Nursing Case Study

8. The nurse is creating a four-column plan of care for a client. For which areas should the nurse prepare to document when creating this care plan?

a. Goals

i. This is part of column two

b. Interventions

i. This is part of column three

c. Nursing Diagnosis

i. This is part of column one

d. Evaluation

i. This is part of column five

e. Medications

i. This is not a part of the column plan of care for a client

Based on http://www.austincc.edu/adnlev1/rnsg1161online/clinical_homework_samples/Nursing_care_plan_sample.htm column one: nursing diagnosis; column two: the expected outcome and goal of what you would like to see from the patient after a specific time frame; column three: interventions; (column four: scientific rationale for each intervention)

Conflict Resolution

i. Conflict resolution deals with resolution of conflicts between health care workers and not between the resolution of a problem the client is dealing with

Page 144

Critical Thinking is the thought process where the client’s problem is defined, evidence based practice in caring is examined, and then choices for the delivery of patient’s care are made.

Page 467

Delegating a Task is when the nurse gives another competent individual a task to perform in a specific situation

Page 195

Priority Setting is where problems are grouped as having high, medium, and low priority based on preferential sequencing for the order in which diagnoses and interventions need to be addressed.

Page 467

Conflict Resolution: In relation to conflict, the book talked about managing conflict between people, groups, and teams, but did not have any relation to having a problem related to the patient’s situation and resolving that.

13. The nurse is assigned two clients. One client needs postoperative teaching in preparation for discharge and the other client with pneumonia has a PaCO2 of 85 which is very high & indicates that pt. is not breathing well. Why does the nurse decide to see the client with pneumonia

According to page 468, client education is a task that may not be delegated to unlicensed assistive personnel. The nurse therefore may not delegate postoperative teaching to UAP since that would be in relation to client education.

b. The client with pneumonia needs more care than the client needing postoperative teaching.

i. The prioritization is not based on which patient needs more care. The patient with pneumonia would have to be helped first because they have a high priority problem that is life threatening (respiratory impairment)

c. The client with pneumonia may be experiencing respiratory distress.

i. Respiratory distress is related to respiratory impairment which is a life threatening problem. Life threatening problems are high priority and need immediate care.

d. The room of the client with pneumonia is closer than that of the client needing postoperative teaching

i. Priority setting problems are not based off of the proximity of the patient, rather, they are based on how threatening the problem is.

Page 195

Priority setting categories include high, medium, and low priority.

High priority is when there are life threatening problems including areas of respiratory and cardio impairment. These problems need immediate