consists of -10 problems with nursing diagnoses using NANDA APPROVED -determine 5 priority diagnoses and state each diagnosis (5 in total)clearly using related to-as evidenced by is not included -one of the 5 diagnoses must be knowledge deficit on one of the care plans and one daignosis must be psych related or ethical/cultural on the other care plan. -minimum of one one (1) goal and one (1) patient centered outcome for each diagnosis -minimum of 5 nursing intervention for each diagnosis that are specific for your patient -SCIENTIFIC RATIONALE FOR EACH EVALUATION -evaluation will document if goal or outcome was met or not met and what changes may need to be made to intervention to meet that goal or outcome. so here's my case: i have a patient that came in to the hospital on 9/26/2011 c/o feeling shortness of breath for several weeks. He was sent to the ER for eval for shortness of breath r/o pleural effusion. He had no acute distress, He had a tachycardia at 142/min. His bilateral legs are swollen with +3 edema and very reddened. The color of the feet was reddened and the layers of the skin to his feet where peeling off, very dry and scaly...looks like the whole skin to his feet will peel right off if u touch it. His right leg has got multiple wounds like stage 2. Venous doppler was done to his legs and it came back negative. His admission diagnosis are AFIB, RENAL FAILURE, CHF, ASCITES AND CAD. His facial skin is yellow in color. His stomach is very distended, very alert and oriented x3. He had a surgical history of tripple by pass last year. He weighs 218 pounds. He' s getting oxygen at 3 liters per minutes. He's taking zofran 4mg IV EVERY 8HRS ROUTINELY, LEVOTHYROXINE 50MCG BY MOUTH DAILY, DILTIAZEM IV/D5W 5ML/HR, piperacillin 2.25gm iv every 6 hours, lasix 40mg iv daily, azithromycin 500mg iv every 24 hours, aspirin 81mg by mouth daily, nephro-vite 1mg by mouth daily, lactobacillus 2tabs by mouth three times daily, thiamine 100mg by mouth daily, levealbuterol 0.63mg inha every 6 hours , heparin 500 unit subc every 12 hours, collagenase 1 app oint topi daily, nitroglycerin 1 inch oint topi every 6 hours, clotrimazole 1 app cream topi twice daily, silver sulfa 1 thin laye topi twice daily. His labs are as follws: wbc 9.1, rbc 3.73, hgb 10.0, hct 32.3, platelets 238, glucose 145, bun 76, creatinine 2.8, calcium 9.3,protein 6.1, albumin 3.9,sodium 139, potassium 4.6. HE'S ON DAILY WEIGHT, INTAKE AND OUTPUT. HIa vital signs are: spo2 is 92% on oxygen at 3l/min via n/c, respiration is 20, B/P 133/83, PULSE= 83, TEMP= 97.6
Sep 30, '11
that's really hard to read... you might get a better response if you formatted the text a bit.
do you have a specific question or problem? you just have no idea where to start? it's due in an hour and you want someone else to do it for you real quick?