Care Plan 

Choose a community setting of your preference and create a patient scenario. Keep in mind this is a community and public health nursing clinical course therefore, your care plan should address a public health concern. 

Planning nursing is nursing action plans to be implemented to address the problems within their nursing diagnosis has been determined with the aim of fulfilling the needs of the client. So public health nursing care plan is based on pre-defined nursing diagnoses and nursing plan drawn up should include the formulation of objectives, plans nursing actions to be performed and the criteria for assessing the results of the achievement of objectives.

The steps in the planning of public health nursing are as follows:

  • Identify alternative nursing actions.
  • Set techniques and procedures to be used.
  • Involve community participation in planning through village community consultation activities, or mini workshops.
  • Consider the community resources and facilities available.
  • Actions to be implemented must be able to meet the requirement, which was felt by the public.
  • Leads to the objectives to be achieved.
  • Action must be realistic.
  • Arranged sequentially.

***Follow example attached to this assignment!

You must utilize the attached form to complete the assignment. This assignment is an individual assignment and everyone must turn in one care plan before the end of class. 

NURSING CARE PLAN

Student:

Date:

9/26/2021

Instructor

Course

NUR4200C

Patient Initial

AD

Unit/ Room#

DOB

07/01/2021

Code Status:

Full Code

Height/Weight

Allergies

No know

Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),

include dates and rationales supported with Evidence Based Citations

Past Medical & Surgical History,

Pathophysiology of medical diagnoses


(include dates, if not found state so)

Supported with Evidence Based Citations

NURSING CARE PLAN

Erikson’s Developmental Stage with Rationale


And supported by Evidence Based Citations

Socioeconomic/Cultural/Spiritual Orientation

& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations

Student:

Date:

Instructor

Course

Patient Initial

JB

Unit/ Room#

2 North / Room 47

DOB

12/2/2015

Code Status:

Full Code

Height/Weight

67.04 cm/ 8.13 kg.

Allergies

No Known Allergies

Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

98.4

133

39

100

95/54

0

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

JB is a 6-month old male infant that was admitted to the emergency room located at Nicklaus Children Hospital with symptoms of diarrhea, fever, respiratory distress, productive cough, and vomiting. Patient is also irritable with a decreased level of energy and seems agitated at times. JB’s mother stated that he seems to be having difficulty breathing at times.

JB was admitted with the diagnosis of Acute respiratory distress syndrome (ARDS) which occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. More fluid in your lungs means less oxygen can reach your bloodstream. This deprives your organs of the oxygen they need to function. ARDS typically occurs in people who are already critically ill or who have significant injuries. Severe shortness of breath the main symptom of ARDS usually develops within a few hours to a few days after the original disease or trauma. Many people who develop ARDS don’t survive. The risk of death increases with age and severity of illness. Of the people who do survive ARDS, some recover completely while others experience lasting damage to their lungs (Mayo Clinic Staff, 2014).

At the time of physical assessment JB was found sitting on his mother’s lap. JB is AAO X3,

Patient Introduction

Location: Inpatient alcohol rehabilitation facility – treatment room

Time: 08:00

Report from charge nurse:

Situation: Mr. Davis is a 56-year-old man who voluntarily admitted himself to the alcohol rehabilitation facility yesterday afternoon. He is currently on the acute detoxification unit. Mr. Davis has been on the unit for about 16 hours.

Background: Mr. Davis is a member of the school board and the pastor of a large church. Yesterday he was removed from a school board meeting by security guards after becoming angry and directing racial and ethnic slurs at students and their family members. His wife afterward asked him to move out of their home, and this led to the admission. He has three children: a son who is 25 years old, and two daughters, aged 21 and 17 years. His daughters will not speak to him. His son accompanied him to the rehabilitation facility. Mr. Davis had an open reduction internal fixation surgery to repair a humerus fracture 2 years ago, but otherwise, he has no significant medical history and no known allergies. He reports that his alcohol intake is approximately 1 pint of vodka per day and his last drink was prior to the school board meeting. He denies using recreational drugs and tested negative for opiates and marijuana. He does not smoke.

Assessment: He is currently oriented ×3 and is embarrassed about his behavior at the school board meeting. He went to a 12-step meeting yesterday but left early, saying that he was “not like those people” and felt he wouldn’t benefit from the meeting. He was restless last night and did not sleep much. Morning laboratory tests were also drawn at 06:00, when he woke up. Their results are available in the chart, together with the laboratory results from yesterday afternoon. His behavior is appropriate, and he engages appropriately with staff, although his affect is constricted. His CIWA-Ar score was 1 on admission. At 04:00, it had increased to 7. His last set of vital signs included the following: temperature, 37.2°C (99.0°F); heart rate, 94 beats/min; respiratory rate, 20 breaths/min; blood pressure, 154/90 mmHg; and blood oxygen saturation, 98%.

Recommendation: He is due for reassessment of the CIWA score in our treatment room. He has an order for as-needed diazepam for a CIWA score of 8 or greater, so he may need that soon. He is supposed to go to group therapy today and to an Alcoholics Anonymous meeting. He is going to be evaluated by a psychiatrist later today.

Causes and Effects of Alcohol Abuse

1. Videbeck, S. (2020). Psychiatric-Mental Health Nursing, 8th Edition.

2. Onset and Clinical Course, Chapter 19, pp. 356-357

3. Alcohol, Chapter 19, p. 359

Assessment and Treatment of Alcohol Abuse

1. Videbeck, S. (2020). Psychiatric-Mental Health Nursing, 8th Edition.

2. Treatment and Prognosis, Chapter 19,