can someone please look at the following care plan and see if I need to change anything.... any input would be helpful...thanksNursing Diagnosis & Patient Goals Implementation Rationale EvaluationNursing Assessment(must be timed & measured)(must have a reference)(subjective & objective)Fluid & Electrolyte ImbalanceSTG#1R/T DiverticulitisPain will be at a tolerable level#1#1#1AEB per pt. (3 on a scale of 0-10)Assess presence/ descriptionChanges in the severity &States "stomach keeps * bloody diarrheaby the end of my shift.of painnature of the pain may indicatecramping" while holding abd.* vomitinga life-threatening condition such* pt stated "pain was 8 on 0-10as perforation of the GI tractscale after eating 4 servingsof salad.#2#2* abnormal labsAdmin. Pain meds as prescribedPt states pain is a 1 on a * WBC- 15.8 (4.5-11.0)by Dr. (Demerol 50mg IM)med will decrease pain to 0-10 scale. * H & H 12.8 (13.5- 17.5)level pt can tolerate38.0 ( 40-51)STG#2 * K - 3.5 (3.6-5.2)Will control vomiting during #1#1#1my shift.Offer cold water, ice chips, These fluids help hydrate. Was able to have 2 popsicles room temp broth, or bouillionFluids with extreme temp may and room temp chicken brothif tolerated and approp per dietbe diff. to tolerate.for supper, tolerated wellstates " it didn’t hurt my stomach to eat this time"#2#2#2Administer antiemetics as Most antiemetics act by raising Pt had no episodes of vomitingordered.(Zofran 4 mg IV)the threshold of the chemoreceptors during my shift. Was given trigger zone to stimulation.Zofran @ 1600.
LTG#1Abnormal labs will be WNL#1#1#1before discharge.Admin D5 1/2 NC- KCL 20 mEql Will hydrate pt & help increase On discharge K- 4.2 * WBC- 15.8 (4.5-11.0)as ordered. low K. H&H 15.2 and 44 * H & H 12.8 (13.5- 17.5)38.0 ( 40-51)#2#2#2 * K - 3.5 (3.6-5.2)Monitor H&H and K levelsMany individuals with GI bleeding Lab levels were checkedhave longstanding nutritional deficits daily till discharge.that result in an altered coagulationprofile because of the liver's inabilityto produce adequate vit KH&H are monitored as indicators of bothblood loss and hydration statusLTG#2Pt will understand proper diet#1#1#1for Diverticulitis ( High-protein, Consult dietician to reviewHigh- protein, low-residue diets Pt was given papers for properlow- residue diet)nutritional Hx. How to perform are recommended to max.adsorptiondiet. Verbalized understandingcalorie count, and assist withmenu selections.#2#2#2Encourage use of vitamins andThese compensate for defec.Pt verbalized understanding ofmineral supplements as orderedneed to take K supplements.