Care plan help - need help with 2 nursing dx

Published

Specializes in General adult inpatient psychiatry.

Sooo I have to do a mini careplan for my patient tomorrow and I'm a little stuck when it comes to nursing dx. I haven't done an assessment on her yet; we go to the hospital the night before just to pick up the Kardex and introduce ourselves to the patients, nothing more. Her reasons for admittance to the hospital are as follows "tele (anyone know what that means?), febrile, hypotensive". The medications my instructor highlighted for me to know for tomorrow are artificial tears, rivastigmine, escitalopram, tamsulosin, risperidone, lisinopril, neutra-phos, magnesium sulfate, calcium gluconate, vancomycin, and piperacil. She's on a pureed diet, which makes me think that risk for aspiration is a good one but I want to write one related to her medical dx or reason for admittance. I think risk for aspiration related to impaired swallowing ability might work. She also had +2 edema when I did see her today. She was unresponsive and the nurse said she had been lethargic all day, to not worry that should was not waking up when I called her name and shook her gently.

Can anyone lead me in the right direction, please? Also, if the mods could kindly delete my first post; it would not let me edit it to add more info.

+ Join the Discussion