Question

Mrs. Y is an 84-year-old client who was recently discharged from the hospital for an infected diabetic ulcer on her left leg. During her hospitalization, Mrs. Y required intravenous antibiotic therapy through a peripherally inserted central catheter (PICC) line. Due to Mrs. Y’s long history of diabetes, her physician ordered that intravenous antibiotic therapy be continued at home. Subsequently, home health services were initiated, a home health nurse was assigned to Mrs. Y’s case, and an initial home visit was scheduled. The home health nurse arrives at Mrs. Y’s home and introduces herself to the client and the family. The nurse explains the home nursing services that will be provided, including the PICC line and intravenous antibiotic therapy treatments. During the initial home visit, the nurse assessed the physiological, psychological, functional, and safety needs of the client. The nurse’s findings were as follows: Mrs. Y lives alone; however, her daughter checks on her frequently throughout the day. The client is noted to have moderate functional issues and ambulates with a cane. The client has several throw rugs in the main walking quarters and minimal lighting throughout the hallways. Mrs. Y states “I used to get around my house with ease, but now I get a little tired and have to sit down and rest frequently.”

Consider Mrs. Y’s current health status and functional decline, then address the following:

1. Download the Concept Map and Plan of Care worksheet below. An example is also provided for your reference.
   • File: Concept Map and Plan of Care worksheet
   • File: Concept Map and Plan of Care example
2. Identify three (3) priority nursing diagnoses for Mrs. Y. Consider using the resource below to assist you.
   • eBook: Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care – Chapter 5 Nursing Diagnoses in Alphabetical Order
3. Create a visual representation of the three (3) priority nursing diagnoses by incorporating them into the Concept Map (template in the worksheet). Be sure each nursing diagnosis includes the following elements:

1. 1. “related to (r/t)” — description of the client’s problem
   2. “as evidenced by” — description of the client’s symptoms
2. Complete the Nursing Plan of Care (table in the worksheet) describing what should be implemented for Mrs. Y.
   1. Goals: Establish at least one (1) goal for each of the nursing diagnoses you identified (for a total of 3 goals). Goals should be: patient specific, measurable, actionable, realistic, and time limited.
   2. Nursing Interventions: Describe at least three (3) nursing interventions for each of the goals (for a total of 9 nursing interventions). Each intervention should be in alignment with the goal it is supporting.

Answer 1

NURSING DIAGNOSES

1. impaired physical mobility

2. risk for Infection

3. Risk for fall

GOALS-

1. impaired physical mobility- mobilize and provide psychological support

2. risk for Infection -- prevent infection and reduce risk factors

3. Risk for fall- use of support for walking

NURSING INTERVENTIONS

1. impaired physical mobility

FUNCTIONAL LEVEL CLASSIFICATION

1—Requires use of equipment or device

· Exercise Therapy: Use of active or passive body movement to maintain or

restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement, etc.

· Pain Management: Alleviation of pain or a reduction in pain to a level of comfort acceptable to the patient

· Provide client with ample time to perform mobility-related tasks. Schedule activities with adequate rest periods during the day to reduce fatigue

2. risk for Infection

· Infection Protection: Prevention and early detection of infection in a patient at risk

· Infection Control: Minimizing the acquisition and transmission of infectious agents

· Change dressings as needed/indicated. Handle and properly dispose of soiled dressings using barriers and bags to contain fluids in dressings

3. Risk for fall

· Fall Prevention: Instituting special precautions with patient at risk for injury from falling

· Environment Management: Safety: Manipulation of the patient’s surroundings for therapeutic benefit

· Risk Identification: Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group