Students General Students
Published Mar 10, 2008
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
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.
excess fluid volume rt fluid retention amb pedal edema, dyspnea at rest, crackles in bilateral lung fields.
bowel incontinence rt medication amb diarrhea, abd cramping liquid stool after taking medication.
risk for falls rt use of wheelchair, impaired physical mobility
impaired physical mobility rt limited endurance amb dyspnea on activity, pain reported to back on movement.
impaired skin integrity rt physical immobility amb open area to coxyxx.
anxiety mild/moderate rt stress amb client states "i feel worried, and anxious." fatigue