charting.... critique? last chance to pass care plan.

Published Nov 14, 2007

39 Posts

This is my last care plan I have to do. I've had a few good ones but mostly NI. This is my last chance to prove myself in my narrative notes for my care plan. I've bought tons of books and studied and read all weekend on charting! I've read countless posts on this site and hope to gosh it has helped me. I would really appreciate critique on this last one.

7:05 93 y.o. Female admitted 11.03.07 for acute gastroenteritis, mental confusion r/t infection. Stool culture shows positive for CDF. Standard & contact precautions maintained. Lying in bed in supine position, resting with eyes closed, mouth open. R-15, equal and unlabored. IV patent & intact on right inner forearm. Free from redness, edema and drainage. Infusing 40cc/hr of 1000ml D-5-W. O2 2liters by nasula cannula. Foley draining by gravity. Urine reddish brown. Both feet in foot pillow under bed cradle. Large left toe with dry dressing, no fluid or drainage present. Bed alarm on, side rails up x2. Remains in bed with eyes closed. Reported urine color to nurse. -----------------s. butler svn

8:30 In bed, supine position, eyes open. Son and daughter-in-law present. No acute distress noted at this time. NPO due to EGD 11.12.2007. VS t -96.6, p 102, r18, bp 123/65. Pulse oximetry 100%. Orientated x2, disorientated to time. Responds to verbal loud stimuli, hearing aid x2. Incomprehensible speech. Head atraumatic, free of infection and normocephalic. Flat affect – Bell's Palsy. Eyes symmetrical, sclera white, pupils irregular and sluggish. Possible cataract surgery. Conjunctiva moist. Drainage bilaterally. Nasal patent bilaterally. 02 at 2 litters by nasal cannula. Buccal mucosa dry, oral mucosa pink and dry. Upper and lower dentures present. Lips dry. Ears symmetrical, dried drainage present. Carotid weak bilaterally. No bruits or thrills present on neck. Full Rom in neck. Breath sounds clear to auscultation. No cough present “She only coughs to clear her throat” states daughter-in-law. R-18 even and unlabored. Apical 65, rhythm equal, s1 and s2 noted but irregular. Skin warm to touch, thin, hyper pigmentation present. Multiple bruises bilaterally on inner and outer forearm and upper arm in various stages of healing. 3 cm bruise noted at old iv site on left hand covered with cotton ball and transparent tape. Iv site patent on right inner forearm, site free of redness/edema/warmth. Dressed with transparent tape. Iv infusing 40cc/ml of 1000 ml d-5-w. Complains of no pain in area. Capillary refill on nail beds 3. Toenails splintered and thick. 2X2 dressing on Greater Large Left toe, no drainage present. Small necrotic tissue present on second left toe

9:15 Standard and contact precautions taken. Assisted can in changing chux. Loose light brown stools. Skin bruising and moist skin on sacral area, >10X10 cm. Stage 1 ulcer, no skin breakdown at this time. Peri care provided. Moisture Barrier Cream applied to sacral and buttock area. Explained reason for sacral area and rational of cream protecting skin and repelling moisture. Instructed family to use call bell for needs or assistance especially when BM has occurred. Explained keeping her dry will help to prevent skin breakdown from runny stools. Verbalized understanding. Drainage from both eyes, wiped eyes with warm cloth. Bed rails up X2, bed in low position, bed alarm on.---------sb svn

9:30 resting, eyes closed. Family stated “comfortable”. Iv site patent, no signs of distress. Will continue to monitor closely----------------------------------------------------------------------------------sb svn

10:42 eyes closed in bed. Family reading. Nurse infused piggyback piperail 2.25g @ 75ml/hr. Awoke to stimulus. C/o “dry mouth”. Explained she cannot have anything to drink because of procedure scheduled today. Insistent on “dry mouth” Explained again she can't have anything to drink but I can return with mouth swaps to help relieve the dryness. Son voiced concern on what time they will be coming to get her for the procedure, “11 hours is a long time to go without water or food, she must be miserable”. Told son i would relay the message to the nurse to call doctor and find out time. 02 at 2liters, pulse oximetry 98%. Reported to nurse--------------------------------------------------------------------sb svn

11:05 back to room with oral care pack. Pt eyes closed, r even and unlabored. Instructed family how to use swabs and tube of lip care upon her awakening. Explained not to allow her to swallow. ------sb svn

12:15 pt in bed resting, eyes closed, family present. “Didn't like the swabs, but better than nothing. Still complains of dry mouth.” Instructed family to swab again in 30 min to help relieve dryness. Reported now news of doctor call back. ----------------------------------------------------------------sb svn

12:26 call be rang, “she need to be changed” states daughter-in-law. Called for can. Standard and contact precautions maintained. Brown runny BM. No odor. No consistency. Changed chux. Peri Care provided. Moisture barrier applied to sacral and buttock area. Pt's words incomprehensible. Family states shes “mumbling.” Bed rails up X2, bed in low position. Iv site patent, site free of complications. -----------------------------------------------------------------------------sb svn

1:20 Nurse in room assisting change to stretcher for EGD. Family “relieved” to finally get her to procedure. Reported off to nurse. ----------------------------------------------------------sb svn

also i am assuming this nanda would be bowel incontinence r/t infectious disease? my stg is teaching of course about the disease but I'm having a bit of a problem with a long term goal.