Care Plan Help?

[bgkynursingstudent]

I am a first semester nuring student and we are writing our first care plans that we will carry out via simulation next week. Is anyone willing to look over what I have and give feedback nd suggestions for the blanks?

[KrCmommy522, BSN, RN]

I'm sure everyone will help if you post what you have! I know I'd help :)

[bgkynursingstudent]

Is there a way to add in word documents?

[KrCmommy522, BSN, RN]

Click on full editor and then click the paper clip button, which is for attachments.

[bgkynursingstudent]

I don't have a paper clip on my full text editorhe

Here is the information I had to go by

Patient Name: Joanna Green Room # 212 Gender: Female Age 90 Code Status: Full Code

Admitting Medical Diagnoses: (Include date of admission)

Date of Admission: Monday Nov. 27, 2017

Left Lower Lobe Pneumonia and Confusion

1. Relevant Medical History?

Ms. Joanna Green, a 90 year old female, has been healthy and living independently at a retirement village since the age of 80. She was hospitalized once in the winter of 2015 for flu like symptoms, but recovered quickly. She has 2 children and 5 grandchildren, all who are living and supportive, and visit her weekly.

2. Basic care information (bathing preferences, transfers, ambulation, elimination, etc.)?

Prefers showers except during the winter months when she takes "sink baths." Generalized weakness and transfers with assist of 1. Ambulates with assist of 1 using gait belt. Uses bedpan or bedside commode for elimination.

3. Priority Nursing Diagnoses?

___4____Impaired Memory

___2____Acute Pain

___1____Impaired Gas Exchange

___3____Urinary Retention

Please rank the diagnoses above in the order of their priority (#1, #2, #3, #4) and explain your rationale for choosing this order.

4. Current Situation? Mrs. Joanna Green in room 212, a 90 year old female was admitted on Monday with left lower lobe pneumonia and confusion. Family reports she was alert and oriented to person, place, time and situation on Sunday, and the confusion began suddenly early Monday morning. When asked if she could recall the year and the name of the president of the United States, Mrs. Green responded, "It is 1985. Ronald Reagan is the president." Mrs. Green rested well through the night except that she required an injection of Demerol 75mg at 0300 for pleuritic pain that she stated was a "7" on a 0-10 scale. Demerol was effective; pain level at 0400 was "1" upon deep inhalation.

Mrs. Green urinated 25 mL of urine at 0630 and stated, "It burns and hurts when I try to pee." Palpation of the lower abdomen reveals bladder distention. Last complete urinary void was yesterday at 2200 with 300 mL of cloudy, foul smelling urine.

She has a nasal cannula at 2L/min. Vital signs at 0300 were: Temperature 100.4 orally; Pulse 90/min; Respirations 14/min; Oxygen Saturation 93%; Blood Pressure 110/70. Head-to-toe assessment findings were within normal limits except some crackles in the left upper and lower lobes and pale skin. Mrs. Green states, "It just seems like I can't get enough air." Dr. Jenkins' orders are on the chart. Two family members are at the bedside.

[KrCmommy522, BSN, RN]

Very good! What do you need help with? I didn't see any blanks other than that you didn't explain your rationale for the order you listed the diagnoses in.

She doesn't have any other medical history? Such as chronic diagnoses (e.g., CAD, HTN, asthma, diabetes, arthritis), other history of diagnoses/previous illnesses (e.g., glaucoma, pneumonia), surgeries (e.g., appendectomy, tonsillectomy, C-section, tubal ligation, hysterectomy). I know it states that was only hospitalized once in winter of 2015 with flu, but just because she wasn't hospitalized doesn't mean she doesn't have chronic illnesses or history of other medical diagnoses or illnesses.

Don't you have to list any nursing interventions and goals/outcomes?

[bgkynursingstudent]

That isn't my care plan. That is what I had to write my care plans one. I haven't figured out how to post them yet

[KrCmommy522, BSN, RN]

That isn't my care plan. That is what I had to write my care plans one. I haven't figured out how to post them yet

Ohhh....okay. Well can you copy and paste it like you did the information on the case?

[KrCmommy522, BSN, RN]

You click on "Comment" first.

[ATTACH=CONFIG]25283[/ATTACH]

Then, the box should appear where you can type your comment. Below that is where you click to "Post Comment" and next to that should be "Full Editor." Click on "Full Editor."

[ATTACH=CONFIG]25284[/ATTACH]

Once you click on "Full Editor" it should take you to where you can change make your type bold, underline it, attach pictures, attach files, etc. You need to click on the paperclip image. It will open up where you can attach your file.

[ATTACH=CONFIG]25285[/ATTACH]

Hopefully this helps you attach what you have! If not, we can figure something else out :)

[KrCmommy522, BSN, RN]

You could also message me on here and I will give you my email and you could email me it too.

[bgkynursingstudent]

It's weird, mine completely skips over the paperclip and it says I don't have enough posts to send a message?

[KrCmommy522, BSN, RN]

Hmmm...I don't really want to post my email on here. I guess I could just create a new email. Do you have a google account? You can use google docs. You can choose to get a shareable link and post it. Or you can use course hero or scribd.