. Please read case study and fill out care plan template attachment on the bottom of the page. Thank you
In this week?s Grand Rounds presentation, we will be discussing topics relevant to the cardiovascular system. Following the Grand Rounds presentation, you will be assigned a patient suffering from a cardiac disorder and you will be in charge of developing a detailed care plan for your patient. You are required to search for evidence as you move on to the task of care plan development. Search for evidence from a variety of sources, including textbooks, current journal articles, peer communication, personal experience, and feedback from patients, based on your experiences in treatment.
Case stuydy:Your first patient will be a 55-year-old man recently discharged from the hospital following a stent placement for coronary artery disease. This patient requires extensive education regarding the medications prescribed at the time of his discharge and the health promotion activities that he should follow based on his post-hospitalization diagnoses.
Case Study Analysis and Care Plan Creation
Analyze the case study assigned to you at the outpatient clinic. 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.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-9 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-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
Care Plan Template
Patient Initials: ______ Age: _______________ Sex: ___________
HPI (History of Present Illness):
PMH (Past Medical History?include current medications, any known allergies, any history of surgery or hospitalizations):
Significant Family History:
Social/Personal History (occupation, lifestyle?diet, exercise, substance use)
Description of Client?s Support System:
Behavioral or Nonverbal Messages:
Client Awareness of Abilities, Disease Process, Health Care Needs:
Vital Signs including BMI:
Physical Assessment Findings:
Lab Tests and Results:
Client?s Support System:
Client?s Locus of Control and Readiness to Learn:
ICD-9 Diagnoses/Client Problems:
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):