Nursing Care Plan Template

The current practices have significantly improved from the previous ones due to transformations in the hospital reimbursement systems and government regulations. These changes such as initiation of potential reimbursement as well as the Diagnostic Related Group classification systems have increased the relevance of the implementation of effective discharge planning (Doenges, Moorhouse & Murr, 2014). However, the current practices have made hospitals to commit themselves more to cost containment measures. Due to this, patients are discharged from the hospital earlier before they are ready as compared with the previous practices (Doenges, Moorhouse & Murr, 2014). Therefore, the current practice indicates that nurses must utilize the planning discharge care information well to ensure that patients are well prepared before they leave.

 A research that was conducted on a sample of 146 patients which were 18 years and above within a period of 24 hours indicated that most patients recorded some concerns after discharge (Silver et al., 2018). The patients were interviewed via phone within a period of three days after being discharged from the hospital. The primary categories of concerns they recorded included medication, psychological, diet, and activity. On the other hand, the major concerns that are captured in the current practice include the psychological and medication (Silver et al., 2018). 50 percent of the patient who was discharged recorded medical errors due to the language barrier. 60 % of the population in Canada speak other languages other than French and English.

Evidence-Based Practice

An example of an evidence-based practice that promotes the health of the medical-surgical client in the hospital following their discharge home is medication management. Almost a third of the patient who is discharged from the hospital have a prospective medication issue or take drugs which are considered inappropriate for them (Marcus, 2014).  Additionally, the aging health care patient at home is susceptible to adverse implications of medication errors – they take several medications for different comorbidities prescribed by various providers. Furthermore, there is a high probability of medication errors in home health care populace due to the unstructured setting and communication (Marcus, 2014).

Teaching Information

The teaching information which is imperative for the medical-surgical client and promotes the health of the client specific to the issues of early discharge of the post-operative from the acute care setting is patient and family education. A well-educated is able to fathom and manage his health and Medicare (Marcus, 2014). Nevertheless, the patient-provider communication is critical and teaching practices should be incorporated. It is worth noting that the most crucial practices suggest that the goal provides are supposed to empathetic and be attentive to the patient’s fears. Practices such as utilization of concrete instructions might be regarded as common sense, but can be hard to achieve unless an individual is focused on doing so (Waller, 2016). As such, the staff educators must learn and reinforce effective patient education to become of the daily provider care setting. The education should employ verbal instructions, demonstrations audio-visual aids and also print methods (Waller, 2016). Thus, when a patient who has discharged from a hospital leaves understanding how he will manage his medication, the issues of readmission will decrease.

Part B: Care Plan Template Student Name:

Actual Nursing Diagnosis

Planning

Interventions

Evaluation

One of the physical nursing diagnoses include ventilation – impaired gaseous exchange

Goal

The patient will maintain an optimal gaseous exchange

Intervention

Assessment of the respiration; quality, depth, breathing effort, pattern, and rate.

The patient is free from distress signs.

The pts respirations are of normal depth and rate.

ABGs displays PaCO2 between 35 and 45

Literature Support

Nursing Diagnosis & Care Plan. (2017). Impaired Gas Exchange? Retrieved from https://nurseslabs.com/impaired-gas-exchange/

Outcome

Patients manifest absence or resolution of the absence of symptoms relating to respiratory duress

Literature Support

Nursing Diagnosis & Care Plan. (2017). Impaired Gas Exchange? Retrieved from https://nurseslabs.com/impaired-gas-exchange/

Potential Nursing Diagnosis

Planning

Interventions

Evaluation

 Acute pain

Goal

The patient will manage pain effectively in 3 hours

The client is going to utilize the patient rating scale to pinpoint the current intensity of pain in the next 40 minutes

Intervention

A single dimension rating of pain is reliable and valid as a measure of the level of pain intensity

 The client has to state the level of pain 2/10, thirty minutes after receiving a medication for pain

Client states the level of pain 8/10 one hour after receiving the medication for pain

Literature Support

Nursing Diagnosis & Care Plan. (2017). Impaired Gas Exchange? Retrieved from https://nurseslabs.com/impaired-gas-exchange/

Outcome

The patient is able to manage pain and records that he is not feeling any pain

Literature Support

Nursing Diagnosis & Care Plan. (2017). Impaired Gas Exchange? Retrieved from https://nurseslabs.com/impaired-gas-exchange/

Teaching Nursing Diagnosis

Planning

Interventions

Evaluation

Goal

The client will be educated on the adverse implications of unrelieved pain

For example, any acute unrelieved pain can lead to psychological and physiological implications which can lead to negative patient outcomes.

Intervention

The client will be educated on the adverse implications of unrelieved pain

For example, any acute unrelieved pain can lead to psychological and physiological implications which can lead to negative patient outcomes.

The client states that unrelieved acute pain can result in deprivation of sleep which can reduce the daytime energy and also cause depression

Literature Support

Waller, P. (2016). Occupational Therapy Goals during Acute Discharge for Older Adults (Doctoral dissertation).

Outcome

The patient can answer all the question regarding pain alleviation.

Additionally, can use the pain rating scale efficiently

Waller, P. (2016). Occupational Therapy Goals during Acute Discharge for Older Adults (Doctoral dissertation).

References

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing care plans: guidelines for individualizing client care across the lifespan. FA Davis

Marcus, C. (2014). Strategies for improving the quality of verbal patient and family education: a review of the literature and creation of the EDUCATE model. Health Psychology and Behavioral Medicine: An Open Access Journal, 2(1), 482-495

Silver, S. A., Saragosa, M., Adhikari, N. K., Bell, C. M., Harel, Z., Harvey, A., ... & Jeffs, L. (2018). What insights do patients and caregivers have on acute kidney injury and post-hospitalization care? A single-center qualitative study from Toronto, Canada. BMJ Open, 8(6), e021418

Waller, P. (2016). Occupational Therapy Goals during Acute Discharge for Older Adults (Doctoral dissertation).