home care patient care plan help

Specialties Home Health

Published

Hi,

need help with this problem. trying to set up a goal for this pt. she was d/c from hosp s/p cellulitis on her lower extremities, Visiting nurse sees her 3 x a week to assess for infection and healing. I need to send in a request to the insurance co for more visits. I need to set up a goal that is specific, measureable ,achievable , realistic and time measured. Have been looking at care plans for cellulitis, infection prevention. can't find one that is specific enough:crying2:

Specializes in Certified Wound, Ostomy & Continence Nurse.

You could split the care plan up into learning objectives and assessment objectives.

"Pt will verbalize s/s of infection and how to report s/s to nurse or MD. Fever, increased pain, increased redness, swelling, foul odor, etc."

The pt is probably receiving antibiotic therapy so you will want to make sure she is using meds as ordered and has no negative side effects.

"Pt will be compliant with med regime. Pt will verbalize s/s to report to nurse or MD: itching, rash, SOB." Also include any dietary restrictions, med interactions, etc., that may be relevant for the ordered med.

The pt probably has an underlying health problem contributing to the cellulitis that will require teaching and assessment.

You will need to see the pt to teach the disease process, assess compliance with and response to treatment, and assess for complications. There might also be something you can teach or implement that can prevent this from happening again. Since the pt needs home care, they may have home safety issues and might even need physical therapy for impaired mobility. I find most insurance companies only want a general idea of what you plan to do at each nursing visit. Most pts are not able to absorb more than one main point per nursing visit.

You might want to check one of your old textbooks for more ideas.

Good luck.

Specializes in Skill Nurse.

Does anyone knows any books to buy about nursing documentation and narrative notes. Please let me know. Thanks :uhoh21:

For Mara

You can find books by perusing the nursing book section at your local bookstore. The major ones carry books like the "Easy" series. You can also get assistance to order any book that is not on the shelf if you would like.

i need to know the management of diabetes mellitus

Specializes in LTC/hospital, home health (VNA).

i need to know the management of diabetes mellitus

That is a pretty vague question...one that is hard to answer here. First off, if you are a nurse you should know the basics of managing diabetes. If you are a nursing student, utilize your text books and instructors. If you are a lay person, then you can google diabetes, use the American Diabetes Association website, or talk to your doctor. If you or a loved one is newly diagnosed, you may ask you doctor for a referral to see a nutritionist or a diabetes educator for assistance. Good luck to you

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