Help: Care Plan

[Neats]

I have tried to be a sponge and try to understand care plans, with experience I am getting better. Thanks to all of you nurses on this site!!!This care plan I am suppose to complete has me at a loss (maybe my brain is just overloaded at this point) Please help!! Guide me!!

Assessment Data: (not in any order)

client 3.5 years old born 24 weeks gestation with multiple cardio abnormalities was on ventilator for 4 months

Current Assessment:

lungs clear, vitals WNL, skin brown, W&D

receives nutrition via pureed food PO

sleeps in crib turnning schedule Q2 hours x 24 hours

only rolls side to side

can grab at developmental level of 0-6 month old

cannot speak,

recent parents move out of state and has new guardian (hard for parents, best for client)

DNR

has NOT had seziure past 2 years

last aspirated one year ago

for the year 2005 received no follow up care

miminal medication ie chewable vita, pedicare PRN, Nasal spray daily, and stool softner PRN.

Primary Med DX congential heart disease W/ASD 2nd to premature

Seizure disorder, s/p ligation of PDA. Current neuro consult indicates scoliosis-POC monitor and re-eval annually and recently-

MD found NO significant heart disease.

MRI findings of white matter volume loss-chronic peri ventricular leukomalacia and complete loss of R cerebellar hemisphere

Theraputic interventions include weekly PT, OT,

Is currently in LTC and is receiving great care. I know there are multiple issues but right now current problems are maintenance issues and I do not want to use Risk for or developmental delay as client will never reach goals, never recover will always be at developmental level of 0-6 months. I ahve grouped all assessments together and just am unsure of nursing diagnoses. I am leaning towards some type of feeding pattern as number one priority and the reason is because you need food to live, immobility and then I am not sure??????Help please. Thank you to all who respond

[Daytonite, BSN, RN]

Looks pretty good. Psych is not my area of practice.

[Nat71]

Thank you for your comment and help

[BeckyKRNinthemaking]

I am horrible at goals for my patients. They have to be two short term goals, each with 3 measurable outcome criteria.

My patient: an 85 yr old woman who is very active in her home, church and community. She suffered a right factured femur and I have to do one psychosocial, I chose ineffective role performance.

My first goal is: p { margin-bottom: 0.08in; } Will verbalize understanding that physical symptoms interfere with role performance.

2nd:

p { margin-bottom: 0.08in; } The patient and patients family will discover adaptive ways to keep the patient's independence.

I have no idea if these are just plain crap? are they realistic? is there something I'm missing that's more important to teach or have the patient attain? and how would I even measure these?

You seem to be the forum superstar and I would greatly appreciate any advice you have to give.

Thanks :)