Help me correct a care plan please!

[AquariusAngl916]

Hi all ,

Everyone in my class had to exchange care plans with another classmate to proof read prior to handing in the final one.

I really want to be able to help my classmate as much as possible so I decided to post her 3 nursing diagnosis's on here prior to making any changes.

A little about her patient:

Primary Diagnosis:

Pneumonia

Hx of Health Problems:

Aneurysm of aorta, hyperlipidemia, hypertension, benign prostatic hypertrophy, A-fib, COPD (emphysema), osteoarthritis, CHF, Alzheimers

Narrative of HEAD-TO-ASSESSMENT:

Vitals - T 97.3, BP 121/76, HR 94, SaO2 97% RA, RR 18

Neuro - PERRL, alert & orientented to person & place on occasion

Cardio - Irregular rhythum, + radial pulse, weak pedal pulses, +2 pedal edema

Resp - L lower lobe crackles, R lower lobe diminished, clear upper lobes, RR - regular, nonlabored, dry dough

GI - Soft, nontender, bowel sounds + all quadrants

GU - Incontinent

Skin - Dry, intact

Muscoskeletal - Generalized weakness

Nursing Diagnosis's:

1. Ineffective airway clearance R/T retained secretions, inflammation secondary to infectious process M/B lower lobe creackles, dyspnea & SOB on exertion, non productive cough

Goal: Patient will have no dyspnea getting into chair & ability to move sputum by end of shift

(This classmate only cared for this patient one day, her goal doesn't seem realistic that the patient will have no dyspnea by the end of her 8 hr shift. I think she needs a more realistic goal but I'm having a hard time timing of one...)

Interventions:

1. Assess RR, effort & breath sounds

2. Teach family how to help patient turn, cough & deep breath to aid in lung expansion

3. Hydration (PO & IV) to help liquify secretions, 1000 ml restriction

4. Administer antibiotics as ordered

5. Administer bronchodilators as needed to maintain SaO2 > 95%

2. Ineffective tissue perfusion R/T decrease venous flow, decrease lung expansion, decrease Hgb, VQ mismatch M/B irregular heart rhythm, dyspnea on exertion, hgb 11.5, +2 edema, weak pedal pulses

Goal: Patient will have only +1 edema, strong pedal puses, no dyspnea setting up to chair by end of shift

(Again, NOT realistic in only a 8 hr time span)

Interventions:

1. Monitor & assess vitals, pedal edema & pulses

2. Monitor lung sounds, SaO2, RR & effort

3. Fluid restriction (1000ml/day) to decrease heart work load, monitor I&O's

4. Administer blood pressure & positive inotropic meds to increase CO & decrease workload

5. Teach patient to provide rest periods b/w activites to prevent fatigue

3. Rise for falls R/T generalized weakness, confusion, anemia, pt over 65 years of age

Goal: Patient will be free of injury for duration of shift

Interventions:

1. Assess LOC & mood

2. Bed rails up X 4 when in bed & waist restraint when in chair to prevent wandering

3. Monitor Q 1 hr for safety & injuries

4. Administer antipsychotic meds when patient is agitated

5. Teach family about safety measures to take at home to prevent falls

Again, I think her care plan needs a lot of help when it comes to making her goals & interventions more realistic. Thought I'd go ahead and post it as is and she what others thought before I made alterations.

Thanks so much for reading!!!

[cardiac~lover]

I agree with the need for more realistic goals and interventions. Do your goals have to be achieved by the end of each clinical session? Ours are allowed to be within a doable time frame even if we are never with that patient again. It's all hypothetical. Her dx, rt, and manifested by's are impressive though.

[AquariusAngl916]

Yes, the goals we make for our patients need to be realistic ones we can attain by the end of 1 shift.

[SuesquatchRN, BSN, RN]

Any "administer" should include "as ordered."

How is teaching the family how to move him and deep breathe him going to move his secretions?

Any drug or fluid restriction, even a bronchodilator, again, is "as ordered"

I'm very concerned about the safety measures. Side rails up x 4, okay, but does he climb? He'll get hurt. Bed alarm, maybe? And is the lap belt ordered? Physical restraints are very restricted. And antipsychotics - does he have a PRN standing order for Haldol or whatever he's on? Again, this could be considered a chemical restraint.

[Daytonite, BSN, RN]

this is also posted on the other forum thread.

there are some problems with the diagnosing based upon the assessment data that is presented. first of all this is an emphysema patient with pneumonia. right off the bat i saw cardiac and respiratory problems and some nursing diagnoses that needed to be used.

decreased cardiac output r/t altered heart rate and contractility m/b irregular heart rhythm, dyspnea and sob on exertion, left lower lobe crackles, cough and +2 pedal edema.

there was no specific information provided about the patient's medications, but emphysema and cardiac problems pretty much go hand in hand. when i saw chf and atrial fib on the list of the patient's health problems i knew the pedal edema was heart related. this patient's heart is in some stage of failure. that means that his lungs are also affected by the congestion which is backing circulation up systemically. there were probably other signs of this that were missed.

ineffective airway clearance r/t retained secretions, inflammation secondary to infectious process m/b lower lobe crackles, dyspnea & sob on exertion, non productive cough.

we are nurses. our expertise is nursing problems. we help patients accomplish their adls. this patient has alzheimer's disease and these patients go steadily downhill and need to be totally cared for eventually. the patient is already incontinent. there are complications connected to incontinence. what is nursing doing about this? because of very little information about the incontinence, it is hard to diagnose the correct type, but this probably works

total urinary incontinence r/t cognitive dysfunction secondary to alzheimer's disease m/b [??]

and

risk for impaired skin integrity r/t moisture from urine

what other self-care deficits exist?

risk for falls r/t generalized weakness, confusion, anemia, pt over 65 years of age, incontinence

does this patient ambulate? is there a history of falling? what anemia? if there is an anemia problem (i saw the low hbg) then there are other symptoms and perhaps it needs to be addressed as a fluid deficit problem, but not if the patient is congested and retaining fluids (the edema). i would write this as

risk for falls r/t generalized weakness, confusion, and patient over 65 years of age.

regarding goals:

goal:

patient will have no dyspnea getting into chair & ability to move sputum by end of shift

goals are the predicted results of the interventions that will be instituted. i'm looking at these interventions and wondering how they are going to fix up the dyspnea--and in 8 hours. a better goal would be based on intervention #2.

at the end of the 8 hour shift the patient

(remember the care plan is about the patient)

will demonstrate the correct way to deep breathe and cough.

interventions:

1. assess rr, effort & breath sounds

2.

teach family how to help patient turn, cough & deep breath to aid in lung expansion

3. hydration (po & iv) to help liquefy secretions, 1000 ml restriction

4. administer antibiotics as ordered

5. administer bronchodilators as needed to maintain sao2 > 95%

i just want to address this last diagnosis and goal:

• risk for falls r/t generalized weakness, confusion, anemia, pt over 65 years of age
  
• goal: patient will be free of injury for duration of shift
  • the anticipated problem is the patient might fall, so the goal by default should be that the patient doesn't fall. if you want the patient to be injury free, use risk for injury.
    
  • the idea behind the interventions for these types of diagnoses is to prevent the problem (a fall) from happening.