Nursing Care Plan
Specific instructions for this task:
Using the clinical case data below, perform your first Nursing Care Plan for this client. You will find the necessary materials and the table to prepare the care plan in the Supplementary Materials Module 2 section:
Identify in order of priority two (2) health needs of this patient: one (1) real need and one (1) at risk.
These health needs will be the ones that have the highest priority when planning the nursing care of this patient.
It groups with each identified need the objective and subjective data that evidences the existence of the need for health.
Identify the focal stimuli or causes related to each need you identified.
Using NANDA 2021-23 and the PES format, write each of the nursing diagnoses.
Write one (1) expected result for each nursing diagnosis identified in this clinical case. Use the format: subject, action verb, indicator/res of modification of inappropriate behavior and time to achieve it, as you learned how to write them in module 2.
Putting them in order of priority, write a minimum of five (5) nursing interventions that you will carry out to achieve the expected results. It is important that you include at least one (1) in the interventions for the prevention and promotion of the patient’s health.
Mention the scientific rationality that validates carrying out each intervention you plan.
Write a probable evaluation for each nursing diagnosis in the light of the expected result you developed.
Clinical case study:
A 91-year-old man, who is a resident of a long-term care center, tells the nurse, “My right foot hurts.” The patient offers the nurse an explanation, suggesting: “I must have stepped on something or twisted my ankle. Maybe I was bitten by an insect when I was away yesterday.” The nurse observes that the patient’s right ankle is red, slightly swollen and warm to the touch. Despite the fact that, his body temperature is within normal limits and he has a strong bilateral pedal pulse. The nurse notifies the doctor, who orders an x-ray of the ankle. No fractures are observed in the results of the X-ray. It has a full range of motion of the right ankle and the lower limb, although the pain in the ankle increases with movement. A Doppler ultrasound rules out deep vein thrombosis.