PATIENT CARE PLAN (EDUCATIONAL)

STUDENT PATIENT INITIALSA.A. ADMITTING DX FRANCISCO J ORTIZ DN AGE 69 PSYCHOSIS ADMISSION DATE OTHER MEDICAL DX 08/25/2011 SEIZURES, LOWER BACK PAIN, ELEVATED CHOLESTEROL, ANEURYSM REPAIR

SEX (F)

NURSING DIAGNOSIS (in priority order) NDKNOWLEDGE DEFICIT REGARDING CONDITION PROGNOSIS, TREATMENT SELFCARE AND DISCHARGE NEEDS RELATED TO COGNITIVE LIMITATIONS BY STATEMENT OF MISCONCEPTION AS EVIDENCE BY S: PT STATING TO ME I DONT THINK WHEN I LEAVE HERE THE MAN UPSTAIRS IS GONNA BE THERE WITH HIS FRIEND BECAUSE I KNOW I AM NOT CRAZY S: PT STATES TO ME MY MIND IS GOING TO BE LIKE NEW:

PATIENT-CENTERED GOALS Short Term goal: PT WILL VERBALIZE THE SIGNIFICANCE OF TAKING MEDICATION FOR HER DIAGNOSIS BY THE END OF ONE DAY

NURSING INTERVENTION SHORT: 1.INCLUDE SO & FAMILY IN DISCUSSIONS & TEACHINGS (Independent) (DOUGNES 172) 2. DISCUSS PLANS FOR MEETING SELF CARE NEEDS (Independent) (DOUGNES 172) 3. DISCUSS SPECIFIC PATHOLOGY & INDIVIDUAL POTENTIALS (Independent) (DOUGNES 173) LONG TERM: 1.DISCUSS TO INDIVIDUAL RISK FACTORS AND DISCUSS NECESSARY LIFESTLY CHANGES Independent) (DOUGNES 172)

RATIONALE

EVALUATION

1. INDIIDUALS WILL BE PROVIDING SUPPORT & CARE & HAVE GREAT I MPACT ON CLIENTS QUALITY OF LIFE 2. VARYING LEVELS OF ASSISTANCE MAY BE REQUIRED & NEED TO BE PLANNED FOR BASED ON INDIVIDUAL SITUATION 3.AIDS IN ESTABLISHING REALISTIC EXPECTATIONS & PROMOTES UNDERSTANDING OF CURRENT SITUATION 1.PROMOTES GENERAL WELL BEING, MAY REDUCE RISK OF REACCURANCE

SHORT TERM: PT UNDERSTOOD MEDICATION SHE WAS GIVEN BY THE END OF THE DAY.

Long term goal: S:PT STATES TO ME I KNOW THEY LEFT MY APARTMENT, THEY ARE ALL GONE YOULL SEE O: PATIENT POINTING TO ME WHERE SHE SEES THE MAN UP STAIRS ON THE ROOF O:PATIENT KEEPS POINTING TO THE ROOF AND DIRECTING ME TO STARE ALONG WITH HER O:PT CHART SHOWS SHE LIVES BY HERSELF PT WILL INITIATE & MAINTAIN NECESSARY LIFESTYLE CHANGES AFTER DISCHARGE

LONG TERM: GoaL NOT MET BECAUSE I WAS NOT THERE LONG ENOUGH TO SEE CLIENT BE DISCHARGED FROM UNIT

2. DEFECITS AFFECT THE CHOICE OF 2.REVIEW TYPE & DEGREE OF SENSORY TEACHING METHODS & CONTENT PERCRPTUAL INVOLVEMENT (Independent) (DOUGNES 172) 3. IF PATIENT UNDERSTANDS DISEASE PROCESS THEY WILL BE OPEN TO UNDERSTAND LIFESTYLE CHANGES 3.ASSESS PATIENT TO DISEASE PROCESS (DOUGNES 173)

REFERENCE: NURSING CARE PLANS: GUIDELINES FOR INDIVIDUALIZING CLIENT CARE ACROSS THE LIFE SPAN 8TH EDITION BY DOUGENS & MOORHOUSE 2011 PAGES 172-173

REFERENCE: NURSING CARE PLANS: GUIDELINES FOR INDIVIDUALZING CLIENT CARE ACROSS THE LIFE SPAN 8 TH EDITION