Case Study for Care Plan 3

Case Scenario

Jeanine Porter is a 75-year-old woman who was admitted to the hospital after she fell at home and sustained an intracapsular fracture of the left hip at the femoral neck. She is widowed and lives with her daughter and son-in-law and their three children, ages 15, 12, and 4. She has a 50 pack-a-year smoking history and denies alcohol use. She has severe osteoarthritis of her knees and coronary artery disease (CAD). She underwent coronary artery bypass grafting (CABG) 9 months ago. Since her surgery, she has engaged in minimal exercises at home. Mrs. Porter underwent a total hip replacement. Her postoperative period was unremarkable, and she was transferred to the rehabilitation facility on her third postoperative day. She did well with her therapy and was discharged home after 10 days.

Nursing Assessment

At a home health visit 2 weeks after discharge, Mrs. Porter was in the living room, seated in a rocking chair. Her walker was across the room. The room smelled of smoke, and a significant amount of dust was evident on all of the furniture, as well as open bags of chips and several open soft drink cans. The floor was littered with toy trains and cars, and the sofa was full of unfolded, clean laundry. In the kitchen, the countertops and sink were loaded with dirty dishes, pots, and pans. Mrs. Porter said, “My daughter is really doing her best. I guess I am just too much for her…what with the children and all.” Mrs. Porter’s daughter replied, “I can handle it, I just don’t get any help from anyone, including my mother.”

Nursing Diagnosis Statement 1:

Nursing Diagnosis Statement 2:

Nursing Diagnosis Statement 3:

Nursing Outcomes for Diagnosis 1

Nursing Outcomes for Diagnosis 2:

Nursing Outcomes for Diagnosis 3:

Nursing Interventions for Diagnosis 1:

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Nursing Interventions for Diagnosis 2:

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Nursing Interventions for Diagnosis 3:

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SBAR Report case Scenario

You are completing an initial assessment on Mr. Edwards, a 62-year-old male with a history of headaches who visits the local medical clinic. You find that Mr. Edward’s vital signs are stable, his eyes open spontaneously, and his bilateral hand and leg strength are normal and equal. He is oriented times 3 and he states that his current pain is 6/10. When asked about how long he has been having the headache, he states “it has been off and on for several months”. He states that sometimes he experiences some nausea, with no vomiting. On PERRLA assessment the RN notices that his right eye is 3+, whereas his left is 5 and non-reactive. As you carry on with the assessment, Mr. Edwards appears to be staring at the wall and suddenly, his legs and arms begin to jerk. He is nonresponsive during this episode; you recognize this to be a clonic tonic seizure. The seizure lasts 45 seconds. Vital signs currently are: T- 36.5 9Sbpm R -26/min 02 saturation 95 % on room air. BIP 130/80. You need to notify the physician.

Possible Points

Successful- Full Points

Unsuccessful- 0 Points

Situation 25 points

Introduces self, states where they’re calling from and identifies patient. Provides a concise statement of the problem

Does not Introduces self, states where they’re calling from and identifies patient. Provides a concise statement of the problem

Background 25 points

Presents appropriate background information, i.e. reason for hospitalization

Does not present appropriate background information, i.e. reason for hospitalization

Assessment 25 points

Concisely articulates assessment of the situation

Does not concisely articulates assessment of the situation

Recommendation 25 points

Recommends appropriate interventions, tests, medication. Inquires need for follow up

Does not recommend appropriate interventions, tests, medication. Inquires need for follow up

Rubric for SBAR Report

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