CAREPLAN HELP!!!!

[cincin1222]

Hello all,

Ok I am having a hard time with this careplan, first patient addmitted for (swallowed a foreign body) but no x-ray was done , pt is alert and walking. The pt has a history of , swallowing a paper clip,depression, pancreatitis and anxiety ect... pt is on ADDERALL, enalapril, oxycodone, alprazolam, assessment was done but the patient was very talkative and sometimes he repeats the same story over and over again he is hyperactive. he has in rash at IV site from receiving parenteral DILAUDID.

I was having alot of problems getting some of his vitals because he couldnt' stop talking, and for some reason patient seem to be a little OCD... please help I'm not sure if I should just focus on just one dx and or the hx of depression...

this is just in a nuttshell. I hope that's enough information.

[ParkerBC,MSN,RN, PhD, RN]

Take your head to toe assessment and create your nursing Dx. I don’t know if you are permitted to do Risk for, but after reading the pts combo of medications, he is a risk for falls. Does he have family that visits? Is he the bread winner for the family? Is her experiencing spiritual distress in any way? Does he have children at home? There are many different things to look at with this patient to come up with a treatment plan. I know it is easier to treat a patient based upon physiological data, but we do provide care in a holistic manner. So, everything about the patient is taken into consideration. I hope this helps. Good luck.