care plan goals

reba77 · Apr 14, 2011

can someone please look at the following care plan and see if I need to change anything.... any input would be helpful...thanksNursing Diagnosis & Patient Goals Implementation Rationale Evaluation Nursing Assessment(must be timed & measured) (must have a reference)(subjective & objective)Fluid & Electrolyte ImbalanceSTG#1 R/T Diverticulitis Pain will be at a tolerable level#1 #1 #1 AEB per pt. (3 on a scale of 0-10)Assess presence/ descriptionChanges in the severity &States "stomach keeps * bloody diarrhea by the end of my shift.of painnature of the pain may indicatecramping" while holding abd.* vomiting a life-threatening condition such * pt stated "pain was 8 on 0-10 as perforation of the GI tractscale after eating 4 servings of salad. #2 #2 * abnormal labs Admin. Pain meds as prescribed Pt states pain is a 1 on a * WBC- 15.8 (4.5-11.0) by Dr. (Demerol 50mg IM)med will decrease pain to 0-10 scale. * H & H 12.8 (13.5- 17.5) level pt can tolerate 38.0 ( 40-51) STG#2 * K - 3.5 (3.6-5.2) Will control vomiting during #1 #1 #1 my shift. Offer cold water, ice chips, These fluids help hydrate. Was able to have 2 popsicles room temp broth, or bouillionFluids with extreme temp may and room temp chicken broth if tolerated and approp per dietbe diff. to tolerate. for supper, tolerated well states " it didn’t hurt my stomach to eat this time" #2 #2 #2 Administer antiemetics as Most antiemetics act by raising Pt had no episodes of vomiting ordered.(Zofran 4 mg IV)the threshold of the chemoreceptors during my shift. Was given trigger zone to stimulation.Zofran @ 1600.

LTG#1 Abnormal labs will be WNL#1 #1 #1 before discharge. Admin D5 1/2 NC- KCL 20 mEql Will hydrate pt & help increase On discharge K- 4.2 * WBC- 15.8 (4.5-11.0)as ordered. low K. H&H 15.2 and 44 * H & H 12.8 (13.5- 17.5) 38.0 ( 40-51) #2 #2 #2 * K - 3.5 (3.6-5.2) Monitor H&H and K levelsMany individuals with GI bleeding Lab levels were checked have longstanding nutritional deficits daily till discharge. that result in an altered coagulation profile because of the liver's inability to produce adequate vit K H&H are monitored as indicators of both blood loss and hydration status LTG#2 Pt will understand proper diet#1 #1 #1 for Diverticulitis ( High-protein, Consult dietician to reviewHigh- protein, low-residue diets Pt was given papers for properlow- residue diet) nutritional Hx. How to perform are recommended to max.adsorptiondiet. Verbalized understanding calorie count, and assist with menu selections. #2 #2 #2 Encourage use of vitamins andThese compensate for defec.Pt verbalized understanding of mineral supplements as ordered need to take K supplements.

Smith.C74 · Apr 17, 2011

The advice we were given for writing goals is that they need to be "patient will" and to use the SMART acronym: Specific; Measurable; Achievable; Realistic and Timely. Keeping these 2 things in mind usually help. Good luck with your care plan.