i'm working on a careplan and i researched many sites to figure out if what i have is okay, but again i just hope that my interpretation is correct. i'm going to post what i have and would love input and what i may be writing is wrong. i'm going to highlight where i think i may be incorrect.
how do these sound?
1) ineffective airway clearance r/t excessive mucus aeb wheezes throughout lung fields.
2)risk for decreased cardiac output: risk factor malfunction of pacemaker.
3)excess fluid volume r/t compromised regulatory mechanism secondary to myocardial infarction aeb taut, shiny skin, generalized edema. i'm not sure this a realistic goal. can nursing realistically address this? i thought meds may help, but i keep second guessing myself.
4) chronic pain : chest pain r/t recurrent chronic coughing to expel airway secretions aeb reporting chest tightness and pain and shortness of breath.
5) activity intolerance r/t compromised oxygen transport system secondary to myocardial infarction, chronic bronchitis aeb shortness of breath, dyspnea, and increased respirations during activities.
6) risk for infection r/t compromised host defenses secondary to respiratory infection. i should be specific on the respiratory infection shouldn't i?
7) risk for acute confusion r/t sleep deprivation
8) risk for constipation r/t diuretic use.
9) risk for self-care deficient r/t activity intolerance.
10) anxiety r/t shortness of breath aeb inability to sleep. i'm not sure if this makes sense to anyone else but me.
11) risk for sexual dysfunction r/t activity intolerance. can i use activity intolerance since it is a nursing diagnosis?
12) impaired social interaction r/t limited physical mobility aeb fatigue. again, not sure this one is proper.
head spinning yet??? mine sure is. i thought i was pretty good at writing these until i i was graded on my last careplan. i think i tend to get too creative at times and miss the boat.
thank you in advance for your time!