CLIENT CARE PLAN: BRIEFLY NOTE YOUR CLIENT’S HEALTH HISTORY INCLUDING BASIC BIOGRAPHICAL DATA (PLEASE REMEMBER CLIENT CONFIDENTIALITY).

CLIENT CARE PLAN: BRIEFLY NOTE YOUR CLIENT’S HEALTH HISTORY INCLUDING BASIC BIOGRAPHICAL DATA (PLEASE REMEMBER CLIENT CONFIDENTIALITY).
March 26, 2019 Off All,

Your assignment should contain: 1 title page; 2 pages for the care plan; and 1 page for references.

• In total, you must use a minimum of three scholarly resources (1 nursing journal article and 2 textbooks).

• If required, seek assistance with APA format. • You must relate the client information to the literature. • Please remember client confidentiality. Do not use real names in your assignment. Refer to your client as “Mrs. X.” or “Mr. X.” Do not use specific identifying information related to your client such as names of places of work, towns, cities, street names, church or social group affiliations, names of previous hospitals or doctor’s names. These identifiers are considered part of confidential information. • Proofread your care plan and your work for grammar, spelling, and punctuation and correct APA formatting prior to submission. FOR MARKS ALLOCATION PLEASE REFER TO CLIENT CARE PLAN QUESTIONS AND RUBRIC. Guidelines for Client Care Plan 1. History and Priority Nursing Problem: a) Briefly note your client’s health history including basic biographical data (please remember client confidentiality). Identify and describe the client’s primary diagnosis, which is why they were admitted to the facility. Include any pertinent information about secondary diagnoses that could influence your care of that client (IE a client with a fractured hip [primary diagnosis] will concurrently require care of their diabetes and dementia [secondary diagnoses]). b) Describe ONE nursing problem of high priority that you identified while caring for the client. (Some examples of nursing problems are: pain management, skin integrity, infection, mobility, nutrition, GI/ GU problems, oxygenation, fluid volume deficit or excess, electrolyte imbalance, anxiety, ineffective coping, or knowledge deficit around a particular disease process, to name a few). Use supporting evidence from the literature to rationalize your choices on the priority care issue. This question is to be answered in APA sentence format 2. Assessment: a) Note what you found when you completed your focused nursing assessment (any health assessment(s) that relate specifically to the client’s one nursing problem). b) Note the subjective and objective findings of your assessment, including what symptoms your client was experiencing (include vital signs). c) Briefly note and describe the diagnostic tests; laboratory (blood and urine) and procedures (X-rays, scans, surgeries) that have confirmed these findings. If not normal, please note why, related to your patients diagnosis or underlying health conditions. (Example: Creatinine elevated because of a history of renal failure or elevated WBC count related to pneumonia infection). Use supporting evidence from the literature to rationalize your choices. 3. Planning and Implementing Nursing Care: a) Provide 2 nursing interventions or ways you did help or could help to promote health or teach your client about their identified problem. State your rationale for choosing these 3 interventions. What strategies or nursing care did you provide? What resources were utilized? Make sure to link the 2 nursing interventions to the client’s assessment and medical diagnoses. b) Include medical treatments such as medications prescribed to alleviate the problem (IE Lasix used between blood transfusions etc). Use supporting evidence from the literature to rationalize your choices. This question is to be answered in APA sentence format 4. Evaluation: a) Describe how your nursing interventions were (or could have been) effective and the client’s response to your nursing care. Identify what you said and did that made your nursing care unique and individual. Provide examples of how this experience has changed your nursing practice and determine what it is that you would do either the same or differently the next time