care plan help

[beelaw33]

Hi all,

This is my first care plan and i really need help.

my patient is

65 yr old widow

right femur fracture

surgery left her with a 10" lateral incision

gets out the bed once a day for PT

T 100.4

P 100

Resp 22

BP 100/60 (admission 116-72)

W 148# (drop 6# from admission)

Reactive hyperemia to lower sacral area that doesnt blanch.

The nursing diagnoses i have come up with is Risk for skin integrity r/t immobility.

I have to devise her a plan of care. I need some guidance.

[RNKel, ASN, RN]

That's a good ND. Also consider impaired mobility, pain, etc...

[4x4country]

:nurse:that is a great nursing dx. you are off to a get start.

[Daytonite, BSN, RN]

Care planning is a problem solving process. All care plans are based upon the patient's symptoms that they exhibit and these symptoms are the foundation of the entire problem solving process. Your nursing diagnoses, goals and nursing interventions are based upon those symptoms.

You have only posted four symptoms that your patient has:

• a 10" lateral incision
  
• 6 pound weight loss since admission
  
• T 100.4
  
• Reactive hyperemia to lower sacral area that doesn't blanch

Every nursing diagnosis has a list of symptoms connected with it and your patient must have one or more of those symptoms in order for you to be able to classify your patient with that diagnosis. A diagnosis is the resulting decision or opinion made after the process of examination or investigation of the facts. In the first step of the nursing process you did your assessment. Now, you take the abnormal items you found during assessment and problem solve them.

A 10-inch lateral incision is Impaired Tissue Integrity R/T surgical intervention AEB a 10-inch lateral incision

The 6-pound weight loss is Imbalanced Nutrition: less than body requirements R/T situation AEB a 6 pound weight loss since admission

Temperatures over 99.6 are considered Hyperthermia R/T [probably to trauma or anesthesia] AEB fever of 100.4

Reactive hyperemia to lower sacral area that doesn't blanch is Risk for Impaired Skin Integrity R/T physical immobility. Assuming you are focusing on the possible formation of a decubitus ulcer, your nursing interventions would be to monitor for and prevent the formation of an ulcer.

For the remainder of your care plan your goals and nursing interventions are then focused on treating the:

• 10" lateral incision
  
• 6 pound weight loss since admission
  
• fevers
  
• hyperemia to lower sacral area that doesn't blanch

[Jaxs]

How do you figure out what is the related to and what is the as evidenced by part?

[Daytonite, BSN, RN]

how do you figure out what is the related to and what is the as evidenced by part?

answered this for you. see https://allnurses.com/forums/f205/care-plan-risk-impaired-skin-integrity-210078.html