Question

Create a Careplan

1. Choose one of the patients from your Maternity/Pediatrics vSim

2. Choose one approved Nanda Diagnosis

3. Include 3 risk factors

4. Include 3 expected outcomes

5. Include 4 nursing interventions

6. Include 2 collaborative interventions

7. Include 2 evaluations (how will you evaluate your interventions are working to meet your outcomes)

Example:

Nanda Diagnosis: Risk for activity intolerance

Risk Factors

• Imbalance between oxygen supply/demand
• Immobility
• Inexperience with an activity
• Physical deconditioning
• Sedentary lifestyle

Expected Outcomes

• The patient will identify controllable factors that produce fatigue.
• The patient will maintain joint range-of-motion and muscle strength.
• The patient will maintain the ability to perform daily activities at the highest level without abnormal changes in vital signs in response to activity.
• The patient will verbalize feelings of improvement in activity status.
• Other:

Nursing Interventions

• Assess the patient's history for factors that may impair activity tolerance. Discuss factors that can produce fatigue in the patient, and help identify ways to reduce factors.
• Assess the patient's level of functioning.
• Assess the patient's vital signs for activity intolerance.
• Encourage progressive self-care or participation in activities, when tolerated; identify and acknowledge the patient's progress.
• Instruct the patient in energy-conservation techniques; discuss alternatives with the patient, as appropriate.
• Limit activities, as indicated, and report changes in abilities.
• Promote rest periods, as needed.
• Provide assistance, as needed.
• Other:

Collaborative

• Assist with strengthening exercises as prescribed, and monitor response.
• Obtain a consult for a cardiac rehabilitation or activity program, as indicated.
• Obtain a physical therapy consult, as indicated.
• Obtain a nutritional consult, as indicated.
• Obtain a social services consult.
• Provide supplemental oxygen, as ordered.
• Treat the underlying disease process as directed, and monitor response.
• Other:

Evaluation

• The patient maintains joint range-of-motion and muscle strength.
• The patient identifies controllable factors that produce fatigue.
• The patient maintains ability to perform daily activities at the highest level without abnormal changes in vital signs in response to activity.
• The patient verbalizes feelings of improvement in activity status.

Answer 1

Nanda Diagnosis:	Risk for Maternal Injury
Risk Factors	· Risk for hypoxia, and dizziness · Risk for Tonic – Clonic convulsions · Risk for abnormal blood profiling
Expected Outcomes	Patient will follow treatment and life style modifications The patient will identify to protect self and enhances self safety Patient understands normal levels of blood profiling
Nursing Interventions	History collection and physical examination Emphasise the importance of prompt reporting of signs and symptoms if any Check gait, level of consciousness, sleeping pattern and associated stress Assess for deep tendon reflexes Educate about seizure protocol, sleeping protocol, walking protocols etc… Check for uterine tenderness Check Foetal heart rate Educate CNS alterations postpartum Encourage good diet, rich in nutrition and vitamins
Collaborative	Assist in educating about pregnancy exercises, like yoga, kegel’s, low intensity exercises. Assist with physical examination by gynaecologist Nutritional consultation reports should be discussed along with councillors Regular interactions and sharing data with community care provider and appointing next schedule
Evaluation	The patient understands the education provided. The patient identifies risk factors and acknowledges to report if any. The patients vital signs and all the parameters are normal. The patient practices various exercises and shows improvement in activity status.