careplan help....major last semester one!

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Ok, so I know I should know how to write a careplan by now...and this one has to be the best we've ever done. I just like to have some other input on my dx's and goals....feel free to comment. (Interventions I really don't feel I have a problem with....just finding the problems and addressing them effectively.)

Here goes:

Air:

Ineffective airway clearance RT retained secretions AMB crackles in bilateral lung fields, dry/ineffective cough.

G:

Client will demonstrate decreased s/s of congestion (noiseless respirations, clear bilateral lung sounds, and productive cough) q shift.

Decreased cardiac output RT increase fluid volume AMB decreased peripheral pulses, bilateral ankle edema, clammy skin.

G: Client will display stable hemodynamic status as shown by systolic BP under 120, pulse 60-100 bpm, decreased edema to ankles, and 2+ or greater peripheral pulses to feet by 3/10/08.

Water:

Excess fluid volume RT fluid retention AMB pedal edema, dyspnea at rest, crackles in bilateral lung fields.

G: Client will have stable fluid volume as evidenced by balanced I/O, stable weight, and 0-1+ edema to legs q day.

Food:

Risk for unstable blood glucose RT medication and disease process (client has Type II DM, and takes oral hyperglycemics only. Figured I can't use DM in the dx at all.)

G: Client will maintain blood glucose between 80-120 at all times.

Impaired swallowing RT esophageal defect AMB coughing while eating, stasis of liquids in oral cavity, unable to swallow meds with water.

G: Client will maintain adequate hydration (moist mucous membranes) and be free of episodes of choking q shift.

Elimination:

Bowel Incontinence RT medication AMB diarrhea, abd cramping liquid stool after taking medication.

G: Client will be free of episodes of incontinence q shift.

Hazards to life/well-being

Risk for falls RT use of wheelchair, impaired physical mobility

G: Client will be free of injury related to falls q shift.

Impaired physical mobility RT limited endurance AMB dyspnea on activity, pain reported to back on movement.

G: Client will maintain ability to perform ADLs (mobility, position changes, grooming, dressing) with minimal assistance.

Impaired skin integrity RT physical immobility AMB open area to coxyxx.

G: Client will display healing of pressure sore by 3/10/08.

Social interaction:

Impaired social interaction RT self-concept disturbance AMB observed sitting quietly in group, not talking to roommate.

G: Client will discuss 1 positive change in social interaction per day.

Normalcy:

Anxiety mild/moderate RT stress AMB client states "I feel worried, and anxious." fatigue

G: Client will report anxiety is decreased after interventions q occurance.

Daytonite, BSN, RN

1 Article; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

locolorenzo22. . .i can't comment on any of your goals because goal statements are linked to nursing interventions. since you didn't list any nursing interventions, i can't really determine if any of your goals are reflective of the outcomes of your nursing interventions, or if your nursing interventions are addressing symptoms supporting the patient problem.

decreased cardiac output rt increase fluid volume amb decreased peripheral pulses, bilateral ankle edema, clammy skin.

your related factor is another symptom of decreased cardiac output and not an etiology (underlying cause) of it. you can view the related factors for this diagnosis on this webpage:
[color=#3366ff]decreased cardiac output
. anyway, you are using fluid volume in your next diagnosis. you may need to read a pathophysiology book to get an understanding of the differences between preload and afterload.

excess fluid volume rt fluid retention amb pedal edema, dyspnea at rest, crackles in bilateral lung fields.

the definition of this diagnosis is:
increased isotonic
fluid retention
.
you can't use fluid retention as a related factor in your diagnostic statement because fluid retention is the problem. the etiology, or cause, of the fluid retention has to be: compromised regulatory mechanisms (this covers all your other electrolyte and fluid regulation disorders), excess fluid intake, excess sodium intake, renal dysfunction, or loss of plasma proteins.

bowel incontinence rt medication amb diarrhea, abd cramping liquid stool after taking medication.

why not just use the nursing diagnosis of
diarrhea
?

risk for falls rt use of wheelchair, impaired physical mobility

why not use
impaired wheelchair mobility
?

impaired physical mobility rt limited endurance amb dyspnea on activity, pain reported to back on movement.

if this patient has activity endurance problems with symptoms of dyspnea, then you've classified the diagnosis incorrectly. you should be using
activity intolerance.
here's a webpage on it:
[color=#3366ff]activity intolerance

impaired skin integrity rt physical immobility amb open area to coxyxx.

you need a better description of this decubitus ulcer.
impaired skin integrity
is only used for stage i and ii ulcers, so you need to make that description of this boo-boo clear in your assessment information that it is only a stage i or ii wound.
impaired tissue integrity
is used for stage iii and iv ulcers.

anxiety mild/moderate rt stress amb client states "i feel worried, and anxious." fatigue

find another descriptor beside "anxious" to use for your defining characteristic here because it's repeating the nursing diagnosis. there's a ton of them listed for this diagnosis.
[color=#3366ff]anxiety

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