Week 4 Assignment 2: Case Study Analysis and Care Plan Creation
Analyze the following case study. Create a holistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Case Study
See add file Gastroenterology Clinical Case
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
• Search term page to identify the codes applicable to the care plan. http://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspx
• This link will lead to an excel version of the latest codes: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html
Click here (See template, I will add) to download the care plan template to help you design a holistic patient care plan. The care plan example provided here is just a reference for you to build your care plan. You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.
Format
Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be double-spaced and in 12pt font.
Name your document: SU_NSG6001_W4A2_LastName_FirstInitial.doc.
Grading Criteria Maximum Points
Care plan demonstrated involvement of the client in the process of recognition, planning, and resolution of the problem. 15
Care plan included effective nursing interventions that were customized for the client and appropriate to the goal. 15
Care plan included diagnostic workup, medications, conservative measures, and a follow-up plan. 15
Care plan provided rationale for choosing a particular treatment modality. 15
Care plan demonstrated logical diagnosis, which was substantiated with relevant evidence. 10
Care plan focused on patient education, maintained a fine balance between major and minor health issues of the patient. 10
Care plan included nursing interventions that are specific, appropriate, and free of essential omissions. 10
Used APA standards consistently and accurately. 10
Total 100
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