HELP PLEASE!!! Do I need to make any changes to my care plan?

Published Oct 14, 2008

9 Posts

]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!

Jen]

Primary Diagnosis (include medical diagnosis, surgical procedure/date, reason for hospitalization):

]Sepsis
- ]Findings on admit date (]9/26/08])
  - ]T 101.2 °F, HR 124, RR 21, WBC 21.1 K/uL
  - ]Crackles in left base
  - ]Bilateral lower extremity cellulites & edema
  - ]Open ulceration L shin & great R toe

]Secondary Diagnosis/Other Health Problems/Previous Hospitalizations/Previous Surgeries:

]DM 2 with renal manifestations (06/03)
]Cerebrovascular disease (09/03)
]Cellulitis of leg (10/05)
]Peripheral edema (11/05)
]Hypertension (05/07
]Renal insufficiency (11/07)
]Spinal stenosis (03/08)
]DM 2 with diabetic peripheral vascular disease/neuropathy (03/08)
]Amputation of right great toe
]GERD (03/08)
]Degeneration of lumbar intervertebral disc (05/08)

]Narrative of HEAD-TO-TOE Assessment:

]10/03/08] 0800 80 y.o. male. V/S T 97.6]°F, P 71, RR 20, BP 140/69, SaO2 96% 2L/min via NC. A&O X3. Responds appropriately to verbal stimuli. Up w/ assist. Generalized weakness/fatigue. Pupils round, equal, & reactive to light. Nasal orifices moist/intact. Lung sounds clear & diminished to auscultation. Reg & unlabored breathing @ rest. SOB, dyspnea, labored breathing, & decrease] in SaO2 as low as 70% on exertion & occasionally @ rest. S1, S2 heart sounds. Apical 71/min & reg. Tachycardic episodes coincide w/ decrease] in SaO2. Radial/pedal pulses palpable. Cold extremities (BUE/BLE's). Blue/purple BLE skin color when dependant. Bilat pedal tingling/numbness. 4mm x1mm open ulceration L shin. Bilat 2+ edema; red, warm, & cracked skin below the knees. Negative Homan's sign. R great toe partial amputation w/ open ulcer. Capillary refill toes

]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.