Using the scenario that follows, develop a plan of care for the following patient. The plan of care must include the following:   Full assessment Three nursing diagnosis Must include all the elements of the nursing diagnosis Three goals for each nursing diagnosis Must meet the SMART metrics At least one intervention for each goal Must be appropriate for the plan/goal identified Evaluation for each intervention Scenario History You have received report of the patient in your care. Patient assessment demonstrates that the patient was admitted overnight. The patient is a 54 year old male patient, married with three children ages 19 to 25. The patient lives at home with his wife, children, and his wife's mother. Patient is admitted after fainting on the golf course at 7am the day before. Emergency medical services was called. Assessment of the EMS personnel demonstrated that the patient suffered a cardiac arrest. CPR was started at the site. ACLS ambulance transported the patient to the hospital. During transportation, the patient was successfully resuscitated. Upon arrival to the emergency room, the doctor ordered tests and the patient was taken to the catheterization lab.   Current condition Patient diagnosis: ST elevation myocardial infarction,  Patient is awake in bed. Cardiac monitor in place. HR 122, BP 150/92, Respirations 20, cardiac rhythm sinus tachycardia. Patient with dressing to right groin dry and intact. Patient denies pain. Labs show the troponin levels are 1000, down from 5000. medication reviewed. From the information herein, develop care plan to care for this patient.

3-2-1 Code It
6th Edition
ISBN:9781337660549
Author:GREEN
Publisher:GREEN
Chapter8: Introduction To Cpt Coding
Section: Chapter Questions
Problem 15MC
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Using the scenario that follows, develop a plan of care for the following patient. The plan of care must include the following:

 

  1. Full assessment
  2. Three nursing diagnosis
    • Must include all the elements of the nursing diagnosis
  3. Three goals for each nursing diagnosis
    • Must meet the SMART metrics
  4. At least one intervention for each goal
    • Must be appropriate for the plan/goal identified
  5. Evaluation for each intervention

Scenario

History

You have received report of the patient in your care. Patient assessment demonstrates that the patient was admitted overnight. The patient is a 54 year old male patient, married with three children ages 19 to 25. The patient lives at home with his wife, children, and his wife's mother.

Patient is admitted after fainting on the golf course at 7am the day before. Emergency medical services was called. Assessment of the EMS personnel demonstrated that the patient suffered a cardiac arrest. CPR was started at the site. ACLS ambulance transported the patient to the hospital. During transportation, the patient was successfully resuscitated. Upon arrival to the emergency room, the doctor ordered tests and the patient was taken to the catheterization lab.  

Current condition

Patient diagnosis: ST elevation myocardial infarction, 

Patient is awake in bed. Cardiac monitor in place. HR 122, BP 150/92, Respirations 20, cardiac rhythm sinus tachycardia. Patient with dressing to right groin dry and intact. Patient denies pain.

Labs show the troponin levels are 1000, down from 5000.

medication reviewed.

From the information herein, develop care plan to care for this patient.

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