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Nursing 270: Nursing Process Assignment NURS 270: 2021 Nursing Process Activity Assignment Overview: Students will review a case study focusing on an elder living in her home. Students will organize data conceptually, determine a nursing diagnosis and a basic care plan. Assignment resources: 1. Potter and Perry, Giddens, and Ackley 2. Comprehensive Care Plan provided in class (included under Nursing Process Assignment tab in D2L). Assignment instructions: 1. Review the provided case study. 2. Place the appropriate data into each concept. Include parts or paraphrases of client statements as appropriate. 3. Review the concepts for areas of concern 4. Write one nursing diagnosis, one goal, and one outcome which are individualized to the client. (Focus on safety.) 5. Develop two nursing interventions that support the outcome. Provide two part rationale: evidence based practice (with citation from a source other than Ackley) and rationale as to why this intervention is good for this client. Provide the full citation at the bottom of the care plan. 6. Submit the care plan below to the assignment folder by the due date on the calendar. Case Study: You are the home health nurse visiting a client for a wellness assessment. Margaret Smith is a 78 year old woman who lives alone in her townhouse in Minneapolis. The townhome association completes all outside maintenance and snow removal. The townhome is two levels; with laundry, living room, dining room, half bath, and kitchen on the first level; two bedrooms and a bathroom on the second level. The townhome has many windows with thick curtains, but you note there are not many lamps or overhead lights. Your home assessment notes clothes on the floor in the bedroom and laundry room. Margaret notes ‘Sometimes I have trouble getting my laundry downstairs so I throw it down the stairs”. There are throw rugs in the kitchen, bathroom, at the front entrance and the entrance from the deck. Margaret asks “Could you please remove your shoes, I don’t want the carpet to get dirty”. You note several pairs of shoes just inside the door at each of the entrances. There are stacks of magazines near the living room chairs and books on the stairs. Margaret states “Sometimes I just don’t get around to putting things away. My intention is to put something away each time I go upstairs, but I don’t always do that.” She states “I have a few plants on my deck. Taking care of the plants gives me purpose every day”. She lives across the street from a large grocery store and is able to walk to the store to buy groceries. Margaret states “I don’t drive, it’s too expensive to have a car and rent garage space, but I takes public transit to my dancing class and to the library. The bus stop is right on the corner.” Margaret is 5’7” tall and weighs 165 pounds. She walks with a slight stoop and you noticed that she has stumbled a few times as she was walking around the house. On the day of your visit, her shoes are untied and her long skirt hem drags on the floor. Her cat runs out in front of you and Margaret without warning. “That silly cat does that all the time”. Margaret states she has a bowel movement every day (“I take some of those fiber pills and that really helps”). She denies constipation or diarrhea and notes her stool is brown and formed. Her urinary output is adequate during the day, light yellow in color, with no burning. She states “Sometimes at night I have to rush to get to the bathroom and, in the dark, it is hard to get there without stubbing my toe.” Margaret is retired from her previous job as a chef at a small local restaurant. She prepares all of her own meals. Her neighbor is her best friend and she brings Margaret seasonal produce from the farmer’s market. Her only child is a farmer and also brings Margaret seasonal produce and meat, some of which she freezes. “I like to cook. Fresh food keeps me healthy and happy”. “I’m lucky I get fresh meat and produce so often!” Margaret eats three meals, with fresh fruit and cheese for a snack. “My one vice is going down to the ice cream shop on Saturday for an ice cream cone”. She drinks approximately four 6 oz. glasses of water, two cups of coffee, and one cola every day. “I tend to get dizzy frequently. My friend says it is because I don’t drink enough liquids.”. Margaret sees her primary care provider and her dentist for annual checkups. She goes to a local holistic clinic for acupuncture and her supply of herbs/supplements. “I think I need to be proactive in staying healthy.” Margaret has a college degree, manages her own finances, and reads every day. Margaret describes herself as spiritual, though not religious. She meditates every day and calls that ‘her prayer to the universe’. She enjoys reading about the major religions of the world. “I think my understanding of others helps me to be a more spiritual person”. Family is very important to her. She has one sister, who lives in St. Paul, and one son. Her husband is deceased. “I miss him every day. We were great partners in our life”. She is friends with many people in her townhome complex and at the library. She goes dancing and out to dinner occasionally with one of her male neighbors. “Fred is a nice person. I feel safe with him and we enjoy each other’s company”. She does not smoke and denies any prescription or street drug use. “I take probiotics, a B12, a multivitamin, vitamin D in the winter, and sometimes ibuprofen if my back hurts. Sometimes when I can’t sleep I take a valerian/lemon balm tablet or drink some chamomile tea”. Margaret sleeps seven hours each night and takes an afternoon nap two to three times a week. “I feel healthy, though I’m not as active as I used to be”. “I used to go to the gym, but it got too expensive. Now I take dance lessons and walk for exercise. Her skin is thin. No bruises or tears are noted. Her hair is white, thick, and braided over one shoulder. She is proud of the fact that she has all of her teeth. “I don’t have one of those icky partials or dentures like most of my friends do”. Her nails are well manicured. Part One: Assessment. Collect and cluster the data relevant to your client Patient Education and Health Promotion Family Dynamics Growth and Development Pain, Stress, and Coping (Include all 3 concepts) Gas Exchange and Perfusion (Include both concepts) Intracranial Regulation and Cognition (Include both concepts) Elimination Tissue Integrity Nutrition and Glucose Regulation (Include both concepts) Functional Ability and Mobility (Include both concepts) Immunity and Inflammation (Include both concepts) Reproduction and Sexuality (Include both concepts) Client initials, age Nursing Diagnosis: Client centered goal: Outcome (SMART) Interventions Rationale Evaluation 1. 1. Scientific rationale (resource and citation required): Client specific rationale: 2. Scientific rationale (resource and citation required): Client specific rationale: References (APA formatting required): Metropolitan State University NURS 270: Health Promotion and the Role of the Professional Nurse NURSING PROCESS ASSIGNMENT: GRADING RUBRIC (10 points) Assignment Criteria Available Points Your Score/Instructor Comments · Appropriate data from case study placed in the correct concept · Parts or paraphrases of client’s statements included (as appropriate) 2 points · Nursing Diagnosis written in correct format and individualized to client in case study 2 points · One Goal (1 points) and · One Outcome (SMART Format) (1 points) 2 points · Two (2) Nursing Interventions that support stated outcome (1 point each) 2 points Two-part Rationale for each nursing intervention that includes: · Evidence based practice (with citation from a source other than Ackley text) (0.5 points for each stated nursing intervention) · Discussion of rationale as to why this intervention is appropriate for this client (0.5 points for each stated nursing intervention) 2 points Additional Instructor Comments: NURS 270 Nursing Process Grading Rubric Fall 2021 Source: https://www.diamondlegacygp.com/setting-smart-goals/ Source: https://www.diamondlegacygp.com/setting - smart - goals/ Source: https://www.diamondlegacygp.com/setting-smart-goals/