First Care Plan! Any obvious mistakes? THANKS!

Nursing Students General Students

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Hello,

This is my first care plan! :eek: I've done a rough draft in some of the parts and was wondering if anyone could find any obvious mistakes?? I especially think that my "Diet Rationale" is wrong?? My teach told us that 80% of the class will fail :crying2: :sniff: and it's worth 30% of our grade so I'd reallllly love to pass it! Any help at all would be really appreciated.

OK. THIS ONE IS BETTER. IDK WHAT HAPPENED WITH THE OTHER THREAD!

Current Diagnosis:

HIV, Epilepsy, Hypothyroidism, IDA, CVA, hypertension, malnutrition, UTI, hyperlipidemia

Diet:

10/23/09 Peg Tube Intact Jevity @ 80cc/hr Regular-Pureed

Diet Rationale:

Peg Tube for CVA provide nutrients for health maintenance, Regular-Pureed for fully edentulous

Diagnostic Tests:Results: Reason for Abnormality:

EKG:Abnormal:??

WBC (4.5-11):3.03:HIV+

RBC (4.2-5.7):2.86:IDA

HGC (12-17.5):9.8:HIV+

HCT (35-52.5):31.2:IDA

MCV (80-100):109.1:IDA

RDW-SD (36-51):71.2:IDA

RDW-CV (11.6-14.2):18.7:IDA

Albumin:2.9:??

Valproic Acid:21.5:??

Creatinine-Kinase:6:??

Treatments:Reasons For Treatment:

Perform Assessment:??

Provide AM Care:To provide comfort and cleanliness

Maintain Safety Measures:To prevent injury and provide security

Perform ROM to BLE's:To increase muscle strength and flexibility

Change Peg Tube Dressing:To prevent infection at peg tube stoma site

Apply moisturizing lip balm:To decrease dry, cracked lips

Maintain semi fowlers:To prevent aspiration

Provide urinal and bedpan:To provide comfort and cleanliness

Provide psychological support:To assist in coping with being HIV+

Provide activity:To lessen lethargy

Nursing Diagnosis:Expected Outcome:

Impaired walking d/t R leg contractured AMB pt unable to walk

Expected Outcome:

The pt. will exhibit increased physical mobility as evidenced by ambulating, with walker, 30 ft. in hallway by 01/01/09

Intervention::Intervention Rational:

1. ROM's to BLE's:1. Promotes Flexibility

2. Sleep with R Leg extended:2. ??

3. Explain importance of physical therapy:3. Provide education

4. ??4. ??

Nursing Diagnosis:

Nausea D/T adverse reaction to medication AMB emesis of 700 m/l, pt complains of nausea

Expected Outcome:

The pt. will exhibit no manifestations of nausea, as evidenced by absence of emesis and pt. verbalizes adequate relief of nausea within 1 hour.

Intervention: Intervention Rationale

1. provide crackers:1. soothes stomach

2. provide ginger ale:2. soothes stomach

3. administer anti-emetics as prescribed: 3. relieves nausea

4. provide emesis basinwithin patients reach: 4. provides comfort

Nursing Diagnosis:

Acute Pain D/T R Leg contractured AMB pt complains of pain of 9 on 0-10 scale

Expected Outcome:

The pt. will exhibit no manifestations of pain, as evidenced by pt. verbalizes adequate relief of pain within 1 hr.

Interventions: Intervention rationale

1. Administer pain meds as prescribed: 1. Relieves pain

2. Provide leg rub : 2. Relaxes muscle

3. ROM's to R Leg : 3. Stretches muscles

4. Provide activity : 4. Provides distraction

Nursing Diagnosis:

Deficient knowledge D/T diet AMB pt is malnourished

Expected Outcome:

The pt. will exhibit understanding of importance of nutrition for health maintenance, as evidenced by patient verbalizing understanding of importance of nutrition within 3 days.

Interventions: Intervention Rationales

1. Education pt. on importance of nutrition: 1. increase pt. knowledge

2. Education pt's family on importance of nutrition : 2. increase pt's families knowledge

3. Provide pt. easy to read information : 3. ??

4. Refer to dietician ; 4. Provide expert advice

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