I need help with my Nursing Care Plan (LPN)

[bigboy18]

My resident has the following dx

Dementia, Alzheimer Disease, HTN, Depression, Osteoarthritis, Pneumonia, Chronic Dermatitis

So far I have

Nursing Diagnosis #1

At risk for infection r/t chronic dermatitis

Goal/Probable Outcome

Resident will not have an infection

Intervention

1. Assess skin q shift

2. Ensure proper AM/HS care is performed

3. Report/Chart any signs of infection such as redness, warmness, body temp etc

4. Apply skin barrier cream to residents stage II pressure ulcer to prevent any skin integrity breakdown and infection

5. Provide adequate fluid/nutrition for resident

Nursing Diagnosis #2

Pain r/t osteoarthritis

Goal/Probable Outcome

Pain level will be controlled

Interventions

1. Assess res. comfort and pain level

2. Admin meds as ordered from physician

3. PRN meds given to alleviate pain

4. Perform passive ROM exercises while in bed to help loosen up the joints, prevent muscle atrophy and maintain muscle tone

I need one more Diagnosis...and a couple more interventions for each (5+ interventions needed) and I can't come up with anything. I was thinking of doing a third diagnosis related to either Alzheimer Disease, HTN, or Dementia.

Can anyone help me add some more interventions and another diagnosis? I was thinking of doing "At risk for impaired breathing pattern r/t Pneumonia"

[cwood88]

My resident has the following dx

Dementia, Alzheimer Disease, HTN, Depression, Osteoarthritis, Pneumonia, Chronic Dermatitis

So far I have

Nursing Diagnosis #1

At risk for infection r/t chronic dermatitis

Goal/Probable Outcome

Resident will not have an infection

Intervention

1. Assess skin q shift

2. Ensure proper AM/HS care is performed

3. Report/Chart any signs of infection such as redness, warmness, body temp etc

4. Apply skin barrier cream to residents stage II pressure ulcer to prevent any skin integrity breakdown and infection

5. Provide adequate fluid/nutrition for resident

Nursing Diagnosis #2

Pain r/t osteoarthritis

Goal/Probable Outcome

Pain level will be controlled

Interventions

1. Assess res. comfort and pain level

2. Admin meds as ordered from physician

3. PRN meds given to alleviate pain

4. Perform passive ROM exercises while in bed to help loosen up the joints, prevent muscle atrophy and maintain muscle tone

I need one more Diagnosis...and a couple more interventions for each (5+ interventions needed) and I can't come up with anything. I was thinking of doing a third diagnosis related to either Alzheimer Disease, HTN, or Dementia.

Can anyone help me add some more interventions and another diagnosis? I was thinking of doing "At risk for impaired breathing pattern r/t Pneumonia"

I really hope this helps you out I still remember what its like to be in nursing school, good luck

for your pain intervention I would also add relaxation skills and diversional activities as well as warm, moist compresses to affected joints several times a day. Also some gentle massage therapy.

For your infection dx I would also include repostioning pt Q2 to prevent pressure and further skin breakdown also wash the skin with mild soap and warm water and avoid rubbing, you should pat dry

Dx 3 fisk for decreased cardiac output

pt to have b/p readings within MD acceptable levels

Interventions: Monitor b/p q shift, lying, sitting and standing for notable variations

note presence, quality of central and peripheral pulses

Auscultate heart tones for S4 heart sound r/t atrial hypertrophy or S3 for ventricular hypertrophy

Auscultate breath sounds for crackles, whezzes which can indicate pulmonary congestion or chf

observe skin color, moisture, temp and cap reful time which can be due to peripheral vasoconstrition or decreased cardiac output

Observe for dependent or general edema which can indicate heart failure renal or vascular impairment

Maintain activity restrictions ie bed/charir rest to reduce physical stress and tension

monitor pt response to medications to control blood pressure

[bigboy18]

^ wow very helpful!!! thanks so much

[Alternator81]

A little advice. You made your 1st nursing diagnosis is risk of infection r/t chronic skin disease. That is definitely a problem, but not a priority. What is the priority for this patient when you learn about their diagnosis/interventions??

When I read your list of diagnosis, this is what my mind started thinking...

- Risk of Injury r/t Dementia and Alzheimer Disease --- is the pt confused? fall risk? Interventions: sitter? move pt closer to

nurses station? bed alarm? The patient's immediate safety is top priority, no?

- Impaired gas exchange r/t aveolar collapse/ consolidation - pneumonia is VERY serious! interventions: incentive spirometry, turn cough deepbreath, have pt ambulate/ change positions often to decrease consolidation, monitor sp02 & cap refill.

Those should be the first 2 things that jump out at you

then PAIN

then risk of infection d/t chronic disease