Correctly identifies 3 diagnosis a physiologic, psychosocial and educational diagnosis 15
Correctly states selected nursing diagnosis including related to/ as evidence by 15
Goals are written using SMART format. One goal for each diagnosis 15
Three interventions for EACH diagnosis. Interventions clearly support the related goals. 15
Rationales clearly support the interventions. One rationale for each intervention 15
All rationales are supported by reference written in APA format. 5
Care plan is typed, free of spelling/syntax/grammatical errors 5
Directions: Complete a care plan utilizing the criteria outline on the nursing care plan criteria sheet.
The client is an 18- year old man who suffered a spinal cord injury at the level of C-5 during a boating accident. He is currently in a rehabilitation setting with assisted ventilation and quadriplegia. He has a reflex neurogenic bladder that fills and empties automatically. The nursing staff is teaching the client?s 17- year-old wife techniques to facilitate bladder emptying and intermittent catheterization. The client is also on a bowel retraining program that includes stool softeners to prevent fetal impaction. At times the client?s wife seems overwhelmed with her husband?s problems, but she is supportive and asks numerous questions.
One afternoon following lunch, the client begins to complain of a throbbing headache. The nurse notes that his forehead is wet with perspiration and his face is flushed. His blood pressure is 250/160, his pulse is 58 beats per minute (bpm) and regular, his respirations are 24 breaths per minute, his oral temperature is 99.8D, and his extremities are cool and pale. His wife is alarmed and wants you to do something immediately.