Course Competency :

  • Design plans for care specific to the older adult.

Consider the scenario below, then follow the instructions underneath it to complete the assignment.

Mrs. Y

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:

  • Download the Concept Map and Plan of Care worksheet below. An example is also provided for your reference.

Concept Map and Plan of Care worksheet

Concept Map and Plan of Care example

  • Identify three (3) priority nursing diagnoses for Mrs. Y. Visit the School of Nursing Guide Nursing Reference eBooks section for resources to assist with nursing diagnoses. 
  • 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:
  • “related to (r/t)” — description of the client’s problem
  • “as evidenced by” — description of the client’s symptoms
  • Complete the Nursing Plan of Care (table in the worksheet) describing what should be implemented for Mrs. Y.
  • 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.
  • 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.
  • Complete the assignment using proper spelling, grammar, and APA.

For information about creating a concept map, review the FAQ, What is a concept map and how do I create one

Example: Case Study Plan of Care and Concept Map

Case Scenario:

Mrs. J is admitted to the emergency department with a diagnosis of congestive heart failure. She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can’t catch my breath and my legs are swollen.” After further questioning, you learn that Mrs. J is strictly following the fluid and salt restriction ordered during her last hospital admission. Mrs. J reports gaining 1 to 2 pounds every day since her discharge.

Concept Map:

Identify two (2) priority nursing diagnoses for Mrs. J and develop a concept map to illustrate them (see example below).

Primary Medical Diagnosis:

· Congestive Heart Failure

Prioritized Nursing Dx# 2

· Fluid Volume Excess r/t fluid retention as evidenced by swelling

Prioritized Nursing Dx# 6


Prioritized Nursing Dx# 5


Prioritized Nursing Dx# 3


Prioritized Nursing Dx# 1

· Impaired Gas Exchange r/t fluid overload as evidenced by shortness of breath

Prioritized Nursing Dx# 4


Nursing Plan of Care

For each of the priority nursing diagnoses, establish one (1) goal. For each goal create two (2) nursing interventions.

Prioritized Nursing Diagnoses


Nursing Interventions

1. Ineffective Gas Exchange

Pt will maintain oxygen saturations greater than 95% during my shift

1. Give oxygen as ordered

2. Monitor clients oxygen saturations

2. Fluid Volume Excess

Pt will have decreased swelling in extremities by the end of my shift.

1. Administer diuretic as ordered

2. Monitor Intake and Output