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last med surg care plan

mfatony mfatony (New) New

I have a patient who was assaulted. She is only 36 yrs old. If she has a rt orbital fx, hematoma in rt eye, quite a bit of bruising, she has several broken ribs, hx of asthma and depression, and she has a chest tube on each side does any one have any suggestions for good diagnoses for this pt?? I can think of a few but we have to have 10! plus 10 interventions and 1 goal for each diagnoses.... thanks for any help! i also have her labs if you want to know them..

Forever Sunshine, ASN, RN

Specializes in LTC. Has 7 years experience.

What are her vitals and assessment details?

Off the top of my head I can think of,

Ineffective breathing pattern

Acute Pain


Risk for infection

same thing i got... thanks


Risk for compromised human dignity

interrupted family processes

Risk for post trauma syndrome

impaired skin integrity

knowledge deficit

Impaired physical mobility

alteration in nutrition: less than body requirements (she will need more protein to heal fractures) probably not going to eat as well due to depression and what she has been through

Activity intolerance.

You can google free care plans and come up with more diagnoses and goals and interventions. I am LPN enrolled in RN ADN program and use some great nursing care plan books also.

Thanks. I got pretty much everything all of you guys said. I have a care plan book also and i definitly use google! thanks :up:

Forever Sunshine, ASN, RN

Specializes in LTC. Has 7 years experience.

What book are you using? The book I used with my careplans is called Nursing Diagnosis: Application to Clinical Practice Edition 12. I owe it my life. Without it.. I would have probably failed each and every careplan(except for OB because OB material was very easy to me). I showed it to one of my clinical instructors one day and they were amazed by it.