Help with Care Plans

I just finished my first practice care and have recieved my feedback. I now have to do a comprehensive care plan for a grade but I was marked off for not correctly identifing my primary secondary or tertiary interventions.
My practice care plan was a 34 y/o gentleman who was 4 days post chest trauma from being run over by a car. This patient was supposed to go home the day that he was assigned to me. After assessing him that morning I was supicious for PE and it turned out I was correct. SO..alot of things happened quickly and he was transferred to the ICU before the end of my shift.
I used nursing diagnosis such as Impaired gas exchange, risk for disuse syndrome (which my instructor was happy with) but I don't understand how to rate the interventions that I used which were related to the nursing diagnosises.
Could anyone help me understand or give me some examples for the "staging" of the interventions.
Thanks

OK! This is information that you can work with. The voiding of 25 mLs was small voiding as the patient was trying to void around an obstructed urethra. "the nurse performed a bladder scan and found >900mls in the bladder" means he is retaining urine and not emptying his bladder completely. These scans are performed after the patient has voided to see how much urine is still in the bladder and indicates residual urine. The correct nursing diagnosis for this is Urinary Retention R/T swelling [this is based on what the information you supplied--the swelling is causing blockage of the urine] AEB 900mls of urine remaining in the bladder after voiding, small voidings and dribbling. You can read more about this diagnosis on this webpage: Urinary retention Without this catheter this patient would not be able to empty his bladder and void efficiently.

The elevated BUN and creatinine probably indicate renal damage, but there are no nursing diagnoses for that. Unless you have patient responses of the elevated BUN, creatinine and potassium (i.e. bradycardia, hypotension, muscle cramps, paresthesias), there is probably nothing you can diagnose in relation to them.

With a foley catheter you can use Risk for Infection R/T invasive procedure [UTI or urosepsis]

DAYTONITE:
I recived my NPR back because my instructor said one of my client goals isn't appropriate. I wrote " The client will void at least 120mL by 11am on 11-03-08. She said that he has a foley so that I can't write void and that I should concentrate more on managment of the foley. So with that being said I looked in my NPR and I am leaning toward writing. I don't even no where to begin. I don't want you to answer for me just some kind of guidance please on what I should focus on as far as the foley goes. Thank you

can you please help me formulate a diagnosis for pregnant women? ahm, it should be about wellness and readiness..thanks!

I am a second year nursing student having difficulty writing a care plan. I had a 83 year old client who had a fall and was anemic. She had guiac stools and recieved a blood transfusion on the day I cared for her. her only other hx was hypothyroidism which was controlled by medications, hypertension which was controlled by medications, hyperlipidemia and osteoarthritis. She recieved 2 units of packed RBCs while under my care...her labs showed the anemia but I do not know what nursing diagnoses to use. I need 3. I think Risk for Falls should be one along with Caregiver Role Strain...she has some forgetfulness but still cooks and cleans her large home for her husband and cooks and bakes for her two sons who live down the street. She is weak and fatigued, anyone with advice it would be much appreciated....I was looking for a fluid imbalance but just cant seem to figure it out...thanks

I am not sure, but it seems you are to reply to threads already established..I am a second semester nursing student and for my Med-Surge class we are to develop a nursing care plan which includes 4 nursing dx with a concept map. I have completed the care plan but I did have a hard time especially with one dx of "ineffective renal tissue perfusion r/t renal insufficiency AEB elevation in BUN/Creatinine RAtio's. I will paste my care plan and if anyone can give me any input it would be greatly appreciated. Sorry its kind of long but any input woudl be great to see if i am on the right track.
my patient was admitted with : altered mental status,fever, chills, back pain.
Hx: Diabetes type 2,COPD,HTN,Spinal Osteomyelitis,Sleep apnea, Renal Insuff.
Priority Assessments: B/P, mental status, respiratory status,safety,pain,
He is receiving treatments via hyperbaric chamber on a daily basis.
Labs: Bun-37H,
Creatinine-1.7H
RBC-4.06L,HGB-12.0L

