Hi everyone, I'm doing my very first care plan and I have decided to do it on this 83 year old man. This mans peg tube fell out a few weeks ago and he has been NPO for 17 years. Instead of getting the tube put back in... him and his wife decided to create their own "liquid only diet" by doing this he began to experience nausea and vomiting a short time after which then led to finally going to the ER, there he was diagnosed with Aspirated Pneumonia. Keep in mind he does his own feedings.
Now he is at a nursing home/rehab facility and walks on his own and sometimes with a walker. He is being given IV antibiotics for the pneumomia so that right there needs to be addressed (nurses need to properly care for that line using SASH) ... he does his own tube feedings at 8am, 12pm, 4pm and 8pm The patient does have below normal calcium levels if that helps, he's a 6 foot tall guy but only weighs 112 pounds and has lost a pound each week for the last 6 weeks. So I see that Imbalanced Nutrition could be a possible nursing diagnosis related to losing weight without trying, unable to swallow, and solely relying on the tube feedings for all essential intake of necessary vitamins and minerals to function in every day life. I do understand that his weight loss isn't the priority for this man but it is a concern, a big priority is obviously if he's able to breathe or not because of the water in his lungs, so he should be exercising, and coughing/deep breathing every two hours to help exercise those lungs of his. Exercising those lungs are very important for anyone with pneumonia and should be encouraged to
do so, as well as cough/deep breathe every two hours
Im just kinda lost as far as what "Nursing diagnosis" I should use , breathing is important before anything when it comes to things about his weight loss. Maybe I'm not giving myself enough credit. I've been brainstorming possible goals as well as interventions... but I'm not so sure what to go with, I mean he his at risk for infection due to all of the above circumstances, also risk for pressure ulcers.
An obvious goal might be that "patient gains at least 2 pounds within the next 7 days. Or patient exercises often, cough and deep breathes often, or patient will demonstrate proper way to administer the self feed??? I say this one because maybe the tube came out due to him not remembering the proper way to care for his tubing/ how to administer his feeding , this could be due to his old age (mental status) or possible his hands don't work like they used to before.As I said I'm very new to all this but I'm just needing some guidance on everything I guess; goals; interventions etc. Maybe I can exaggerate the importance of adequate nutritional intake? I mean nutritional intake efficiency is important when it comes to immune responses but there's not much I can do since the doc controls how much of the feeding to give.. I mean I can encourage him to take in all of the ordered feedings as perscribe to receive that full nutritional intake . My care plan has to be an actual diagnosis then I have to have a "related to" statement and then 3 "as evidenced by's" 1 main overall goal, 3 goals and 3 interventions with a rationale for each intervention. Then I have to have a risk diagnosis which is a risk diagnosis followed by a "related to" and then I need a mains goal and 3 goals/interventions/rationales again. I was thinking about "risk for fall" or risk for further infection, I can't use medical
diagnoses in my nursing diagnosis, so I can't just say "Oh Imbalanced Nutrition related to Pneumonia" or "impaired breathing related to pneumonia" it has to have signs/symptoms in there followed by 3 as evidenced by's. I guess I could do "impaired breathing, related to ineffective airway clearance in lungs , as evidenced by..... and then idk lol. A good goal I was also thinking of depending on the diagnosis I select is that "patient will have normal balance of I's & O's , I say this because we don't want them to be constipated but as well as we dont want them dehydrated/diarrhea right? I'm not really sure where or what direction to take all of this. I feel like I have all the pieces of the puzzle but not sure how to start. sorry to make this so long but I really appreciate any advice on all of this. Thanks guys. I'm sorry again . I hope I'm at least kinda going in the right direction ?
I'm a first year nursing student and just trying to learn how to prioritize care. Thanks again