What can you, the nurse, do to reach the goal and improve the problem?

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Course Project Case Study: Mr. Clooney is a 76-year-old Caucasian male who was admitted to the
rehabilitation hospital following a 6 week stay in a local acute care hospital. He suffered a T3 burst
fracture after a MVA and the site was surgically stabilized. He is paralyzed in his lower extremities and
has no sensation below the clavicles. He is incontinent of bowel and bladder and has a stage 3 pressure
ulcer to his coccyx. Medical history includes asthma, substance abuse (alcohol), obesity, constipation,
prediabetes (has not progressed to type II diabetes) and tested positive for Covid-19 in November 2020
after experiencing shortness of breath and fever.
Mr. Clooney is single and lives alone in a second story apartment. His son lives three states away and he
has no relatives in the area. He is a retired construction worker, denies any religious affiliation, and
speaks English.
Orders include:
Full resuscitation
PT, OT TID, 5 days per week
Dressing changes to sacral pressure ulcer: cleanse with wound wash, alginate dressing daily
Cervical collar when OOB
Transfer with sliding board per PT
Regular diet
Ensure high protein shake BID
Foley catheter to dependent drainage
Cleanse catheter site with soap and water BID
Medications Include:
Dulcolax suppository every 3 days rectally
Baclofen 5mg PO QID
Midodrine 10 mg PO at 0800, 1300 and 1800
Albuterol inhaler: 180 mcg (2 puffs) every 6 hours PRN
Complete Plan of Care on your client (10 points)
In this third and final submission of your Course Project, you will be completing the comprehensive care plan. Include safety needs, special considerations regarding personal needs, cultural/spiritual implications, and needed health restoration, maintenance, and promotion.
This written assignment should include the following:
• Your Nursing diagnoses from Part 2 (use the table below)
• One short term goal and one long term goal per NDx
• Four Nursing interventions per NDx . .
• Prioritization per Maslow with an explanation and an expected evaluation. Make sure to include a teaching plan in your care plan. Upload the table below into your paper. Reflect on the following in your paper: Which of your nursing diagnoses are priority using Maslow’s Hierarchy of Needs? If you were to implement this plan of care, would you expect any of your short-term expected outcomes met during your shift? Explain. How might you revise your care plan next time to achieve at least one outcome during your shift?
1. Decreased cardiac output, related to the motor vehicle accident and the surgery, as evidenced by resuscitation order and Midodrine (Doenges et al., 2019).
2. Inability to sustain spontaneous breathing, related to sudden admittance into the rehabilitation center, as evidenced by resuscitation order, Albuterol inhaler, and asthma (Doenges et al., 2019).
3. Impaired physical mobility, related to fracture and paralysis, as evidenced by lack of sensation below the clavicles (Doenges et al., 2019).
4. Disability (partial or total) to wash/perform their hygiene, related to spinal injury and paralysis, as evidenced by therapies and dressing changes (Doenges et al., 2019).
5. Acute pain, related to stage 3 pressure ulcer, as evidenced by dressing changes and cleansing procedures (Doenges et al., 2019).
Nursing Diagnoses
Use your Assessment data to ID clinical problems Expected Outcomes (S.M.A.R.T.)
Specific, measurable, attainable, realistic, & time-oriented (ID a future time or date for reassessment/evaluation) Nursing Interventions
What can you, the nurse, do to reach the goal and improve the problem?
#1
R.T.
A.E.B.
The patient will…
Short-term goal:
Long-term goal: The nurse will…
1.
2.
3.
4.
#2
R.T.
A.E.B. Short-term goal:
Long-term goal: 1.
2.
3.
4.
#3
R.T.
A.E.B.
Short-term goal:
Long-term goal: 1.
2.
3.
4.
#4
R.T.
A.E.B.
Short-term goal:
Long-term goal: 1.
2.
3.
4.
#5
R.T.
A.E.B. Short term goal
Long term goal 1.
2.
3.
4.
Part 3 – (Due Week 10): 35 pts
Topic Points
Complete Nursing Care plan following instructions above and prioritization using Maslow and how you would evaluate the plan of care 10
Presentation to clinical group (done individually – see below) 15
APA and Mechanics (for all 3 parts) 10

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