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Discussion

Help with care plan

I am about 5 months into my program and we have to make a care plan for our patient. I am totally lost and don't know what to do. I have to come up with correlating treatment's and nursing interventions along with 3 short term goals and one long term goal. I have a 26 year old male pt. came in for elective colostomy d/t fecal incontinence.Incision is fine. No issues with colostomy. Pain has been at a steady level of 5. Has fever of 101.2-101.8 steadily. O2 sat was at 88% before O2 @ 2L via NC which then went back up to 100%. He also has ulcer's on his feet. Diagnosed with MD, Type II DM, lipoprotein deficiency,list goes on and on. My first Nursing diagnosis is Impaired gas exchange related to collapsed lung tissue as evidenced by O2 Sat. Of 88%. Need advise on nursing implications. Second diagnosis is with pain but cant figure how to word it third is Altered skin integrity related to wound as evidenced by abdominal incision. Any advise on how to reword it to make more since? Anyone have any advice on what I could do for long term goal and interventions for my nursing diagnosis's? I have some but I don't know if there orders or implications/interventions. Help please!

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Altered skin integrity nursing diagnosis.

If you fall down and scrape your knee, or you get a cut on your finger, what would you do to heal the cut and to prevent infection. This would be your interventions. Your long term outcome would be what you would finally like to happen with your scraped knee or your cut. You would like it to heal.

For a patient with altered skin integrity the interventions should be whatever you or the nurse did to assist in healing the wound or did to prevent infection of the wound or did to prevent the wound from getting worse. Or the treatments and dressings etc.that was ordered for this patient.

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