Nursing Care Plan
Instructions:
Create a nursing care plan using the following scenario.
The client, Mark S., is a 57-year-old male who was admitted to the hospital with “severe” abdominal pain that was unable to be managed in the Emergency Department. The physician has informed Mark that he will need to undergo some diagnostic tests.
The tests are scheduled for the morning. After receiving the news about his condition and the need for diagnostic tests, Mark begins to pace the floor. He continues to pace constantly. He keeps asking the nurse the same question (“How long will the tests take?”) about his tests over and over again. The client also remarked, “I’m so uptight I will never be able to sleep tonight.”
The nurse observes that the client avoids eye contact during their interactions and that he continually fidgets with the call light. His eyes keep darting around the room. He appears tense and has a strained expression on his face. He states,“My mouth is so dry.” The nurse observes his vital signs to be: T 98, P 104, R 30, BP 180/96. The nurse notes that his skin feels sweaty (diaphoretic) and cool to the touch.
Critical Thinking Activity:
Imagine that you implemented the interventions that you identified. Evaluate the degree to which the expected outcome was achieved: Met – Partially Met – Not Met.
Group (cluster) the cues (subjective and objective data).
Create a problem-focused nursing diagnosis (hypothesis).
Develop a broad goal and then identify an expected outcome in “SMART” format.
Outline three interventions for the nursing diagnosis to meet the goal and their rationale.
Cite an evidence-based source for the interventions and rationale
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