HELP PLEASE!!! Do I need to make any changes to my care plan?
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]Ok sooo this is MY care plan. I think I've touched on everything but PLEASE, please, please give me some feedback. Are my goals/interventions realistic ONES for a 8 hour shift? Is there a better NANDA Nursing Diagnosis I could of used in place of one I choose? Thanks so much for your help!
Primary Diagnosis (include medical diagnosis, surgical procedure/date, reason for hospitalization):
]Secondary Diagnosis/Other Health Problems/Previous Hospitalizations/Previous Surgeries:
]Narrative of HEAD-TO-TOE Assessment:
]NANDA Nursing Diagnosis:
]Impaired gas exchange
]Related to (etiology)
]Ventilation perfusion imbalance, alterations in alveolar-capillary membranes, & alveoli hypoventilation
]Manifested by (S&S):
]Hypoxia (SaO2
]Lethargy/fatigue
]Diminished lung sounds
]Dyspnea
]SOB
]Labored breathing
]Bilat pulmonary interstitial edema CXR ]09/26/08
]Planning
]a. Goal (patient will...) demonstrate improved ventilation and adequate oxygenation of tissues as evidenced by SaO2 > 90% & absence of symptoms indicating increased respiratory distress (restlessness/confusion/LOC, nostril flaring, á] HR, â]/á] RR, use of accessory muscles) through out shift
]b. Interventions with Rationale:
]1.]Administer O2 (2L/min via NC) to increase SaO2 levels > 90% per M.D. order
]a.]Provides for adequate oxygenation
]2.]Assess/trend oxygenation levels by monitoring continuous pulse oximetry, RR, HR, presence of any crackles or wheezes in lungs, ABG's if available, skin color, cap refill, & changes in orientation & behavior (restlessness & agitation).
]a.]Know patient's oxygenation level baseline to be able to note any changes
]3.]Position patient in upright, high-Flower's position to facilitate ventilation/perfusion matching
]a.]High-Fowler's position allows for optimal diaphragm excursion
]4.]Encourage deep breathing, using incentive spirometer
]a.]R]educes alveolar collapse
]Evaluation/Revision
]1.]Met
]a.]Patient's SaO2 levels stayed above 90% majority of the time through out shift. He had frequent episodes of hypoxia on exertion & @ rest. Told patient to take deep breathes when he heard his continuous pulse oximetry alarm set off
]2.]Met
]a.]Checked on patient Q 30 mins & monitored for signs/symptoms of decreased oxygenation levels (restlessness / confusion / LOC, nostril flaring, á] HR, â]/á] RR, use of accessory muscles). No changes from baseline.
]3.]Met
]a.]HOB was set @ 45 degrees at all times. Checked Q 30 mins while implementing intervention #1.
]4.]Met
]a.]Taught patient how to use incentive spirometer, encouraged patient use @ least 5 times / hour. Set goal of 1500ml for the day. Patient showed willingness & interest.
]NANDA Nursing Diagnosis:
]Impaired skin integrity
]Related to (etiology)
]Poor circulation, altered sensation, fluid shift, & tissue inflammation
]Manifested by (S&S):
]L shin & R great toe ulcer
]Bilat 2+ edema; red, warm, & cracked skin below the knees
]Bilat yeast infection in folds b/w groin and thighs
]Bitlat pedal tingling/numbness (PVD)
]Planning
]a. Goal (patient will...) understand the plan to heal skin & prevent reinjury as evidence by verbal repeat after teachings.
]b. Interventions with Rationale:
]1.]Encourage patient to inspect skin on a daily basis and report any signs or symptoms of infection; fever, chills, redness, swelling, heat, pain, etc
]a.]Early assessment & intervention help prevent serious problems from developing
]2.]Teach patient to self turn Q 2 hrs & to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury
]a.]Turning & the use of effective pressure-reducing devices significantly prevent skin breakdown
]3.]Demonstrate to patient wound/skin care @ times of dressing changes; cleansing, topical ointment application & wet-to-moist dressing changes
]a.]Demonstration enhances comprehension & patient adherence
]4.]Encourage patient to stick with recommended diet plan created by dietitian (1800 kcal/day, increase protein intake, supplemental vitamins, 2g Na diet w/ 1.5 L fluid restriction)
]a.]Aids in healing & maintains good health & skin integrity.
]Evaluation /Revision
]1.]Met
]a.]Patient verbally repeated back the signs & symptoms of infection & acknowledge the importance of seeking medical advise/treatment when symptoms arise
]2.]Met
]a.]Patient complied to teachings, self turned on own Q 2 hrs, followed PT orders (OOB to chair X3), and used pillows to free float heels on shift
]3.]Met
]a.]I verbally explained each step of the dressing change @ the time of dressing change & answered all questions he had at the time to enhance comprehension
]4.]Met
]a.]Place where he resides (Eskaton) makes his meals & he says he is on the Diabetic meal plan there. Verbally said he wants to continue with diet to loose weight
]NANDA Nursing Diagnosis:
]Acute pain
]Related to (etiology)
]Tissue/skin damage secondary to inflammation/fluid shift
]Manifested by (S&S):
]Verbalized pain rate 6/10 on 1-10 pain scale.
]C/O head/ache and BLE pain
]L shin & R great toe ulcer
]Bilat 2+ edema; red, warm, & cracked skin below the knees
]Planning
]a. Goal (patient will...) verbalize pain rate at a 3 or below on a 1-10 pain scale by end of shift
]b. Interventions with Rationale:
]1.]Determine location, frequency, and severity of pain on a 1-10 pain scale
]a.]Assessment of current pain. Used for comparison after intervention
]2.]Administer analgesics as indicated to maximal dosage if pain persists > 3 on a 1 - 10 pain scale
]a.]Alleviate pain sufficiently.
]3.]Encourage/teach pt importance of taking analgesic medication around the clock at regular intervals
]a.]Maintain constant control of pain.
]4.]Administer analgesics 30 mins before treatments, tests, PT, etc. & provide rest periods in between each
]a.]Facilitate patient comfort for adherence/compliance
]Evaluation/Revision
]1.]Met
]a.]On assessment 0800 verbally stated a pain rate of 7 on a 1-10 pain scale. Throbbing headache, aching lower back pain. Lower back pain is chronic r/t ]degeneration of lumbar intervertebral discs & spinal stenosis. Headache is acute, patient states r/t to lack of sleep. Administered 1 ]Norco] tablet and reassessed patient 30 mins later. Pain level a 3 on a 1-10 pain scale after intervention.
]2.]Met
]a.]Pain level a 3 on a 1 - 10 pain scale after administration of maximal dose order of pain analgesic
]3.]Met
]a.]Verbalized to patient not to wait till pain is intolerable to ask for pain medication again. Reassessed pain levels 30 mins after pain medicine was given & Q 6 hrs when pain medication could be administered again.
]4.]Met
]a.]1 ]Norco] tablet administered beginning of shift (0815), PT came shortly after & patient cooperated/tolerated well. Sufficient break b/w PT and lunch time. Lunch time got OOB to chair to eat.