Help with Patient Goals and Interventions

[gordielocks]

Hi everyone! I'm a new nursing student and new to this site. I am just finishing up Pharmacology and will be starting clinicals in the fall.

My question is....we have to write a goal statement, interventions and teaching strategies for a fictional patient with minimal information and I'm having a hard time coming up with anything.

Here's the info we got:

[TABLE]

[TR]

[TD][/TD]

[TD][/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Iron 1 tab PO QD[/TD]

[TD]1000[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Amoxicillin 500mg PO QD[/TD]

[TD]1000[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Doxycycline 200 mg PO QD[/TD]

[TD]1000[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Prevacid 15mg PO QD[/TD]

[TD]1000[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Furosemide 40 mg PO QD[/TD]

[TD]1000[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Tagamet 100 mg PO TID AC[/TD]

[TD]0700 1100[/TD]

[TD]1700[/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Colace 100 mg prn PO BID[/TD]

[TD]1000[/TD]

[TD]2200[/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Neomycin/polymyxin 2 drops

right ear QID[/TD]

[TD]1200[/TD]

[TD]1800[/TD]

[TD]2400

0600[/TD]

[/TR]

[TR]

[TD]Imdur 30 mg PO QD[/TD]

[TD]1000[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Lipitor 10mg PO QD[/TD]

[TD]1000[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Ibuprofen 400mg PO TID PRN[/TD]

[TD][/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[/TABLE]

Mary Jane is a patient admitted with cellulitis right lower extremity. Her assessment at this time is:

Alert and oriented times 3, VS- BP 140/ 88, HR 80, Resps 24, Temp. 101.0. complains of mild pain score 5 to right lower extremity.

Heart rate and rhythm regular. Lungs clear to auscultation. Right lower extremity with redness extending from ankle to mid calf red and warm. Also complains of right ear pain.

History of GERD. History of depression. History high cholesterol and angina.

I would appreciate any advice. Thanks!!

[smatrang001]

https://evolve.elsevier.com/ sign up and add the resource for a nursing care plan book. I used ackley. I'd say based off the info you gave, pain would be the big diagnosis, goal should be measurable and realistic. Something like pt will verbalize a pain below 5/10 within an hour. Interventions are given on that website I gave you, just tweak it to meet your patients needs, include both non pharmaceutical and pharmaceutical interventions. Teaching is also on that website, but off the top of my head, teaching about side effects of meds, techniques such as repositioning, etc. to assist patient with how to relieve pain. Good luck