Care plan help please..

squishy11 · Mar 21, 2010

Hi all, I got a tremendous amount of help here my last semester, so I am back :). I have a pt and our care plan is of course supposed to be more involved I suppose then last semesters.. I just wanted to know if these diagnosis look ok... I am not sure if you are allowed to include lab numbers in your diagnosis or not.. Here is some info about my client that I thought would be relevent. 80 yr old with pneumonia her h&h are low her bun and creatnine are high (still trying to figure out what that means to her system as a whole.. know its the kidneys.. thinking a volume prob?) umm and everything else is ok cept her glucose is 137.. Can someone just let me know if these diagnosis make sense... I am pretty confident they do.. here they are in no particular order

ineffective airway clearance rt/ retained secretions AEB nonproductive cough

impaired gas exchange r/t ventilation-perfusion imbalance AEB tachycadia

deficient fluid volume r/t active fluid volume loss AEB diarrhea

acute pain r/t inflammation of lung tissue AEB pt's report of pain at a 6 on a scale of 1-10

deficient knowledge of pneumonia and treatment r/t lack of information AEB pt states "this is the first time I have had pneumonia"

risf for infection r/t hospitalization.

risk for injury r/t altered clotting factors (she is on coumadin)

imbalance nutrition : less then body requirements r/t illness AEB pts consumption of less then 50% of her meals

(that one I am not sure about... dont know if I can blame it on the illness.. she just told me she doesnt like hospital food)

hyperthermia r/t illness ARB increase in body temp above normal range

Ineffective cardiopulmonary tissue perfusion r/t hemoglobin in blood AEB dyspnea and low hemoglobin level of 9.3.

I am sure there are many more that I can use. We need to write 10 and choose 5 to write up. I had a patient last semester with Pneumonia as well that I had to write up 3 on.. so I am trying to expand my horizions and use totally different diagnosis so as not to right up the same ones. Any thoughts on these? good..? bad?.... any help would be appreciated! :confused: :heartbeat

Thanks everyone!

j