Eighty-year-old Mrs. Hernandez is newly admitted your acute care hospital unit.
ID: 62123 • Letter: E
Question
Eighty-year-old Mrs. Hernandez is newly admitted your acute care hospital unit. She is there for observation and testing after a witnessed syncopal episode. She lives with her 90-year-old husband, who has mild dementia, and her 60-year-old daughter. Her daughter admits to you that neither of her parents has been doing well and that the doctors “just haven’t been able to figure it out.” You know that Mrs. Hernandez will be receiving both neurological and cardiac testing. However, as a gerontological nurse you also know that she and her family may benefit most from a comprehensive evaluation. The decision of which assessments to do is within the scope of practice for nurses at your facility.
On the basis of the case study, develop a nursing care plan using the following procedure*:
List Mrs. Hernandez’s comments that provide subjective data.
List information that provides objective data.
List two of Mrs. Hernandez’s strengths that you have identified from the data.
From these data, identify and state, using accepted format, two nursing diagnoses you determine are most significant to Mrs. Hernandez at this time.
Determine and state outcome criteria for each diagnosis. These must reflect some alleviation of the problem identified in the nursing diagnosis and must be stated in concrete and measurable terms.
Plan and state one or more interventions for each diagnosed problem. Provide specific documentation of the source used to determine the appropriate intervention. Plan at least one intervention that incorporates Mrs. Hernandez’s existing strengths.
Evaluate the success of the intervention. Interventions must correlate directly with the stated outcome criteria to measure the outcome success.
Explanation / Answer
Solution:
Nursing Care Plan
Patient Name: Mrs. Hernandez
Age: 80 yrs
Sex: Female
Health
Problems
Family
Nursing
Problems
Goal of
Care
Objective of Care
Intervention Plan
Evaluation Plan
Intervention
Method
Resources
Criteria
Standard
Method
Syncopal episode
1. Her 90-year-old husband, who has mild dementia.
After Hospital
Discharge
a) be able to gain knowledge about Syncopal episode
b) will prevent the recurrence of disease in the future
After hospital admission
a) acquire idea and information about the disease including signs and symptoms of the disease immediate health care assistance and preventive measure
b) Enumerate the importance of prevention of the disease
c) Utilise resources openly available in resolving the problem
1) Assess the family’s status of personal hygiene
2) Discuss with the family the cases and effects and complication of Syncopal episode.
Hospitalised
Neurological and cardiac testing Reports
Time and effort on the part of the nurse and the family
Compliance to the agreed upon intervention
a) Acquired ideas and information about the disease including signs and symptoms immediate health care assistance and preventive measures
b) Enumerated the importance of prevention of the disease
c) Utilised community resource
Hospital Treatment
Health
Problems
Family
Nursing
Problems
Goal of
Care
Objective of Care
Intervention Plan
Evaluation Plan
Intervention
Method
Resources
Criteria
Standard
Method
Syncopal episode
1. Her 90-year-old husband, who has mild dementia.
After Hospital
Discharge
a) be able to gain knowledge about Syncopal episode
b) will prevent the recurrence of disease in the future
After hospital admission
a) acquire idea and information about the disease including signs and symptoms of the disease immediate health care assistance and preventive measure
b) Enumerate the importance of prevention of the disease
c) Utilise resources openly available in resolving the problem
1) Assess the family’s status of personal hygiene
2) Discuss with the family the cases and effects and complication of Syncopal episode.
Hospitalised
Neurological and cardiac testing Reports
Time and effort on the part of the nurse and the family
Compliance to the agreed upon intervention
a) Acquired ideas and information about the disease including signs and symptoms immediate health care assistance and preventive measures
b) Enumerated the importance of prevention of the disease
c) Utilised community resource
Hospital Treatment
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