Care plan

Hello I am having a hard with my nursing dx! Will someone kindly help me please! So far this is what I have: (please have in mind this is only my second semester and I have never had any clinical experience before starting nursing school, so feel free to correct me on anything I am open to ANY suggestions, also have in mind that they are asking us to set goals that we can do as students and evaluate by the end of our 8hr clinical) Thank you all! I hope to hear from some one soon!

Reason for Admission: hernia/small bowel obstruction

Patient Assessment Data:

Vital Signs: BP: 128/80, P: 75, T: 36.5 C, RR:18, O2Sat: 93

Neuro: alert and oriented x3, speech and hearing clear, cooperative, follows commands

Cardiovascular: S1 and S2 sound present, apical pulse 75, capillary refills

Pulmonary: unlabored lung sounds

HEENT: head: shape is symmetrical, facial features symmetrical, Eyes: conjunctiva pink and moist, sclera is white, PERRLA bilateral. Pupils equal round and reactive to light. Ears: symmetrical, nose: is clear and pink, mouth: pink and moist has all dentures

GI: continent, bowel sounds present x4 quadrants, lower right quadrant distended,

GU/Reproductive: Continent, pt stated she voided in the morning and urine was yellow and a little cloudy.

Integumentary: has 2 stage 2 wounds on both upper and lower right quadrants and a stage 1 wound above umbilicus, no edema or redness present

Musculoskeletal: strong upper and lower extremities, move all extremities independently, ambulates independently,

Pain: Pt states pain is 6 on a scale of 1-10

Psychosocial: live alone in a ground level home, does not need assistance with ADL's

DIAGNOSIS #1: Abdominal Pain

R/T: hernia repair

AEB: pt states pain level is 6 out 10

Short Term Goal #1

The patient will: state pain level has decreased to 3 in one hour

Interventions: The nurse will:

1. Administer Tylenol #3 as prescribed

2. Apply a wet warm towel over abdominal to help relieve pain while we wait for pain med to take effect

3. Turn on TV in a low volume to help distract pts pain.

Evaluation: Pt states pain levels decreased to 2 on a scale of 0-10.

Short Term Goal #2

The patient will: Verbalize non-pharmacological methods to help control pain.

Interventions: The nurse will:

1. Ask pt to describe past methods used to relieve pain when medication was not available.

2. Help pt identify the s/s of pain before it reaches its peak level

3. Teach pt relaxation techniques that will help ease pain (warm blanket, deep breathing, guided imagery)

Evaluation: pt verbalized and demonstrated relaxation methods to help reduce pain.

NURSING DIGNOSIS #2 Impaired issue Integrity

R/T: hernia repair

AEB: pt has 3 abdomen wounds

Short Term Goal #1

The patient will: maintain tissue integrity during shift

Interventions: The nurse will:

1. Inspect and monitor impaired tissue integrity at least once a day for any signs of infection (color changes, redness, swelling, warmth, pain)

2. Instruct the pt to avoid straining

3. Instruct the pt to hold a pillow firmly over the incisions when coughing or sneezing.

Evaluation: pt incisions stayed intact by the end of the shift

Short Term Goal #2

The patient will: maintain adequate nutrition

Interventions: The nurse will:

1.

2.

3.

Evaluation:

NURSING DIAGNOSIS #3 Risk for infection

R/T: hernia repair

AEB: there is no evidence it's a risk for

Short Term Goal #1

The patient will: remain free of symptoms of infections during shift.

Interventions: The nurse will:

1. Administer Levaquin as prescribed

2. Monitor WBC count and differentials

3. Monitor for any signs of infection

Evaluation: pt did not have any signs of infection at the end of the shift

Short Term Goal #2

The patient will: demonstrate appropriate care of infection prone site.

Interventions: The nurse will:

Evaluation:

[Rose_Queen, BSN, MSN, RN]

I have a question about this part of the assessment:

Integumentary:has 2 stage 2 wounds on both upper and lower right quadrants and a stage 1wound above umbilicus, no edema or redness present

I've only heard of staged wounds related to pressure ulcers. Did the patient have pressure ulcers on her abdomen? Or are you referring to surgical incisions? If surgical incisions, they definitely aren't staged.

Other than that, I will say it looks like you've done a good job of looking at the nursing assessment of the patient to create nursing diagnoses rather than the medical diagnosis.

[isela0523]

Thanks! yes I meant the incision so should I remove the stages.... what nutritional interventions do you suggest I add for goal number 2?