Care plan help

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I always have trouble with care plans and I want to make sure that I'm choosing the priority medical diagnoses. I had a patient who had an infected hip arthroplasty. The day I cared for this patient, they were scheduled for a surgery to revise it. The pt was hypokalemic by just a little so the Dr ordered to give him IV KCl to elevate it before the surgery.

My care plan was going to focus on hypokalemia since the patient was going into surgery soon. Would this be appropriate?

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Specializes in Complex pedi to LTC/SA & now a manager.

No. It's not. Your care plan is based upon your nursing assessment. The first step is always you assessment.

VS

Level of consciousness

Pain

Edema

Bowel/bladder status

Skin integrity

Hydration status

Nutritional status

Any signs of infection/isolation needs?

Mobility status

Mental status

Cardio pulmonary status

Environmental or safety concerns?

Communication needs?

Neurological status

Past medical & social history

Discharge plans (which start upon admission)

Family status

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In the nursing assessment I had the following:

His temperature was elevated (101.8) this is because of the infection, which he was receiving meds for . His pain was a 3, A&O *4, he was npo after breakfast and was having difficulty with BM, the wound of the arthroplasty was infected so it was draining a bit, it was a yellow-green tinge. He had asthma and other respiratory problems so his lung sounds were abnormal. He was ambulating but with a bit of difficulty due to the pain.

In the care plan we are to do we were instructed to choose the medical diagnosis the patient had to justify our priority care for the day. I think that's where my question is more than the nursing diagnoses. For the nursing diagnosis I was thinking to prevent future infection

I think I just answered my own question. Thank you so much for your comment

I will use the medical dx of the infection to guide my care plan towards preventing future infection

would that be more appropriate?

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Specializes in Complex pedi to LTC/SA & now a manager.

No such nursing diagnosis as "prevent future infection".

Think maslows. What is the priority? You have a few. Infection has already been addressed. Pain? Constipation? Impaired mobility? Risk for fall?

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Ineffective Airway? You've got a lot to pick from. As Just Beachy stated, "Think Maslows."

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