Care Plan HELP!

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Hi there,

I am having trouble writing out my care plan. My pt is having left sided lower flank pain ( maybe nephritis) Here are my diagnosis. Which do you think should be my top 3?

1. Sleep deprivation related to someone coming in early in the morning

2. Disturbed sleep pattern related to someone coming in early in the morning

3. Fatigue related to someone coming in early in the morning, lack of sleep,

4. Risk for injury related to lack of sleep, not having glasses with her, high RBC

5. Disturbed Visual Sensory related to not having glasses

6. Risk for falls related to lack of sleep, disturbed sleep patter, acute pain, not having glasses

7. Risk for infection related to UTI, past kidney infections

8. Impaired gas exchange related to high level of RBC

9. Risk for activity intolerance related to acute pain

10. Acute pain related to nephritis, inflammation, and infection

12. Impaired Urinary Elimination related to dysuria

13. Risk for fluid imbalance related to dysuria

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#10 is ok, the others need some work. Try to limit your "risk for's" and also try to shorten your "related to's". Like related to not having glasses can come off all together. Make sure your diagnosis relates to the actual problem. Disturbed visual sensory does not apply to nephritis. #1-6 can come off the list.

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Specializes in Critical Care.

Your patient is having pain, and you are not (yet) sure of the cause?

Your priority problem is PAIN.

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Specializes in NICU, Trauma, Oncology.
Your patient is having pain, and you are not (yet) sure of the cause?

Your priority problem is PAIN.

This was my first thought before even reading your potential diagnoses. Pain is major and contributes to many of your diagnoses and can be managed through interventions.

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Thank you!!! If I do risk for infection related to UTI. Does that work? Because a UTI is already an infection?

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Specializes in med/surg.

Just a thought: Risk for infection related to (improper hygiene, improper toileting, catheterization, chronically alkaline urine, urinary retention)- why is your patient at risk, why do you think your patient get UTI based on history..like elderly-hygiene, toileting pattern, leaving soiled briefs for a long time OR is it a chronic incidence d/t anatomical kidney problems.

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Specializes in Critical Care.

I don't think risk for infection works, since he may actually have an infection, not be at risk for it.

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