https://www.youtube.com/watch?v=wLaQgoIogEg
After watching each of the case studies and choosing a client, complete the following:
1. What screening and assessment tools might you utilize when interviewing Steve or Alice? How come? To what end? Provide your rationale for choosing this assessment tool and how will this assessment tool help with your nursing care planning for the client? – choose one client only, this should be clearly stated in your care plan.
2. Choose and create a care plan for either Steve or Alice using the nursing process- choose one client only that includes the following:
A) Assessment Data:
Objective Data
Subjective Data
MSE: Write your MSE documentation in paragraph form. Your MSE will be on one client only, the same client you have choose above, and will be completed in pairs (both partners will contribute to the development of this MSE documentation).
Appearance
Attitude (also referred to as “rapport”)
Behavior
Mood and affect
Speech
Thought process
Thought content
Perceptions
Cognition
Insight
Judgment
B) Nursing Diagnosis: List One Nursing Diagnoses in PES format
C) SMART Goals: Develop Two short term goals. Goals should be S.M.A.R.T. and based on your choose nursing Dx listed above:
Specific (to the assessed priority)
Measurable
Attainable
Realistic
Time limited (should be accomplished within a realistic time frame – this may be a shift, a set of shifts, or by discharge, but not after discharge)
D) Interventions: Two evidence-informed interventions based on your chosen nursing Dx listed above
E) Evaluation: Two evaluations based on your chosen nursing Dx listed above
