Critique Care Plan Please!

[ndh_cna_studentRN]

this is the first care plan i've had to do. i am looking for some advice and suggestions to make this an a+ care plan. if we get below an 80% we get kicked out of the program so it's very important that i get a good grade. i have spent (probably) a total of 8-10 working on this assignment so i'm not asking for anyone to do my homework for me. any help will be greatly appreciated!!! (my clinical instructor suggested that i use ineffective tissue perfusion and my priority nursing dianosis, based on abcs)

[color=gray]pt info:

[color=#808080]admitted with acute diverticulitis. futher testing showed a perforated bowel. pt was taken to surgery and a sigmoid colon resection with temp colostomy placement was performed. (post-op day 1) loc= x2 (anesthesia has made pt confused). hx of lung ca (recent chemo), copd, asthma, iddm, anxiety disorder.

maslow: physiology

erickson: integrity versus despair

p. ineffective tissue perfusion

e. r/t anemia and lung disease

s. as evidence by abnormal lab results (h&h 9.1 and 27), the need for supplemental oxygen, the physician's order for prbc transfusion, and hx of small cell lung ca, copd, asthma, and dm.

outcome: pt will have normal h&h lab results, be weaned from supplemental oxygen, and have an oxygen saturation >90% on ra prior to discharge.

interventions:

1) transfuse packed red blood cells to pt as ordered by physician. (collaborative)

2) monitor pts hemoglobin and hematocrit lab values qdaily. (collaborative)

3) monitor pts v/s (o2 sat, b/p, p, t, r) q4h and document. notify physician if significant deviation from baseline occurs.

4) administer oxygen to pt as ordered (3l via nc). (collaborative)

5) assess pts lung sounds qshift and prn and document. notify physician if significant deviation for baseline occurs.

6) monitor pts skin temperature and color to assess peripheral perfusion qshift and prn.

7) discuss diagnosis, current and planned therapies, and expected out comes with pt. provide information on normal tissue perfusion and possible causes for impairment. evaluate the pts knowledge of possible causes of impairment by asking the pt to list signs and symptoms that should be reported to the physician. this will be done once the effects of anesthesia have worn off.

rationales:

1) page 1021 (p&p) "the objectives for blood transfusions include (1) increasing circulating blood volume after surgery, trauma or hemorrhage; (2) increasing the number of rbcs and maintaining hemoglobin levels in clients with severe anemia; and (3) providing selected cellular components as replacement therapy (e.g., clotting factors, platelets, albumin)." page 912 (p&p) hemoglobin carries the majority of oxygen to tissues. anemia decreases the oxygen-carrying capacity of the blood.

2) page 300-301 (pagana) decreased levels of hgb and hct indicate anemia. decisions concerning the need for blood transfusion are usually based on the hgb or the hct. in an older individual with an already compromised oxygen-carrying capacity, transfusion may be recommended when the hgb level is below 10 and the hct level is less than 30%.

3) page 503 (p&p) as indicators of health status, these measures indicate the effectiveness of circulatory, respiratory, neural, and endocrine body functions. measurement of vital signs provides data to determine a client's usual state of health (baseline data). a change in vital signs indicates a change in physiological function. assessment of vital signs provides data to identify nursing diagnoses, to implement planned interventions, and to evaluate outcomes of care. vital signs are a quick and efficient way of monitoring a client's condition or identifying problems and evaluating the client's response to intervention.

4) page 951 (p&p)" oxygen therapy is cheap, widely available, and used in a variety of settings to relieve or prevent tissue hypoxia (thomson and others, 2002). the goal of oxygen therapy is to prevent or relieve hypoxia. oxygen is not a substitute for other treatment, however, and is used only when indicated. oxygen is a medication. as with any other medication, the dosage or concentration of oxygen is continuously monitored. routinely check the physician's orders to verify that the client is receiving the prescribed oxygen concentration."

5) page 561 (iggy) provides information about the flow of air through the tracheobronchial tree and helps identify fluid, mucus, or obstruction in the respiratory system.

6) page 607 (p&p) the condition of the skin, mucosa, and nail beds offers useful data about the status of circulatory blood flow.

7) increased knowledge leads to a change in attitude that in turn affects behavior. (http://www.ncbi.nlm.nih.gov/pmc/articles/pmc227189)

[xtxrn, ASN, RN]

Since this is the area your instructor wanted you to focus on, I'd say you did a great job. :)

The only thing I'd add is the specific things you want the patient to tell you re: s/s to report to the physician in # 7.

# 3- If the instructor is going to be nit-picky, you could give more specific parameters for the vital signs to be reported to the doc (ie- BP more than 20mm/hg above/below baseline, heart rate +/- 30 bpm from baseline, resp rate >24 or

# 6- perhaps include the acceptable cap refill time

Your documentation for rationales is really good, and your interventions are realistic

You did an outstanding job (starting yesterday) of presenting your information, and the specific questions you had :) While care plan terminology isn't always the same as school, the essentials (specific to the patient, goal measurable, time specific) are there; I used to do care plans for 120 bed facility (all Medicare and change of condition care plans), and train whoever was supposed to replace me when I resigned).... you would have been a joy to teach :)

[xtxrn, ASN, RN]

And maybe post it only in one forum :)