Need help with careplan please

[oostarglowos]

Hi everyone!! I am in Fundamentals right now but we started our clinicals last week. We are supposed to make a care plan every week for the pt that they assign us. This is the first time I am doing a care plan and would really be thankfull for any help. Ok see what you think about this : Pt is a female 63yrs status post CVA, hemiplegia, HTN Completly immobile and needs total care form the long term facility she is placed in. She has cognitive impairment, dysphagia and has a feeding tube directly attached to her stomach. She has NIDDM and has old pressure sores and is developing a new one on her inner thigh on left leg. I am thinking about using Impaired skin intergerty as my first nursing dx and than related to destruction of skin surface and risk for infection related to break in skin integrety, also risk for disuse sydrome related to pt cant move on her own. This is kind of the direction im heading in. Any input would be great, I need some help also for my goals and my as evidenced by.

[DSplendid]

off the top of my head....

Risk for aspiration r/t dysphagia

Or Risk for ineffective airway clearence r/t dysphagia

-interventions-

HOB >30 degrees

TCDB PRN

Suction as needed (if ordered)

Swallow eval (if needed)

(is she allowed to have anything by mouth, if so are you required to use thick-it)

v/s & lung sounds q shift and prn

-goal-

pt. will not asp. during my care aeb, no s/s able to clear airway of secretions with cough

>Risk for injury r/t confusion,

-interventions -

re-orient pt, PRN

call light

bed low, side rails up

Keep items within reach

-goal-

pt will remain free from injury while in my care

Impaired skin intergrity r/t inability to re-position & autoimmune dz process AEB skin breakdown

-interventions-

ROM q 4/h

re-position q 4/h

adequate hydration & nutrition (vit. c, protein, zinc, fluids)

keep pt clean and free from soil (urine and feces)

examine skin q shift

-goal-

pt will not have any further skin breakdown

Risk for decreased cardiac output r/t HTN

-interventions-

Adm. B/p meds as ordered

v/s q 4 and PRN

diet (is she on a low salt diet,)

avoid stimulants i.e. coffee, smoking, etc.

-goal-

pt. v/s will remain wnl while in my care

risk for infection r/t skin breakdown

-interventions-

diet( vit.c, protien, zinc, to increase wound healing)

maintain sterile tech. with dressings

adhere to strict hand washing

keep clean from soil

change dsg, as ordered

mon. labs as ordered

adm. antibx if ordered on time

mon. temp & v/s prn or as ordered

-goals-

pt will remain free from infection while in my care AEB

no s/s of infection

afebrile

labs wnl

hope this helps...i'm a little tired, so they're just off the top of my head...good luck

[Daytonite, BSN, RN]

you almost always want to address your abcs (airway-breathing-circulation) first 'cause if you ain't breathing or your heart pumping, you're dead and nothing else after that matters. now, some people will say potential for aspiration should be right up there in the top diagnoses because it affects the breathing. however, i was always told to "keep it real" and go with the actual problems that exist first, and this patient has plenty of them. so, in order of priority i'd go with the complications of the self care deficit and immobility as the first diagnoses (inadequate nutrition which covers your tube feedings, and immobility which covers a multitude of things including your decubitus and most of the adls that have to be done for the patient). you can even break the immobility diagnoses down if you like because they will run into extensive listings of nursing interventions. remember to look up the complications of stroke and the deficits that stroke patients experience because nursing has to take those into account when planning care. if you had been able to see the actual nursing care plan that the facility had for this patient it probably ran quite a number of pages.

http://www.rncentral.com/careplans/contents.html - bookmark this site for reference. there are a couple you can use to help you with this patient: physical immobility, skin integrity, potential for infection and self care deficit to get you started.

[flowerchick]

By Fundamentals, do you mean 1st semester? If so, Risk for falls r/t cognetive deficits s/p CVA is a good safe one. I highly recommend a care plan book. I didn't get one until my 3rd semester and it really would have saved some time for me in the beginning.

[ftr_bb_catchr]

DSplendid... Could you please write my careplan for me? LOL. Off the top of your head? YOU ROCK! Nicely done!