Help with Care Plan Needed

here's what i come up with. . .

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

• stage iii ulcer on sacrum
  
• hx of recurrent uti's caused by mrsa
  
• indwelling catheter

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

• 79 years old
  
• a&o x 1
  
• dry skin and mucous membranes
  
• dark, concentrated amber urine
  
• temp. 101.3 f
  
• respirations 28
  
• weak
  
• non-weight bearing
  
• grimacing
  
• restless
  
• moaning when asked level of pain
  
• assistance with adl's

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

• deficient fluid volume r/t ??? aeb dry skin and mucous membranes and dark, concentrated amber urine, elevated temperature of 101.3 f and weakness
  
• hyperthermia r/t infectious process aeb elevated temperature of 101.3 f and respirations of 28
  
• impaired physical mobility r/t ??? aeb non-weight bearing
  
• acute pain r/t ??? aeb grimacing, restless and moaning when asked level of pain
  
• (bathing/hygiene, dressing/grooming. feeding, toileting) self-care deficit(s) r/t ??? aeb [assistance with adl's needs to be more specific]
  
• impaired tissue integrity r/t pressure, fluid deficit and impaired physical mobility aeb stage iii ulcer on sacrum
  
• risk for injury r/t altered mental status [the risk is for fall or accidentally pulling out the foley - interventions would be to prevent these from happening]

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions are the actions you will take to modify, or change, the effect caused by a problem - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

for example, hyperthermia r/t infectious process aeb elevated temperature of 101.3 f.

• maintain oral temperature below 99.6 f.

• assess the patient for flushed skin, diaphoresis, chills, restlessness, lethargy, tachycardia and tachypnea.
  
  
• monitor an elevated temperature every 2 hours; monitor vital signs every 4 hours.
  
  
• administer antipyretics as prescribed.
  
  
• take temperature 30-60 minutes after an antipyretic has been given to assess its affect.
  
  
• use the same site and deice to assess the temperature for consistency.
  
  
• add linens and blankets to the bed to help maintain comfort and body temperature.
  
  
• encourage the patient to drink fluids such as water, juice, tea, broth and sports drinks to replace lost fluid and nutrients.
  
  
• notify the physician if the fever goes above 104 f or there is a change in the patient's mental status.

here are the problems with your diagnoses and interventions: everything is supporting data--none of it is an intervention.

another question i have with this is in prioritizing.

1. physiological needs (in the following order)
   • the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
     
   • the need for food and water
     
   • the need to eliminate and dispose of bodily wastes
     
   • the need to control body temperature
     
   • the need to move
     
   • the need for rest
     
   • the need for comfort

[*]safety and security needs (in the following order)

• safety from physiological threat
  
• safety from psychological threat
  
• protection
  
• continuity
  
• stability
  
• lack of danger

[*]love and belonging needs

• affiliation
  
• affection
  
• intimacy
  
• support
  
• reassurance

[*]self-esteem needs

• sense of self-worth
  
• self-respect
  
• independence
  
• dignity
  
• privacy
  
• self-reliance

[*]self-actualization

• recognition and realization of potential
  
• growth
  
• health
  
• autonomy

1. deficient fluid volume (actual physiological need for fluid)
   
2. acute pain (actual physiological need for comfort)
   
3. impaired tissue integrity (actual safety need for protection)
   
4. risk for injury (anticipated physiological need for safety and protection)