Care plan

[HCC_Nurse]

I'm stuck on this care plan!

My patient 80yrs old admitted for Pneumonia with pleural effusion and exacerbated CHF. 10yr Hx of paraplegia which he seems to have overcome to a great degree. I got him as a patient the day he was discharged. All his VSS were normal, lungs were clear, heart rate regular, no visual signs of respiratory distress. He needed minimal assistance with showering because he was in the hospital and was not familiar with the shower but besides that he was completely able to carry out his own ADL's. I was thinking self care deficit for bathing related to environmental barriers as evidenced by patient stating "I'm not use to this shower and am going to need some help"

I'm just feeling that there was not very much intervention needed and i'm making somthing up just for the careplan.

Any suggestions would be great. Thanks!!

[Daytonite, BSN, RN]

this man is a paraplegic. if he was left alone, could he get along all by himself? what assistance would he need? those would be his deficits. these elderly people will say stuff like, "i can do this myself" because they don't want to be a bother to the nursing staff. i saw this time and time again. until you actually see them do these things independently for you, never assume anything.

even though his lungs are clear, he still needs teaching regarding post discharge care. he needs to continue coughing and deep breathing--especially with his paraplegia. pneumonia takes a long time to heal. he will be on atbs post discharge and the importance of continuing to take them post discharge until they are completed is important. discharge teaching includes diet, allowed physical activity, medications they will need to take, treatments and tests they need to be doing after discharge, follow up appointments with doctors have been made and patient knows about them, referrals to any outside agencies or support groups have been made, and teaching materials and/or contact with outpatient professionals for continued care and teaching have been provided to the patient.