Uncategorized
Care Plan: 8.5 of 8.5 (100.0%)
Nursing Diagnosis
3 out of 3
International classification for nursing practice (ICNP) nursing diagnoses (v2019_06_27) [Data set]. (2019). International Council of Nurses (ICN). https://www.icn.ch/what-we-do/projects/ehealth-icnptm/icnp-download
Diagnosis
| Student Response | Model Answer | Explanation | Points Earned |
| Risk for injury | Risk for injury | “Risk for injury” is the most appropriate diagnosis. The patient currently does not exhibit any signs and symptoms that suggest he has impaired cognition or is at risk for impaired cardiac function. | 0.5 out of 0.5 |
Signs & Symptoms
| Student Response | Model Answer | Explanation | Points Earned |
| Sleeping 3 hours or fewer in the past few days | Sleeping 3 hours or fewer in the past few days | Because “risk for injury” is the most appropriate diagnosis for Mr. Callahan, the relevant signs and symptoms are those that align with his current manic state and put him at risk for injury, such as his impulse control, paranoid thoughts, and self-destructive behavior. Additionally, his excessive energy and lack of sleep can further exacerbate his other signs and symptoms and increase his risk for injury. Mr. Callahan has not expressed any current suicidal ideation or thoughts of self-harm; therefore, his prior suicide attempt does not support his current diagnosis of “risk for injury.” He is also not currently disoriented or experiencing hallucinations, so these answers would be inappropriate. Additionally, a history of cocaine use would not contribute to his current “risk for injury” as he is not under the influence of any substances at this time. | 0.5 out of 0.5 |
| Excessive energy and restlessness | Excessive energy and restlessness | Because “risk for injury” is the most appropriate diagnosis for Mr. Callahan, the relevant signs and symptoms are those that align with his current manic state and put him at risk for injury, such as his impulse control, paranoid thoughts, and self-destructive behavior. Additionally, his excessive energy and lack of sleep can further exacerbate his other signs and symptoms and increase his risk for injury. Mr. Callahan has not expressed any current suicidal ideation or thoughts of self-harm; therefore, his prior suicide attempt does not support his current diagnosis of “risk for injury.” He is also not currently disoriented or experiencing hallucinations, so these answers would be inappropriate. Additionally, a history of cocaine use would not contribute to his current “risk for injury” as he is not under the influence of any substances at this time. |
| Evaluate Mr. Callahan’s readiness for care. | . | Mr. Callahan, are you ready to move forward with the care plan? | Before proceeding with interventions, it is important to assess a patient’s readiness to listen, learn, and participate in the care plan. |
| Based on your presentation today, I believe you are at risk of injury. |
Intervention & Evaluation
2.5 out of 2.5
| Student Response | Model Answer | Explanation | Points Earned |
| Fully | Fully | The goal of having Mr. Callahan remain injury free while he was waiting to be evaluated by a psychiatric provider has been fully met. The selected interventions helped reduce the patient’s risk of injury and keep everyone, including staff and other patients, safe. Additionally, providing Mr. Callahan with writing materials kept him occupied. The data collected through the physical examination determined that Mr. Callahan did not present with any injuries. Your goal has been fully met. | 2.5 out of 2.5 |
Intervention & Evaluation Rationale
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
| Prompt | Student Response | Model Answer | Explanation |
| Did you achieve your goal of having your patient remain injury free until he could be evaluated by a psychiatric provider? | The goals of having the patient remain injury free until he was evakuated by a psychiatrist was fuly achieved. The selected intereventions helped reduce risk of injury. The patient did not present with any injuries during physical exam. Therefore, the goal was met. | The goal of having Mr. Callahan remain injury free while he was waiting to be evaluated by a psychiatric provider has been fully met. The selected interventions helped reduce risk of injury and keep both the patient and staff safe. Additionally, providing Mr. Callahan with writing materials kept him occupied. Based on the data collected, Mr. Callahan did not present with any injuries when he was physically examined, so the goal was met. | Given the details of this case, it is important to conduct a focused physical exam to confirm that Mr. Callahan has remained injury free. You can trust the objective data gathered through a physical exam and determine if your goal has truly been met or not. Given Mr. Callahan’s manic state, it would be inappropriate to merely ask him if he had remained injury free, because he may not answer honestly or accurately. |
