Need help on care plan

my care plan is activity intolerance r/t disease process

she can aspiration pneumonia

so any help will be appreciated

i have some outcome indicators but i need help on the rest

thanks so much!

we need a little more information to help you......some basics that have been provided by other an members rn writer and daytonite(rip) https://allnurses.com/general-nursing-student/help-care-plans-286986.html

care plan basics:

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)
   

http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

[quote=beckyry;5844443so for being so invasive, this is not my first care plan so i do know the process of writing one i am just hung

ok some general info

admitted with community aquired pneumonia

after dysphasia gram she has dysphasia which changed her dx to

aspiration dysphasia

honey thickened

normal diet

98% eater

1500 ml/day liquid

h and h and low

wbc low

lung clear x4 --- abulates -- no energy

nc 2l

meds are abuderal

some anitibiotics

bowel hypo x4 last bm 10-31 --- gave her a supository ducolax

]

i picked activity inteolerance because she was so out of breath when she would go to the bathroom. (could that be her chf?)

this is her 3rd bout of pneumonia since june so she has been less active and very deconditioned. she stated that she does not go outside the home much. (could this be because she is asparating?) deficient knowledge becuase she was not taking care of her health she even refused the flu and influenza vaccines in the hospital. ( did you ask why she's refusing the vaccine? maybe she's had a problem in the past with the vaccine)

i completely see your point that is why i am stuck.

she does have chf

she is on 2 anitdepressants, gerd, copd

dysphasia is difficulty speaking. did you mean, dysphagia, difficulty swallowing?

as an unrelated question, i am familiar with meds oral and meds parenteral, but what are meds abuderal? help me out here.

first it's albuterol and not abdueral....obviously someone mispelled the meds (a huge pet peeve). as for being invasive if you clicked on some of the , instead of being put out you weren't given the answer, you'd find pre made care plans to help guide your thought process and give you the answers you need.

http://www.pterrywave.com/nursing/care%20plans/12.aspx

http://www.pterrywave.com/nursing/care%20plans/13.aspx

http://www.pterrywave.com/nursing/care%20plans/14.aspx

http://www.pterrywave.com/nursing/care%20plans/14.aspx