Care Plan Help PLEASE!!!

Home Health Columnist / Guide · Mar 30, 2015

Hi,,,

Moved your request to our Nursing Student Assistance See the many resources under our FAQ section top of this forum

Can anyone help on care plan? -- see Esme post on how PATIENT ASSESSMENT drives care plan, not medical diagnosis.

Please provide info about your assessment of client: what problems did you identify so we can help you further. Look up how ANEMIA affects oxygen transport too.

:yes:

Waffles2015 · Mar 30, 2015

Iron studies show adequate stores. I really feel this is lack of ambulation. The Pt will not ambulate, only when PT takes her. I was told by the RN that she needs to ambulate & she is doing this to herself by not ambulating. I tried to get her to ambulate but she says not now, all day of my 12 hr shift. Very needy patient

Waffles2015 · Mar 30, 2015

I need a physical ND, maybe Activity Intolerance RT lack of motivation and depression AEB verbal report of fatigue.

Im not sure if this is a physical ND or Not

billybulldog · Mar 30, 2015

Knowledge deficit. This lady needs an education on the seriousness of her condition and needs to be on board with her plan of care, including ambulation & incentive spirometer. Surgery will not "fix" her. She needs to get off her butt & walk. Respirations 18-20 are on the high side of normal for someone just lying in bed. Why is she so poorly motivated?!?

billybulldog · Mar 30, 2015

If you need a physical ND, than activity intolerance would be good but I'd shy away from saying R/T motivation or depression. You could also ND impaired physical mobility R/T surgery AEB decreased muscle strength and coordination, inability to move as desired.

Waffles2015 · Mar 30, 2015

Yes, I agree she needs to ambulate but will not. Therefore, she is accumulating fluid 1+ ankles & feet, fluid in the lungs. She had a thoracentesis & 700mls were removed 2 days ago 03-24. the CXR on 03-26: heart is less enlarged. There is decreased right pleural effusion, increased bibasilar atelectasis, less pulmonary congestion. I was told she was going to go for another thoracentesis on the 26th. She did was very afraid and tearful. Then there was an order for Lasix 20mg IV push, Potassium chloride 40mEq (her K level was 4.4), and Magnesium 2g IVPB (her Mag Level was 1.8). I know the lasix was given to help remove the fluid. The Potassium to supplement since giving a diuretic. The Mag, I'm not clear on. Her mag level was on the low side. Does Lasix decrease mag too?

If I use the ND impaired physical mobility R/T surgery AEB decreased muscle strength and coordination, inability to move as desired. The short term goal could be: Patient will ambulate 3 times during my shift. Im not sure

Waffles2015 · Mar 30, 2015

Also, Hgb 8.0 and Hct 24.8,

jennaroo · Mar 30, 2015

possible nursing dx:

Ineffective self health management AEB refusal to comply with or allow interventions (ambulating), that would reduce risk factors that could induce or increase poor health.

You could also use:

impaired gas exchange

risk for impaired skin integrity

risk for activity intolerance

knowledge deficit

risk for infection

risk for constipation

However, the first one would be my one of my priorities if his vitals remained stable, his airways patent, continued to deny pain and showed no sign of infection, as most of the other nursing dx's could be eliminated by effective self health management