Care Plan
Overview
The nursing process incorporates the use of theoretical and evidence-based knowledge to assess, diagnose, plan, implement, and evaluate client care outcomes. The nursing process is closely related to the evidence based and research process. Each step in the nursing process requires the nurse to critically think to develop an effective client plan of care. In this assignment you will review a clinical case scenario and develop a plan of care. The plan will incorporate generating two nursing diagnoses, with interventions, and evaluation strategies to assess the interventions.
Clinical scenario: Mr. Smith is a 70-year old male with a history of hypertension, congestive heart failure, and diabetes mellitus type 2. He currently is experiencing increased fatigue, shortness of breath, and lower extremity edema.
His vital signs include HR 90, BP 160/90, RR 14, Temp 98.9. Mr. Smith is admitted to the telemetry unit for worsening congestive heart failure. He admits to you that he currently lives alone and takes several medications. He states that he has been having trouble remembering to take his medications daily.
Task
Review Mr. Smith’ scenario, noting his diagnoses.
Develop a plan of care for Mr. Jones using a nursing care plan template.
Include in your plan of care:
Two priority nursing diagnoses
Assessment data: subjective and objective information from the case.
4 measurable goals/outcomes based on evidence-based literature.
Four evidence-based interventions for each diagnosis with rationales with APA support from the literature.
Four strategies to evaluate intervention outcomes for each diagnosis with rationales with APA support from the literature.