can someone please help me out? I would like to know if I did ok on this careplan,

Daytonite, BSN, RN · May 25, 2008

what you have done is, basically, posted a synopsis of the doctor's orders, assessment of the patient and what looks like some kardex information. a care plan begins with assessment, but it only starts there. from assessment, the patient's problems are determined. then, nursing interventions for the problems are worked out. you cannot do any nursing interventions until you have decided what the nursing problems are. you do not clearly define what this patient's problems are.

what's going on with this person's skin?

hygiene

lotion to back &

heels

(skin breakdown? why? potential for skin breakdown?)

clotrimazole cream to

perineum area

(rash? why? sweating? scratching? folds of skin on skin? patient has a foley so perineal area should be dry of urine)

how many people do you know that weigh 81.82 pounds? do you think there might be a nutritional problem here? i see that a regular diet was ordered for this patient, but were they eating any of it? you don't get down to 81 pounds by eating 100% of the food on the trays sent to you.

this patient was incontinent and now has a foley catheter. what are the complications of an indwelling catheter, especially a long dwelling one? one of these complications is a nursing problem that must be addressed which is partly why the catheter is being changed every month and why foley care should be given (although i don't see an order for it).

while we're on elimination. . .this patient has a history of diverticulitis and constipation with an order for "bowel care" what ever that is (although i suspect it is a facility protocol for laxatives). i know you have a last bm listed, but are the patient's bms on a daily basis? or, is there a constipation problem here requiring the "bowel care" order? there is a nursing diagnosis for constipation problems.

since this patient has had a knee replacement, what kind of mobility and movement does the patient have, what has been ordered, what is already being done? some of the things you copied down are already nursing interventions.

mobility

fear of falling and getting seriously hurt

at risk for falls

(this is a nursing diagnosis, so someone must has assessed the patient's likelihood to fall already)

1 person assist

(this is an intervention)

activity order

painful to lift right leg straight,

assist with arm strength

mobility devices

assist with adl & mobility

4 ww, cane, grab bar

(these are interventions)

with glasses and a hearing aid this patient has sensory deficits.

this patient has pain? if so, where is it? what is the assessment of it? pain is also a nursing problem. having the patient rest after receiving pain medication may have been ordered by the doctor, but it can also be considered a nursing intervention.

treatment for pain tylenol prn with

rest

these problems need to be expressed as nursing diagnoses for your care plan, don't they? give this another whack before i give you more information. there is information on how to write a care plan at https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans

2bLPNhoneybee · May 25, 2008

am I missing anything?
It does not seem right?
Please take a look
age 88
room 8769087
admission date 01/01/1817
medical diagnosis RT kneee replacement
Treatment for pain tylenol PRN with rest
baseline vitals
Temp 35.4
pulse 82
oxygen sat 93%
BP sitting 146/68
weight 81.82
Hygiene
Lotion to back & heels
Clotrimazole cream to perineum area
Bath
assist
glasses, hearing aid, upper and lower dentures
Mobility
fear of falling and getting seriously hurt
at risk for falls
1 person assist
Activity order
painful to lift right leg straight, assist with arm strengh
Mobility devices
assist with ADL & mobility
4 WW, cane, grab bar
Hard of hearing
Allergies
penicillin, sulfa, erythromycin, and possibly milk
previous medical/surgical Hx
hypothyroidism, anxiety, diverticulitis,(bilateral caterac surgery), cholecystectomy, cystoscopy, hypothyroidism, urinary incontinence, constipation, B 12 deficiency, diverticular diseases an element of COPD, anxiety, catherization
Treatments
physiotherapy, GRU, urology
Rehab/physio
Recent diagnostic tests
Coagulation
INR * 2.6 H 0.8 - 1.2 electrolytes NA 136 K 4.0 Cl 99 l
Co2 -29
urea 3.9
Nutrition
Regular
Elimination
uses commode at night
Last BM
may 22/19
bowel care order
Urination
incontinent
requires catheter
Indwelling catheter
size #14
last changed
q6h or keep foley in permanently change every month
incontinent (requires catheter)
Please can you help me do the nursing interventions?
Thank you :typing

oh dear I made a typo my client is 81.82 kg

Daytonite, BSN, RN · May 25, 2008

That doesn't change the fact that there are other problems that need to be addressed.

me33 · May 26, 2008

if you email me I can send you some copies of my careplans.

Please PM for details of contact