Correcting Classmates Care Plan

  1. 0
    Hi all ,

    Everyone in my class had to exchange care plans with another classmate to proof read prior to handing in the final one.

    I really want to be able to help my classmate as much as possible so I decided to post her 3 nursing diagnosis's on here prior to making any changes.

    A little about her patient:

    Primary Diagnosis:
    Pneumonia

    Hx of Health Problems:
    Aneurysm of aorta, hyperlipidemia, hypertension, benign prostatic hypertrophy, A-fib, COPD (emphysema), osteoarthritis, CHF, Alzheimers

    Narrative of HEAD-TO-ASSESSMENT:
    Vitals - T 97.3, BP 121/76, HR 94, SaO2 97% RA, RR 18
    Neuro - PERRL, alert & orientented to person & place on occasion
    Cardio - Irregular rhythum, + radial pulse, weak pedal pulses, +2 pedal edema
    Resp - L lower lobe crackles, R lower lobe diminished, clear upper lobes, RR - regular, nonlabored, dry dough
    GI - Soft, nontender, bowel sounds + all quadrants
    GU - Incontinent
    Skin - Dry, intact
    Muscoskeletal - Generalized weakness

    Nursing Diagnosis's:

    1. Ineffective airway clearance R/T retained secretions, inflammation secondary to infectious process M/B lower lobe creackles, dyspnea & SOB on exertion, non productive cough

    Goal: Patient will have no dyspnea getting into chair & ability to move sputum by end of shift

    (This classmate only cared for this patient one day, her goal doesn't seem realistic that the patient will have no dyspnea by the end of her 8 hr shift. I think she needs a more realistic goal but I'm having a hard time timing of one...)

    Interventions:
    1. Assess RR, effort & breath sounds
    2. Teach family how to help patient turn, cough & deep breath to aid in lung expansion
    3. Hydration (PO & IV) to help liquify secretions, 1000 ml restriction
    4. Administer antibiotics as ordered
    5. Administer bronchodilators as needed to maintain SaO2 > 95%

    2. Ineffective tissue perfusion R/T decrease venous flow, decrease lung expansion, decrease Hgb, VQ mismatch M/B irregular heart rhythm, dyspnea on exertion, hgb 11.5, +2 edema, weak pedal pulses

    Goal: Patient will have only +1 edema, strong pedal puses, no dyspnea setting up to chair by end of shift

    (Again, NOT realistic in only a 8 hr time span)

    Interventions:
    1. Monitor & assess vitals, pedal edema & pulses
    2. Monitor lung sounds, SaO2, RR & effort
    3. Fluid restriction (1000ml/day) to decrease heart work load, monitor I&O's
    4. Administer blood pressure & positive inotropic meds to increase CO & decrease workload
    5. Teach patient to provide rest periods b/w activites to prevent fatigue

    3. Rise for falls R/T generalized weakness, confusion, anemia, pt over 65 years of age

    Goal: Patient will be free of injury for duration of shift

    Interventions:
    1. Assess LOC & mood
    2. Bed rails up X 4 when in bed & waist restraint when in chair to prevent wandering
    3. Monitor Q 1 hr for safety & injuries
    4. Administer antipsychotic meds when patient is agitated
    5. Teach family about safety measures to take at home to prevent falls



    Again, I think her care plan needs a lot of help when it comes to making her goals & interventions more realistic. Thought I'd go ahead and post it as is and she what others thought before I made alterations.

    Thanks so much for reading!!!
  2. 2 Comments so far...

  3. 0
    there are some problems with the diagnosing based upon the assessment data that is presented. first of all this is an emphysema patient with pneumonia. right off the bat i saw cardiac and respiratory problems and some nursing diagnoses that needed to be used.

    decreased cardiac output r/t altered heart rate and contractility m/b irregular heart rhythm, dyspnea and sob on exertion, left lower lobe crackles, cough and +2 pedal edema.
    there was no specific information provided about the patient's medications, but emphysema and cardiac problems pretty much go hand in hand. when i saw chf and atrial fib on the list of the patient's health problems i knew the pedal edema was heart related. this patient's heart is in some stage of failure. that means that his lungs are also affected by the congestion which is backing circulation up systemically. there were probably other signs of this that were missed.
    ineffective airway clearance r/t retained secretions, inflammation secondary to infectious process m/b lower lobe crackles, dyspnea & sob on exertion, non productive cough.

    we are nurses. our expertise is nursing problems. we help patients accomplish their adls. this patient has alzheimer's disease and these patients go steadily downhill and need to be totally cared for eventually. the patient is already incontinent. there are complications connected to incontinence. what is nursing doing about this? because of very little information about the incontinence, it is hard to diagnose the correct type, but this probably works
    total urinary incontinence r/t cognitive dysfunction secondary to alzheimer's disease m/b [??]

    and

    risk for impaired skin integrity r/t moisture from urine
    what other self-care deficits exist?

    risk for falls r/t generalized weakness, confusion, anemia, pt over 65 years of age, incontinence
    does this patient ambulate? is there a history of falling? what anemia? if there is an anemia problem (i saw the low hbg) then there are other symptoms and perhaps it needs to be addressed as a fluid deficit problem, but not if the patient is congested and retaining fluids (the edema). i would write this as risk for falls r/t generalized weakness, confusion, and patient over 65 years of age.
    regarding goals:
    goal: patient will have no dyspnea getting into chair & ability to move sputum by end of shift
    goals are the predicted results of the interventions that will be instituted. i'm looking at these interventions and wondering how they are going to fix up the dyspnea--and in 8 hours. a better goal would be based on intervention #2. at the end of the 8 hour shift the patient (remember the care plan is about the patient) will demonstrate the correct way to deep breathe and cough.
    interventions:
    1. assess rr, effort & breath sounds
    2. teach family how to help patient turn, cough & deep breath to aid in lung expansion
    3. hydration (po & iv) to help liquefy secretions, 1000 ml restriction
    4. administer antibiotics as ordered
    5. administer bronchodilators as needed to maintain sao2 > 95%


    i just want to address this last diagnosis and goal:
      • risk for falls r/t generalized weakness, confusion, anemia, pt over 65 years of age
      • goal: patient will be free of injury for duration of shift
        • the anticipated problem is the patient might fall, so the goal by default should be that the patient doesn't fall. if you want the patient to be injury free, use risk for injury.
        • the idea behind the interventions for these types of diagnoses is to prevent the problem (a fall) from happening.
  4. 0
    The interventions need to have a time frame-- Assess RR, effort & breath sounds every 4 hours-- you get the point.

    I might change the fall intervention simply to patient will not experience a fall this shift rather than an injury (patient could bite her tongue eating! )

    I hope your partner is this enthusiastic about helping with your care plan!


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