Michelle Mason is a 62-year-old African American female who lives at home alone. She has been under the care of her PCP for hypertension and diabetes. Recently she has not been feeling well, she complains of dizziness and fatigue. The dizziness has caused her to be afraid to leave the house. The fatigue has caused her to lose interest in her ADLs. She has been sleeping throughout the night and most of the day, in addition she has not been in contact with her friends or her family.
Develop a Care Pan for Michelle Mason with:
1. Three priority nursing diagnoses
2. One goal for each nursing diagnosis
3. Three interventions for each goal
4. A rationale for each intervention
5. One evaluation for each goal
CLINICAL APPLICATION OF THE NURSING PROCESS TOOL
Client’s initials:__________ Actual Developmental Stage: _________________________
Gender: _____ Age: _____ Perceived Developmental Stage: _______________________
Reason for admission (if applicable) _____________________________________________
(client goals) Implementation
(nursing interventions) Rationales
(Why? w/ references) Evaluation
Scoring Code Key Student Name: _____________________
S – Satisfactory
NI – Needs Improvement
U – Unsatisfactory
Please submit this scoring criterion with the Care Plan.
Area to be scored Scoring code
a. Determined basic needs of the client which are threatened
b. Nursing Diagnosis are in priority order based on Maslow’s Hierarchy of Needs, and ABC’s (airway, breathing, circulation)
All parts of the nursing diagnoses present and appropriate (Diagnosis statement, Related to (R/T) factors, patient specific – as evidenced by (AEB) subjective and objective (S / O) data)
a. Goals are appropriate (time specific, measurable, focused, realistic) and related to the Nursing Diagnosis
b. Measures to accomplish goal are appropriate
a. Uses scientific principles
b. Reference sources are noted
a. Nursing actions carried out are specific and appropriate for goal attainment
a. Describes clients responses to nursing interventions
6. Determines the extent to which goals have been met
(States goal attained, not attained or partially attained)
Michelle Mason, a 62-year-old African-American woman, lives alone at home. Her primary care physician has been treating her for hypertension and diabetes. She hasn’t been feeling well lately, complaining of dizziness and exhaustion. She is afraid to leave the house because of the dizziness. She has lost interest in her ADLs due to weariness. She has been sleeping all night and much of the day, and she has not communicated with her friends or relatives.
Create a Care Plan for Michelle Mason that includes:
1. Three top nursing diagnoses
2. One objective for each nursing diagnostic
3. There are three interventions for each aim.
4. A justification for each intervention
5. Only one evaluation
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