Pain
Rated 10/10 located on his back from spinal osteomyeltis, and sacral/coccyx area from wound
-Agitated
-Facial grimace with activity
patient had a fever, chills,a positive sputum culture, with productive cough,fatigued, and the spinal osteomyelitis. Patient has a bed sore as well on his sacral/coccyx area appears to be red in color, no blanching, no discharge.
CARE Plan:
Nursing DX
Ineffective renal tissue perfusion R/T renal insufficiency AEB elevation in BUN/Creatinine ratio
Outcomes
-Client will maintain optimal tissue perfusion to vital organs ensured by presence of strong peripheral pulses, absence of respiratory distress, absence of chest pain, adequate urine output while on unit.
-Client will remain free of peripheral/pulmonary edema while in hospital
-Client will verbalize knowledge of treatment regiment, including medications and their actions and possible side effects while in hospital.
Interventions
-Monitor strict I&O’s
-Monitor labs, notify M.D. of any changes-Assess for signs of decreased tissue perfusion i.e. weak/absent pulses, edema, cool extremities, mottling, prolonged capillary refill, tachycardia, hypotension, and tachypnea.
Evaluation
-B/P remained within acceptable parameters: 126/79-128/80
-Pulses present in all locations, no edema found, lungs clear to auscultation, capillary refill <2seconds, respirations between 18-20 breaths per minute, o2 saturation-94%-96% room air.
-Client able to recognize medications administered and verbalizes actions/side effects.
Nursing Dx
Impaired tissue integrity R/T pressure, altered circulation AEB damaged integumentary tissue to sacral/coccyx area
Outcomes
-Client will report any altered sensation/pain at sight of tissue impairment while on unit
-Client will demonstrate understanding of plan to heal tissue/prevent injury by discharge
-Client will describe measures to protect and heal the tissue, including would care prior to discharge
Interventions
-Monitor status of skin around wound, assess blanching. Monitor client’s skin care practices, noting type of soap used, temperature of water, and frequency of skin cleaning
-Don’t position client on site of impaired tissue integrity
-Assess nutritional status
-Reposition client every 2 hours
Evaluation
-Client able to readjust position independently, and was doing so as necessary in 2 hour increments
-Client consuming 100% of meals offered
-Sacral/Coccyx area site inspected, redness present, no swelling, abrasion like in appearance, no discharge noted.
Nursing Dx
Risk for further infection R/T inadequate primary defenses (broken skin), tissue destruction, and spinal osteomyelitis.
Outcomes
-Client WBC will remain within acceptable parameters (4.3-12.0) while in hospital.
-Temperature will remain below 100.0F while in hospital
-Client will be free of symptoms of infection (fever, redness, pus discharge, and swelling) while in hospital
-Client will demonstrate appropriate care of infection prone site 3 days before discharge by washing hands, and performing appropriate wound care technique.
Interventions
-Wash hands before and after each patient care activity; ensure aseptic handling of all IV lines, ensure appropriate wound care technique
-Ensure appropriate hygienic care with hand washing; bathing, hair and nail, and perineal care performed by nurse or client
-Observe and report signs of infection i.e. redness, swelling, discharge, elevated temperatures.
-Teach client symptoms of infection that should be promptly reported to primary medical provider
Evaluation
-WBC levels consistently within parameter (4.3-12.0): 4.70, 5.60, and 5.40
-Oral temperature measured: 98.6F, 98.0F, no swelling, no discharge, redness present with complaints of pain.
-Client able to explain signs of infection by stating “if finds swelling, discharge, develops fever, excess redness he will report to care provider.”
-Hand washing performed before/after all patient care/interaction; aseptic technique performed with IV line/picc; wound care instructions followed.
-Client reports fatigue.
Nursing DX
Chronic pain R/T Spinal Osteomyelitis AEB patient stating “his pain is 10/10 on a 1 to 10 scale.”
Outcomes
-Client will use pain rating scale to identify level of pain intensity to determine comfort/function goal while in hospital
-Client will verbalize to staff when pain level reaches 5 on a 1 to 10 scale while in hospital
-Client’s pain level will not exceed 8 on a 1 to 10 scale while in hospital
-Client’s pain will be less than 2 within the hour after administration of pain medicine
Interventions
-Instruct client to notify staff when pain level reaches 5
-Medicate client as soon as reports pain 5/10
-Assess therapeutic effect of medication within 15minutes of administration
-Monitor client for any nausea/vomiting side effects
Evaluation
-Client reported pain reached 10/10 on a 1/10 scale
-Pain medication successful in reducing pain level to 2/10
-Client did not have any complaints of nausea/vomiting