Care plan input

[Leftwinger17]

I am new to this site so I am not sure of the appropriate means of posting and etiquette so my apologies in advance.....I am a second semester nursing student and for my Med-Surge class we are to develop a nursing care plan which includes 4 nursing dx with a concept map. I have completed the care plan but I did have a difficult time especially with one dx of "ineffective renal tissue perfusion r/t renal insufficiency AEB elevation in BUN/Creatinine RAtio's. Not much is listed for that Dx as far as interventions and goals. I will paste my care plan and if anyone can give me any input it would be greatly appreciated. Sorry its kind of long but any input would be great to see if i am on the right track.

my patient was admitted with : altered mental status,fever, chills, back pain.

Hx: Diabetes type 2,COPD,HTN,Spinal Osteomyelitis,Sleep apnea, Renal Insuff.

Priority Assessments: B/P, mental status, respiratory status,safety,pain,

He is receiving treatments via hyperbaric chamber on a daily basis.

Labs: Bun-37H,

Creatinine-1.7H

RBC-4.06L,HGB-12.0L

Pain

Rated 10/10 located on his back from spinal osteomyeltis, and sacral/coccyx area from wound

-Agitated

-Facial grimace with activity

patient had a fever, chills,a positive sputum culture, with productive cough,fatigued, and the spinal osteomyelitis. Patient has a bed sore as well on his sacral/coccyx area appears to be red in color, no blanching, no discharge.

CARE Plan:

Nursing DX

Ineffective renal tissue perfusion R/T renal insufficiency AEB elevation in BUN/Creatinine ratio

Outcomes

-Client will maintain optimal tissue perfusion to vital organs ensured by presence of strong peripheral pulses, absence of respiratory distress, absence of chest pain, adequate urine output while on unit.

-Client will remain free of peripheral/pulmonary edema while in hospital

-Client will verbalize knowledge of treatment regiment, including medications and their actions and possible side effects while in hospital.

Interventions

-Monitor strict I&O's

-Monitor labs, notify M.D. of any changes-Assess for signs of decreased tissue perfusion i.e. weak/absent pulses, edema, cool extremities, mottling, prolonged capillary refill, tachycardia, hypotension, and tachypnea.

Evaluation

-B/P remained within acceptable parameters: 126/79-128/80

-Pulses present in all locations, no edema found, lungs clear to auscultation, capillary refill

-Client able to recognize medications administered and verbalizes actions/side effects.

Nursing Dx

Impaired tissue integrity R/T pressure, altered circulation AEB damaged integumentary tissue to sacral/coccyx area

Outcomes

-Client will report any altered sensation/pain at sight of tissue impairment while on unit

-Client will demonstrate understanding of plan to heal tissue/prevent injury by discharge

-Client will describe measures to protect and heal the tissue, including would care prior to discharge

Interventions

-Monitor status of skin around wound, assess blanching. Monitor client's skin care practices, noting type of soap used, temperature of water, and frequency of skin cleaning

-Don't position client on site of impaired tissue integrity

-Assess nutritional status

-Reposition client every 2 hours

Evaluation

-Client able to readjust position independently, and was doing so as necessary in 2 hour increments

-Client consuming 100% of meals offered

-Sacral/Coccyx area site inspected, redness present, no swelling, abrasion like in appearance, no discharge noted.

Nursing Dx

Risk for further infection R/T inadequate primary defenses (broken skin), tissue destruction, and spinal osteomyelitis.

Outcomes

-Client WBC will remain within acceptable parameters (4.3-12.0) while in hospital.

-Temperature will remain below 100.0F while in hospital

-Client will be free of symptoms of infection (fever, redness, pus discharge, and swelling) while in hospital

-Client will demonstrate appropriate care of infection prone site 3 days before discharge by washing hands, and performing appropriate wound care technique.

Interventions

-Wash hands before and after each patient care activity; ensure aseptic handling of all IV lines, ensure appropriate wound care technique

-Ensure appropriate hygienic care with hand washing; bathing, hair and nail, and perineal care performed by nurse or client

-Observe and report signs of infection i.e. redness, swelling, discharge, elevated temperatures.

-Teach client symptoms of infection that should be promptly reported to primary medical provider

Evaluation

-WBC levels consistently within parameter (4.3-12.0): 4.70, 5.60, and 5.40

-Oral temperature measured: 98.6F, 98.0F, no swelling, no discharge, redness present with complaints of pain.

-Client able to explain signs of infection by stating "if finds swelling, discharge, develops fever, excess redness he will report to care provider."

-Hand washing performed before/after all patient care/interaction; aseptic technique performed with IV line/picc; wound care instructions followed.

-Client reports fatigue.

Nursing DX

Chronic pain R/T Spinal Osteomyelitis AEB patient stating "his pain is 10/10 on a 1 to 10 scale."

Outcomes

-Client will use pain rating scale to identify level of pain intensity to determine comfort/function goal while in hospital

-Client will verbalize to staff when pain level reaches 5 on a 1 to 10 scale while in hospital

-Client's pain level will not exceed 8 on a 1 to 10 scale while in hospital

-Client's pain will be less than 2 within the hour after administration of pain medicine

Interventions

-Instruct client to notify staff when pain level reaches 5

-Medicate client as soon as reports pain 5/10

-Assess therapeutic effect of medication within 15minutes of administration

-Monitor client for any nausea/vomiting side effects

Evaluation

-Client reported pain reached 10/10 on a 1/10 scale

-Pain medication successful in reducing pain level to 2/10

-Client did not have any complaints of nausea/vomiting

[Daytonite, BSN, RN]

You posted this on the Help with Care Plans thread. It took me several hours, but I posted an answer there for you.

[Leftwinger17]

Daytonite,

Thank you so very much for your critique and expertise, they are greatly appreciated. It has helped me tremendously and I have learned a thing or two from your input.