Careplan help/review

Nursing Students Student Assist

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I am working on getting this posted so please bear with me, I'm having some technical difficulties.

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Ok, I will try not to be too long winded here & just give the needed info. Written careplans have been a challenge for me in the past, so this semester I really want to "nail" them. This was my first week of clinicals this semester & we have to do 3 priority careplans & a discharge careplan. I have my 2 priority careplans done & would really appreciate it if I could get some feedback ont hem before they are due. I feel like I am missing something really obvious, or maybe I'm just paranoid because I have a tough clinical instructor. I am open to suggestions & critisism. Thanls in advance.

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Pt info: Pt is a 52yo female, 1mo post-op CABG, wound dehisence wound is now infected w/ 6cm of tunneling & about 1in in depth. Admitted w/ pneumonia & pain at incision site. on 2L NC, IV antibiotic, scheduled & PRN pain meds. Hx of GERD, CAD, COPD, HTN, high cholesterol, hystorectoy, hernia repair. Pt. c/o pain at incision site. Here are my 2 careplans:

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Nsg Diagnosis:

Acute pain r/t CABG incision & tunneling of surgical incision aeb pt stating “I need a pain pill I hurt here” while drawing a line with her finger over her incision, pt. stating “pain is 8 out of 10”, pt states “I have a really bad headache”, facial grimacing, & intermittent sharp intakes of breath with some movements, increased HR & BP

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i have a question.. im semester one student and NUrsing role is kicking my butt... any suggestions from you all that could help me tackle tests more at ease.? thank it will be very helpful to gather your feedback.. :)

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