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Comprehensive Plan of Care

Comprehensive Plan of Care

The patient I’ve been working with at Rennes Health and Rehabilitation Center has a lengthy medical history. Anemia, acute cystitis, acute kidney injury, coagulopathy, elevated IRN, falls, hypertension, lipedema, atrial fibrillation, cerebral artery occlusion with cerebral infarction, arthritis, dementia with delusions, neuropathy, bilateral lower extremity edema, obesity are among the patient’s medical history. The patient’s bodily function was impaired, resulting in urinary incontinence, impaired dentition, impaired memory, reduced physical mobility, and impaired transferability (Doenges et al., 2016). To prevent aspiration, the patient was placed on a soft food diet and given thickened liquids. The student nurse concluded that the main concern for this patient is a lack of self-care and ineffective health management, as evidenced by the reduced bodily functions mentioned above (Doenges et al., 2016). Because the patient is a poor historian, all of this was obtained through the chart in the medical history section. The patient was unable to provide any family history, and the chart contained no information about family members other than the fact that she was widowed. The following is a summary of the patient’s lab results: INR is 1.1, potassium is 15.7, iron is 23, hemoglobin is 9.8, white blood cells are 9.8, and platelets are 3.6. The patient’s INR is low and should be between 2 and 3 to prevent any further clots. Because of the stroke, the patient suffered in January, the INR is critical. Because of her history of anemia, the patient’s hemoglobin level is critical. As of the last blood draw, the patient’s hemoglobin was within normal limits.

The patient’s musculoskeletal mobility and cognitive functions have declined; the patient is at risk of falling. Clients who are at risk of falling require special attention to their living environments. During the transfer, healthcare workers must ensure that the patient’s bed, wheelchair, or other assistive device is locked and grounded. Before attempting to ambulate out of bed or chair, the patient should be encouraged and demonstrate understanding to call for assistance. This patient is at risk of aspiration and must be administered thickened liquids. To reduce the risk of aspiration, the client should eat while sitting up in a high fowler’s position. The client should not be left alone during feedings due to his or her cognitive ability. When sleeping in bed, the patient should have a safety mat lateral to his mattress, and the bed should be in the lowest position.

The patient can no longer perform all activities of daily living (ADLs) on his own. The patient will require 24-hour care for the majority of his medical needs. It is critical for healthcare professionals to work together to promote the patient’s health in the best way possible. Short-term goals included the patient’s vocalization and understanding of his strengths and weaknesses in ADL activities to allow for room and assistance. This goal will be measured by the client’s daily adherence to the healthcare plan (Doenges et al., 2016). This patient’s long-term goal is to maintain or improve his health by performing self-care activities to the best of his ability (Doenges et al., 2016). An evaluation will be conducted every month to demonstrate an improvement in ADL activities and to make adjustments as needed for the plan’s continuous improvement.

Personal needs, such as cultural and spiritual implications, should be incorporated into client care to provide the client with a sense of customized care. This not only promotes patient-centered care but also encourages patients to adhere to the healthcare team’s health maintenance and promotion efforts. This patient is a devout Mormon who treasures his time with the local pastor as well as his fellowship with other patients and his family. Allowing the patient time to visit when possible promotes holistic care nursing competency. When possible, the client’s personal needs should be met. Through group activities and meal times, the patient should be given opportunities to socialize with other residents. Family visits should be encouraged in order to promote social interaction and reduce the risk of social impairment and depression (Doenges, Murr, & Moorhouse, 2016).

When implementing a care plan, strategy is essential. Chronically ill patients, such as the patient, require a continuous effort to promote and maintain health. To effectively achieve all of the goals in the care plan, the healthcare team must collaborate to ensure adherence and continuation. Competent and open communication will encourage improvement while also pointing out flaws in the plan. This also facilitates the smooth implementation of new strategies, medications, and therapies, among other things. Continuous improvement and evidence-based practice promote patient safety, which is an important component of all nursing care plans. When possible, the client should be allowed to participate in ADLs to ensure proper adherence and promote client autonomy (Doenges et al., 2016). Regular checks should be carried out on a small and large scale to ensure that all critical components of the plan are seamlessly working to improve the patient’s health condition.

References

Jarvis, C. (2016). Physical examination and health assessment (7th ed.). St. Louis, MO: Elsevier.

Doenges, M. E., A. C., & Moorhouse, M. F. (2016). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales. Philadelphia, PA: F.S. Davis

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Question 


In this third and final submission of your Course Project, you will be completing a comprehensive care plan. This written assignment should include the following:

Comprehensive Plan of Care

Comprehensive Plan of Care

Comprehensive Plan of Care

Develop a comprehensive plan of care/treatment with short and long-term goals and include safety needs, special considerations regarding personal needs, cultural/spiritual implications, and needed health restoration, maintenance, and promotion.

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