pain stems from her urinary tract infection (UTI).

  • Points Earned: 0.5 out of 0.

Signs & Symptoms

  • Student Response: altered epidermis

  • Model Answer: appetite change

  • Explanation: Ms. Young does not report altered epidermis, a change in pigmentation, diaphoresis, or hypothermia. She does, however, report pain in her abdomen and back, as well as an appetite change and agitation.

  • Points Earned: 0 out of 0.5

  • Student Response: change in pigmentation

  • Model Answer: agitation

  • Explanation: Ms. Young does not report altered epidermis, a change in pigmentation, diaphoresis, or hypothermia. She does, however, report pain in her abdomen and back, as well as an appetite change and agitation.

  • Points Earned: 0 out of 0.5

  • Student Response: self-report of pain

  • Model Answer: self-report of pain

  • Explanation: Ms. Young does not report altered epidermis, a change in pigmentation, diaphoresis, or hypothermia. She does, however, report pain in her abdomen and back, as well as an appetite change and agitation.

  • Points Earned: 0.5 out of 0.

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt: Why might a Readiness for Enhanced Knowledge diagnosis be inappropriate for a patient in Patricia Young's condition?

  • Student Response: The patient is currently confused and likely will not remember the information provided at this time.

  • Model Answer: Because Ms. Young is suffering from confusion and having difficulty remembering things, framing a care plan around a diagnosis that would require comprehensive teaching (and thereby an expectation of learner retention) would be inappropriate. Ms. Young is not currently oriented enough to remember or reiterate extensive information and instructions.

Note: Some nursing diagnoses may share aspects in common that make it difficult to prioritize one over the other. Paying close attention to the details of the case can help you determine the right diagnosis and therefore the correct interventions.

Short-Term Goal

  • Student Response: Self Assessment

  • Planning: 2.5 out of

Goal To have the patient, by the end of the shift, determine a comfort-function goal and exhibit an understanding of how to notify a healthcare member if she experiences a pain intensity level greater than the comfort-function.

Explanation To ensure optimum patient compliance, assist your patient with determining an appropriate comfort-function goal. Working together will help you determine and address any of the patient's misunderstandings or hesitations.

  • Points Earned: 0.5 out of 0.

Interventions

  • Student Response: Show patient where call light is located, and demonstrate how to use it

  • Model Answer: Show patient where call light is located, and demonstrate how to use it

  • Explanation: Determining a comfort-function goal involves an enormous array of considerations and strategies. The salient themes include the safety, health, and comfort of the patient.

  • Points Earned: 0.5 out of 0.

  • Student Response: Conduct and document a comprehensive pain assessment, using appropriate pain assessment tools

  • Model Answer: Conduct and document a comprehensive pain assessment, using appropriate pain assessment tools

  • Explanation: Determining a comfort-function goal involves an enormous array of considerations and strategies. The salient themes include the safety, health, and comfort of the patient.

  • Points Earned: 0.5 out of 0.

  • Student Response: Ensure patient does not lie or position themselves on the site of healing skin impairments

  • Model Answer: Review patient’s full medication profile for potential drug interactions

  • Explanation: Determining a comfort-function goal involves an enormous array of considerations and strategies. The salient themes include the safety, health, and comfort of the patient.

  • Points Earned: 0 out of 0.5

  • Student Response: Assist patient in developing an effective comfort-function goal

  • Model Answer: Assist patient in developing an effective comfort-function goal

  • Explanation: Determining a comfort-function goal involves an enormous array of considerations and strategies. The salient themes include the safety, health, and comfort of the patient.

  • Points Earned: 0.5 out of 0.

Intervention Rationale Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt: In 1 or 2 sentences, explain how your selected interventions work to accomplish your goal.

  • Student Response: Having the call light close and understanding how to use it will allow the patient to reach out to a nurse faster. Not laying on the impaired skin will help the wounds to heal faster. Having a goal to attain that is understood by the patient and the nurse will allow for a more cohesive healing process.

  • Model Answer: These interventions help prepare Patricia for outlining an appropriate comfort-function goal, as well as how to request help should her pain become unmanageable.

Note: It's important your patient teaching is thorough enough to cover all necessary safety and health considerations, but also detailed enough that patients can make accurate, evidence-based decisions.

Data Collections

  • Student Response: Record vital signs and reassess patient’s pain level. Ask patient to state back and agree to the outlined comfort-function goal.

  • Model Answer: Record vital signs and reassess patient’s pain level. Ask patient to state back and agree to the outlined comfort-function goal.

  • Explanation: To ensure optimum patient compliance, ask your patient to state back their understanding of the outlined goal. This helps you determine potential misunderstandings and gives you an opportunity to address them.

  • Points Earned: 0.5 out of 0.

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt: Explain the rationale behind your nursing diagnosis, as well as your goal(s) for Ms. Young and the interventions and data collections you will use to help her achieve this goal(s).

Student Response: Showing a patient that you understand their needs can help build rapport and ensure that you have your information right. Additionally, explaining the details of your interventions and data collections will help Ms. Young understand the plan, and give her an opportunity to raise concerns.

Model Answer: Ms. Young, it sounds like you're experiencing acute pain right now. In order to help you feel more comfortable, while also prioritizing your safety, we're going to have a detailed discussion about how to create a comfort-function goal that fits with your overall health and health history. I'll go over key things with you, including where your call light is located and how to use it, as well as review your medication profile with you to note any potential drug interactions. I'll also continue to monitor your vitals and reassess your pain level. Finally, I'll have you state back and agree to the outlined comfort-function goal we create for you to make sure you don't have any misunderstandings.

Explanation: A patient must consent to all interventions in their Care Plan. Disagreements are opportunities to provide further patient education and to consider alternative options.

Prompt: Do I have your consent for the Care Plan?

Student Response: Ms. Young, if you don't have any other questions, we can start our discussion now. Does this plan I just talked about sound good to you?

Model Answer: Before beginning her pain management education, ask for Ms. Young's consent to the Care Plan.

Intervention & Evaluation: 2.5 out of 2

Intervention & Evaluation Rationale: Ms. Young successfully determines an appropriate comfort-function goal with your assistance, and exhibits complete understanding of how to notify a healthcare member if she experiences a pain intensity level greater than the comfort-function goal. Your goal has been fully achieved!

Did you achieve your goal of having the patient, by the end of your shift, determine a comfort-function goal and exhibit an understanding of how to notify a healthcare member if she experiences a pain intensity level greater than the comfort-function?

Student Response: The answers that were given by Ms. Young were straightforward and concise. They were consistent with the expectations of someone who would reasonably understand the instructions given. Ms. Young demonstrated the knowledge of where the call light button is and how it is used. She agreed to using an appropriate pain assessment tool. The patient appears to comprehend her medical history reconciliation and the purpose of the comfort-functional goal.

Model Answer: Ms. Young successfully determines an appropriate comfort-function goal with your assistance and exhibits complete understanding of how to notify a healthcare member if she experiences a pain intensity level greater than the comfort-function goal. Your goal has been fully achieved!

Explanation: Listen closely to your patient when they state back their understanding of your instructions so you can determine if there are any misunderstandings.

Comments: If your instructor provides individual feedback on this assignment, it will appear here.

© Shadow Health 2012 - 2021 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy ↗ (/static/privacy_policy) | Patents (https://www.shadowhealth.com/patents)