Introduction to the Case
This case involves Sally, a Caucasoid Canadian woman aged 19 and currently in her final year in the faculty of nursing at the university. Her parents live in New Brunswick, where she was born and raised. However, she has recently moved to Alberta to live with her boyfriend.
Sally is hardworking and ambitious, as she does not want to rely on her parents for support. She has a part-time working job that she attends at night for two shifts. In addition, she is studying hard to achieve better grades in the forthcoming final exams and writing her final college paper.
It is almost Christmas time, and her friends and family expect her to be with them back in New Brunswick. She also wishes to purchase gifts for the occasion. She reports that her boyfriend is increasingly giving her pressure as he questions her tight schedule and demands more attention. Sally reports that all these issues put her under pressure, and she feels unable to meet the demands.
Sally has a history of asthma and has been using Ventolin MID when necessary. She has recently confessed to feeling muscle pain, chest aches, headaches, and general weaknesses. In addition, she has lost her appetite, and most of the time, she feeds on energy drinks and pizza and has started to have nausea and vomiting.
Summary of the Plan
This plan is designed to meet the physical and psychological needs of the client experiencing stress and anxiety, followed by signs and symptoms of mild asthma. It is an evidence-based approach based on the best guidelines that allow nurses and practitioners to gather information, provide a diagnosis, and establish and execute intervention plans meant to treat and manage the condition affecting the patient (Ackley et al., 2019). The procedure is cyclical, with steps that can be repeated upon assessment to continuously improve the situation.
The ultimate aim of the plan is to promote wellness and help the client return to normal life. In a care plan, the goals are customized or centered on the client’s specific needs, and all the strategies, tasks, and schedules are tied to those goals. Moreover, the care plan helps the nurses conduct a comprehensive assessment of the patient to determine their medical and family background that can impact the current situation (Ackley et al., 2019). Five important steps of the plan were accomplished- assessment, diagnosis, outcomes, planning, implementation, and evaluation.
Analysis of the Care Plan Process
A comprehensive understanding of the client’s background ensures that the diagnosis step is well-informed and that there is no room for ambiguity. The assessment stage requires critical thinking skills and the collection of data that is subjective and objective in nature. Without this data, it is difficult to comprehensively understand the client’s medical and family background and the factors that may affect their health and well-being (Ackley et al., 2019). In turn, it is difficult to establish an effective diagnosis without subjective and objective data.
The second stage involved developing a nursing diagnosis, a clinical judgment about the client’s response to health conditions and life processes or vulnerability for that specific response by a person, family, group, or the whole community. In this stage, the rationale is to set a basis for choosing the best actions by the nurse to achieve specific outcomes (Ackley et al., 2019). Maslow’s hierarchy of needs applies in this case, with psychological needs such as food, sleep, and water coming top of the list.
Based on the diagnosis results, the plan sets goals to resolve the client’s problems through implementation. In the third stage of the plan, the SMART goals are outlined based on evidence-based practice guidelines. The patient’s overall condition, together with the diagnosis and other information, applies to setting the achievable goals needed to achieve desired and realistic health outcomes on a short-term and long-term basis (Ackley et al., 2019).
The purpose of the implementation stage is to carry out the necessary steps to assist the patient in reaching their goals. Here, nurse interventions are expressed by following the physician’s orders or developing them from scratch based on the EBV approach and guidelines. The final stage of evaluation involves determining whether the desired outcomes have been met and adjusting the plan based on the findings.
SMART Criteria and the Metaparadigm’s Function in the Creation of Care Plans
When developing the care plan, the focus was on the four components of the metaparadigm approach- person, environment, health, and nursing. These components greatly help nurses when developing a comprehensive care plan. In this case, the person component of the paradigm helped consider the client’s social, spiritual, and physical needs since various factors associated with them contribute to the individual’s general well-being (Ackley et al., 2019). The goal was to put the person first and provide her the freedom to control her well-being in a way that would preserve her dignity and self-preservation.
The environment component guided me in examining the person’s surroundings, including internal and external influences. Such contributing factors and players as social connections and economic conditions affecting the client were considered, along with their possible impacts on her health and well-being. On its part, the health component guided the examination of the extent of the client’s wellness and access to healthcare.
Together with their contributions to general health, the physical, emotional, intellectual, and social aspects were taken into account (Ackley et al., 2019). Lastly, by stressing the use of knowledge, technology, skills, professional judgment, and teamwork, the nursing component helped me in my endeavor to provide the best possible health results. The SMART criteria, on the other hand, enhanced the care plan by assisting in the establishment of clear, quantifiable, relevant, and achievable conditions in respect to the chosen timetable.
Conclusion
Several challenges affected the development of the first nursing care plan. Because they were afraid to answer personal inquiries, it was initially challenging to get information about them. Similarly, establishing the SMART goals proved to be a challenge. However, given my background in nursing, I had no difficulties establishing the correct diagnosis. I learned that the best way to overcome challenges is to engage multiple clients with different needs and learn from experience.
Reference
Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing diagnosis handbook E-book: An evidence-based guide to planning care. Elsevier Health Sciences.
