ENF 108 University of Sacred Heart Plan de Cuidados de Enfermeria
Description
Esta estudio de caso tiene como objetivo principal el desarrollar del pensamiento crítico y juicio clínico en cada uno de ustedes.
El plan de cuidado es la guía escrita que organiza la información sobre los cuidados del cliente como un todo significativo (cuidado holístico). Es el instrumento de trabajo principal para el profesional de enfermería.
Para la construcción de los diagnósticos de enfermería, debe utilizar las etiquetas de la NANDA 2018-2020 en formato PDF.
Utilice la situación hipotética y los formatos de plan de cuidado y nota de progreso de enfermería para completar la guía.
Debe leer cuidadosamente las instrucciones y rubrica del trabajo.
Esta guía será trabajada de manera grupal.
Lea cuidadosamente las siguientes instrucciones:
1. Utilizando los datos de la situación hipotética adjunta, trabaje de manera grupal, un plan de cuidados de enfermería.
a. Identifique en orden de prioridad dos necesidades de salud, una real y una a riesgo, que sean las de mayor prioridad para trabajar con esta situación hipotética.
b. Enumere los datos objetivos y subjetivos que evidencien la existencia de la necesidad de salud.
c. Identifique los estímulos focales relacionados a ambas necesidades.
d. Utilizando las etiquetas de NANDA 2018-20 y el formato PES, redacte cada uno de los dos diagnósticos de enfermería de prioridad, real y a riesgo.
e. Redacte un resultado esperado para cada uno de los diagnósticos de enfermería identificados en esta situación.
f. Redacte en orden de prioridad, al menos cinco intervenciones de enfermería que llevaría a cabo para lograr cada uno de los dos resultados esperados. Es importante que incluyas en las intervenciones al menos una para prevención y promoción de la salud del cliente-familia.
g. Mencione el racional científico que valide el llevar a cabo cada intervención.
h. Redacte una evaluación (una revisión hipotética) para cada diagnóstico de enfermería a la luz del resultado esperado que desarrollaste.
2. Luego de finalizado el plan de cuidados, redacte la nota de progreso de enfermería para este cliente.
INSTRUCCIONES:
Plan de cuidado 1:
Situacion: La Sra. Romero, viuda de 65 años se encuentra soñolienta pero orientada, piel pálida y ligeramente fría. Se queja de dolor y frío. Fue sometida a una cirugía de prótesis de cadera derecha. Esta con orden de NPO, con una solución de glucosa y agua 100 ml a través de una bomba de infusión. Se le administra antibiotico de Ciprofloxacina. Vendaje lateral y superior del muslo y cadera derecha con Hemovac. Foley con orina transparente y color ámbar. Se encuentra acompañada de la Sra. Morales, quien dice ser su amiga. La Sra. Romero vive sola, los familiares mas cercanos viven fuera de Puerto Rico y se niega a dejar su país.
Recuerde:
1. Realice la lectura de la Unidad IV, Capitulo 14, 15 y 16 (pag. 228 a la pag. 288).
2. Realice una introducción presentando el caso desde su punto de vista y su análisis del mismo.
3. Realice un plan de cuidado utilizando la situación presentada. Utilice formato de la institución.
4. Recuerde realizar una conclusión explicando el porqué de sus intervenciones de enfermería justificándolas con teorizantes de enfermería.
5. Finalicé con las referencias utilizadas para la elaboración del estudio de caso que estén actualizadas (no más de 5 años) y de fuentes confiables en estilo APA.
Referencias: Ignatavicius, D. D., Workman, M. L., & Rebar, C. R.(2018). Medical-surgical nursing: Concepts for interprofessional collaborative care (9th ed.). St. Louis, MO: Elsevier Saunders.
Files:formato (.docx, 37K)
Rubric
Your assignment will be graded based on this rubric.
Rubric
Estudio de caso.
44 possible points
Excellent
4 points
Very Good
3 points
Satisfactory
2 points
Deficient
1 point
Not Present
0 points
Presentation
/4 points
Formality of the written presentation.
Include in the task a cover with identification of the institution and the program, name and student number of each participant, and date of delivery.
Include in the task a cover with identification of the institution and the program, name and student number of each participant.
Include in the task a cover with identification of the institution and the program, and name of students.
Include in the task a cover with identification of the institution and the program.
Student did not complete assignment and delivery in the period assigned.
Assessment
/4 points
Includes domain, needs, subjective and objective data and focal stimulus that support nursing diagnosis.
Utilizes multiple sources for data. Correctly identifies subjective and objective data which is clear, specific, and relevant. All data is clustered in a coherent manner and is related to a nursing diagnosis.
Identifies some significant, accurate and relevant data from more than one source. Does not consistently identify subjective and objective data correctly. Most assessment data supports nursing diagnosis.
Assessment portion is incomplete or inaccurate. Assessment data is not well organized. Subjective and objective data are not identified. Assessment data is irrelevant or does not support nursing diagnosis.
Student did not complete assignment and delivery in the period assigned.
Nursing Diagnosis
/4 points
The diagnoses are identified and are clearly supported by assessment data, and reflect accurate clinical judgement. They are appropriate for patient, well prioritized, NANDA 2018-20 approved, and written in correct format.
One or two diagnosis are identified that are appropriate for patient and are NANDA 2018-20 approved and clearly supported by assessment data. May not be listed in order of priority, or lack the proper format.
Diagnosis portion is incomplete or irrelevant. Diagnosis not clearly supported by assessment data.
Diagnosis are not NANDA 2018-20 approved, appropriate for patient or not prioritized. Diagnosis not clearly supported by assessment data.
