This is my first care plan!
I've done a rough draft in some of the parts and was wondering if anyone could find any obvious mistakes?? I especially think that my "Diet Rationale" is wrong?? My teach told us that 80% of the class will fail
and it's worth 30% of our grade so I'd reallllly love to pass it! Any help at all would be really appreciated.
HIV, Epilepsy, Hypothyroidism, IDA, CVA, hypertension, malnutrition, UTI, hyperlipidemia
10/23/09 Peg Tube Intact Jevity @ 80cc/hr Regular-Pureed
Peg Tube for CVA provide nutrients for health maintenance, Regular-Pureed for fully edentulous
Diagnostic Tests: Results: Reason for Abnormality:
EKG Abnormal ??
WBC (4.5-11) 3.03 HIV+
RBC (4.2-5.7) 2.86 IDA
HGC (12-17.5) 9.8 HIV+
HCT (35-52.5) 31.2 IDA
MCV (80-100) 109.1 IDA
RDW-SD (36-51) 71.2 IDA
RDW-CV (11.6-14.2) 18.7 IDA
Albumin 2.9 ??
Valproic Acid 21.5 ??
Creatinine-Kinase 6 ??
Treatments: Reasons For Treatment:
Perform Assessment ??
Provide AM Care To provide comfort and cleanliness
Maintain Safety Measures To prevent injury and provide security
Perform ROM to BLE's To increase muscle strength and flexibility
Change Peg Tube Dressing To prevent infection at peg tube stoma site
Apply moisturizing lip balm To decrease dry, cracked lips
Maintain semi fowlers To prevent aspiration
Provide urinal and bedpan To provide comfort and cleanliness
Provide psychological support To assist in coping with being HIV+
Provide activity To lessen lethargy
Nursing Diagnosis: Expected Outcome: Intervention:
Impaired Walking The pt. will exhibit 1. ROM's to BLE's 1. Promote flex
D/T R Leg contractured increased physical 2.Sleep with R 2. ??
AMB pt unable to walk mobility, as evidenced Leg extended
by ambulating, with 3. Explain Importance 3. ??
walker, 30 ft in hallway of physical
by 01/01/09 therapy
Nausea D/T adverse The pt. will exhibit 1. provide crackers 1. sooths stomach
reaction to medication no manifestations 2. provide ginger ale 2. sooths stomach
AMB emisis of 700m/l, of nausea, as 3. administer 3. relieves nausea
pt complains of nausea evidenced by anti-emetics
absence of emesis as prescribed
and pt. verbalizes 4. provide emisis basin 4. provides comfort
adequate relief of within pt reach
within 1 hour.
Acute Pain D/T R The pt. will exhibit 1. administer pain 1. Relieves pain
Leg contractured AMB no manifestations meds as
pt complains of pain of pain, as evidenced perscribed
of 9 on 0-10 scale by pt. verbalizes 2. provide leg rub 2. Relaxes muscles
adequate relief of 3. ROM's to R Leg 3. Stretches muscle
pain within 1 hour 4. Provide activity 4. Provides
Deficent knowledge The pt. will exhibit 1. Educate pt on 1. increase family
D/T diet AMB pt understanding of importance knowledge
is malnutritioned importance of of nutrition
nutrition for 2. Education pt's 2. increase pt.
health maintence, family on knowledge
as evidenced by importance
patient verbalizing of nutrition
understanding of 3. Provide pt with 3. ??
importance of easy to read
nutrition within information
3 days 4. refer to dietician 4. Provide expert