Nursing Care Plan (Linear and Concept Map)

Nursing Care plan( Linear and concept map)

Learning Objectives: Upon completion of the simulation, the student will be able to:

Establish a therapeutic environment and alliance for engaging patients and their families

Document nursing assessment activities in a concise, descriptive, and legally appropriate manner

Provide a safe environment for both patients and staff while maintaining patient privacy

Apply principles of infection control, including demonstrating hand washing and appropriate use of personal protective equipment

Use therapeutic communication techniques in a manner that illustrates caring for the patient’s overall well-being and re ects cultural awareness and psychosocial needs

Demonstrate a process of critical thinking when conducting an assessment and interpreting data Make clinical judgments and decisions using evidence-based practice

Perform a general survey and obtain vital signs

Conduct an organized head-to-toe physical assessment

Assess  uid balance and identify normal  ndings

Evaluate patient outcomes of IV therapy, potassium replacement, and antibiotics

Note: The general objectives are generic in nature and once learners have been exposed to the content, they are expected to maintain competency in these areas.

Medical unit in an acute care hospital

Time: 1000

Report from midnight shift nurse:

Mr. Rashid Ahmed was admitted 2 days ago with a diagnosis of gastroenteritis secondary to E. coli with dehydration and hypokalemia. He has responded well to treatment and his condition has stabilized, so he is ready to be discharged this afternoon.

Mr. Ahmed is a 50-year-old Middle Eastern male. Five days ago, he ate lunch at a local restaurant and subsequently developed abdominal cramping, vomiting, and severe diarrhea. At admission, he had signs and symptoms of dehydration and hypokalemia.

Mr. Ahmed is alert and oriented to person, place, and time. He stated that he is feeling much better this morning. He denies nausea and abdominal pain and reports sleeping well last night. Daily orthostatic blood pressure readings performed at 0600 were 118/76 lying, pulse 72, 114/74 sitting, pulse 76, and 110/68 standing, pulse 78. He has been afebrile for 24 hours. His skin is tan and dry, and skin turgor shows immediate return. His heart rate is regular. Bowel sounds are active in all quadrants, and his abdomen is soft. He last received antiemetic treatment yesterday afternoon. He is now tolerating oral uids and needs encouragement to increase intake as tolerated. He is ready for discharge to home this afternoon. He had a small amount of soft formed stool at 2200 last night. His diet order is advance to regular as tolerated, and he was able to eat some dry toast last evening without nausea, vomiting or loose stools. He has been voiding without dif culty. He has an IV catheter in place with a saline lock.

Mr. Ahmed’s vital signs are up, and he will need a head-to-toe assessment. Please also continue to monitor his intake and output and uid status, and he needs encouragement to increase the oral intake.