care plan help!

sophie<3 · Sep 9, 2010

okay so i have 2 health hx packets due next week...my first patient had several pressure uclers- 1 stage IV on sacral area, stage II on R and L ischial area (?), and stage II on L heel (related to paralysis and AK amputation), she had suprapubic cath, L chest wall port-a-cath, etc. The floor is a CCH floor so she was admitted on 8/10..according to her chart she had a wound debridement on 7/29...she was my patient towards the end of August. What would her diagnosis be if she was admitted several weeks before i cared for her? She doesn't have one written in her chart because she was moved from one unit to another...anyway, just a little confused about that. i need 3 priority diagnosis statements for her and this is where i am having the most trouble. Impaired skin integrity and risk for infection are two that i can think of but i'm not sure if they are priority...i always have a hard time prioritizing my NANDAs and it makes it even harder when i'm confused on the actual medical diagnosis.

anyway, so my other patient was admitted to another hospital on 7/15 for a pleural effusion and pericardial effusion. she had a pericardial window on 7/17 which is now healed. she was moved to my unit on 8/2 so is her admitting diagnosis still pleural effusion and pericardial effusion even though she was my patient on 9/2?? she is incontinent both urinary and bowel...no IV, no cath except for an in and out cath PRN q 6 hours. and for her NANDAs- Impaired Gas Exchange, Impaired Skin Integrity (she also has a healing stage II pressure ulcer), and???? i can't think of anything else...i would have said Ineffective Breathing Pattern but her RR is normal (20) and her pleural effusion was months ago. I know there are different types of plural effusion, I don't know what type she was..she did have a Hx of CHF if that helps? sorry for so many questions and i know it sounds confusing. i am still new to care plans and have such a hard time prioritizing them. and it doesnt help that neither of my patients would talk about their condition to me...patient #1 was depressed, flat affect, wanted to be left alone, refused bath, etc. patient #2 was confused, didn't know why she was in the hospital, said she couldn't remember what the doctor said.