Student did not complete assignment and delivery in the period assigned.
Outcomes and Planning
/4 points
Short and long term outcomes are identified that clearly relate to the nursing diagnosis, are written in a patient focused manner, and are realistic. Each outcomes contains clear criteria for measurement and a time frame for evaluation.
Outcomes statements are identified that relate to the nursing diagnosis, and are patient focused. Criteria for measurement included but may not be clear or contain realistic time frame for evaluation.
Outcomes statement are not relevant to nursing diagnosiss. Outcomes are consistently not client centered, measurable or have achievable target dates.
Outcomes portion is incomplete or completely unrelated to nursing diagnoses.
Student did not complete assignment and delivery in the period assigned.
Implementation
/4 points
Identifies all specific interventions for each outcome criteria in order to help the patient/family reach the desired goal. Interventions are specific in action and frequency, and include rationales which are researched and clearly referenced with very reliable sources.
Identifies at least 3-4 specific interventions for each outcome criteria in order to help the patient/family reach the desired goal. Interventions are specific in action and frequency, and include rationales which are researched and clearly referenced with very reliable sources.
Identifies two or less interventions for each outcome that relate to the etiology of the nursing diagnosis. Not all interventions may be specific. Rationales included but may be weak, or references are incomplete or from sources that may not be reliable.
Interventions are unclear or do not clearly focus on the etiology of the nursing diagnosis or relate to patient goal outcomes.
Rationales provided do not demonstrate an understanding of the purpose of the interventions or no references are provided.
Student did not complete assignment and delivery in the period assigned.
Evaluation
/4 points
Evaluation portion contains data that is listed as criteria in outcomes statement and lists expectations for meeting the goal. Clear explanation of the criteria for goals being met, partially met, or not met. Includes plan for continuation or revision, clearly referenced rationale for revisions from reliable sources, and a new evaluation date/time.
The evaluation contains data that are listed as criteria in the statement of results and lists the expectations to achieve the goal. There is no clear explanation of the criteria to meet the results, partially meet or not meet them. It does not include a plan for the continuation or revision, the clearly mentioned reasons for reviews of reliable sources and a new date / time of evaluation
Clearly states how each outcome would be evaluated. Able to correctly identify criteria for goal being met, partially met, or unmet. Identifies revisions for care plan but may not include accurate rationale for revision or references may be from sources that may not be reliable, or a new date is not provided for reevaluation.
Evaluation portion does not consistently contain data that is listed as criteria in outcomes statement. May also not describe outcomes as met, partially met, or not met. May also not include revision or new evaluation date/time.
Student did not complete assignment and delivery in the period assigned.
Reflection
/4 points
Reflect critically in 15 sentences or more on the importance of the concepts raised in the guide for nursing discipline.
Reflect critically in 15 sentences or more on the importance of the concepts raised in the guide for nursing discipline.
Reflect critically in 10 sentences or more on the importance of the concepts raised in the guide for nursing discipline.
Reflect critically in 5 sentences or more on the importance of the concepts raised in the guide for nursing discipline.
Reflect critically in 4 sentences or less on the importance of the concepts raised in the guide for nursing discipline.
It does not reflect.
Professionalism
/4 points
Identifies implications for the practice of nursing discipline.
Identify implications for the practice of nursing discipline in 15 sentences or more. Providing always valid and verifiable arguments through scientific evidence.
Identify implications for the practice of nursing discipline in 10 sentences or more. Providing almost always valid and verifiable arguments through scientific evidence.
Identify implications for the practice of nursing discipline in 5 sentences or more. Providing sometimes valid and verifiable arguments through scientific evidence.
Identify implications for the practice of nursing discipline in 5 sentences or less. It does not provide valid and verifiable arguments through scientific evidence.
It does not identify implications for the practice of nursing.
Conclusion
/4 points
Summarize the learning obtained through the answers of the study guide.
Make a critical, analytical and profound summary of the learning obtained in 15 sentences or more. Includes at least 3 citations of authors of updated nursing references that support their approaches.
Make a critical, analytical summary, but with less depth of learning obtained in 10 sentences or more. Include at least 2 contributions from authors of updated nursing references that support their approaches.
Make a summary of learning obtained in 5 sentences or more. Include at least 1 contribution from authors of updated nursing references that support their approaches.
Make a short summary of the learning obtained in less than 5 sentences. It does not include contributions from authors of updated nursing references that support their approaches.
It does not include a summary of the learning obtained. It does not include contributions from authors of updated nursing references that support their approaches.
References
/4 points
The student cites authors of recent references (5 years or less of published) related to the topic of the discussion forum, written according to the latest edition of APA.
Sometimes the student cites authors of recent references (5 years or less of published) related to the topic of the discussion forum, written according to the latest edition of APA.
On rare occasions the student cites authors of recent references (5 years or less of published) related to the topic of the discussion forum, written according to the latest edition of APA.
The student never cites authors of recent references (5 years or less of published) related to the topic of the discussion forum, written according to the latest edition of APA.
Does not include references in the task.
Nursing Note
/4 points
Includes for this case along with the care plan, the nursing progress note with date, time, focus, data, action and evaluation.
It includes the nursing progress note with date, time, focus, but the data, action and evaluation are not clear.
It includes the nursing progress note with date, time, focus, data, action, but the evaluation does not appear and the identified focuses are not clear.
It includes the nursing progress note, but does not consider the format FOCUS CHARTING in the writing.
Does not include the nursing progress note.
PLEASE FOLLOW ATTACHED MODEL FOR ASSIGNMENT.
ASSIGNMENT MUST BE IN SPANISH!
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