Neuro Care Plan
Use the following information/scenario to create a care plan that identifies resources to assist J.M. and his family.
Scenario:
J.M. is a 78 year old man. He lives with his wife of 55 years, C.M. One son and his family lives near, their other 3 children and their families live in other states. J.M. is a Native American, and is active in his local tribal council. He and his wife “walk in two worlds”, meaning they strive to “fit in” in society while practicing their spiritual and cultural way of life at home. J.M. seeks care from both a traditional medical doctor and a healer.
J.M. loves to cook and garden, and is involved in volunteer work through his tribe and at his local Alcoholics Anonymous. He is retired now, and his wife works part-time as a teacher’s aide. J.M. has a medical history of Diabetes Mellitus Type II, which is well controlled, hyperlipidemia, hypertension, renal disease and is recovering alcoholic. J.M. has been sober for the past 20 years.
J.M. experienced a stroke 2 weeks ago. he was hospitalized and then discharge to a rehabilitation facility 5 days ago. His deficits include right sided weakness and some aphasia. Assessing J.M. has been difficult and he has been struggling with the treatment regime in the rehab center. he eats very little, and has lost 12 lbs since admission to the hospital. His only visitors at the rehab center have been his wife and son. The staff are frustrated because he has made little progress, yet his rehab potential remains excellent.
Today, his urine output is low and his urine is dark, he winces with movement but denies pain, his BP is 178/102, temperature is 99.1-tympanic, RR-22 and HR-100. The rehab assistant reported his vital signs and said “he seems more quiet than usual, he was staring out the window and his eyes look funny-he barely acknowledge my presence”.
Instructions on the Care Plan
The Care Plan must include all of the following:
1. Organization and Formatting
a. Use the provided Care Plan Template.
b. Use professional language, free of spelling and grammar errors.
c. Include at least two peer-reviewed or evidence based resource to support the care plan.
d. The Care Plan must be well organized, following the Nursing Process with a logical flow and accurate content that clearly relates to the topic.
e. Follow APA guidelines to cite sources and provide a reference page.
2. Care Plan includes the following:
a. Data Collection and Organization
i. Include subjective and objective data to support each nursing diagnosis.
ii. Be thorough and detailed, data should be clustered to each nursing diagnosis, and be sure to demonstrate cultural awareness in your assessments.
iii. Use your imagination to fill in gaps so that a clear picture is provided.
b. Three priority nursing diagnoses:
i. Each nursing diagnosis is written following the correct format
ii. Supports attention to immediate needs of the patient and her family
iii. At least one addresses the patient’s culture
iv. At least one addresses caregiver stress
c. One short term and one long term SMART Goal for each nursing diagnosis:
i. Each goal follows the SMART format
ii. Each goal demonstrates cultural awareness by aligning with the patient’s health beliefs, traditions, and practices.
d. Three evidence-based nursing interventions for each goal
i. List the nursing interventions in order of priority.
ii. Each nursing intervention demonstrates cultural awareness by aligning with the patient’s health beliefs, traditions, and practices.
iii. Provide a rationale for each nursing intervention supported with a peer-reviewed or evidence based resource.
e. Goal Evaluation
i. Provide an accurate and realistic description of how you would evaluate each goal.
ii. Provide an alternate outcome or intervention for each goal.