Plan of care

i need to put her diagnosis.

then, write down the nursing diagnosis, the expected outcome and the nursing interventions.

• merck manual of diagnosis and therapy
  http://www.merck.com/mrkshared/mmanual/sections.jsp
  
  
• family practice notebook (use search box and input a disease)
  http://www.fpnotebook.com/index.htm
  
  
• medicine net diseases & conditions a to z index
  http://www.medicinenet.com/diseases_and_conditions/article.htm
  
  
• http://www.stroke.org/site/pagenavigator/home
  - national stroke association
  
  
  
  
• http://www.stroke.org/site/pageserver?pagename=las
  - life after stroke
  
  

If that is what the face sheet on her chart says then that is what the doctor told the admitting office her diagnosis was. He would have also put her diagnosis on his history and physical exam.

i am trying to help you. i already told you that you need to look up the pathophysiology and the signs and symptoms of the patient's medical disease and that nursing diagnoses are based upon those signs and symptoms that the patient has. you must first establish what those signs and symptoms are by delving into the signs and symptoms of this patient's medical disease(s). if i give you the answers you will never learn anything about this patient's condition or how to find any of this information on your own. worse, you will never learn to think on your own. i am willing to help you, but not if you don't put any effort into this yourself. i already gave you websites on which to look up information. whether you want to look up stroke, alzheimer's disease or a dvt is up to you. i can't see the scenario information for this assignment, but you can. look back at what i first posted. i asked you to post a list of the symptoms that you found and i will give you further help if you cannot figure out how to come up with the nursing diagnoses. there are many examples of how i determine nursing diagnoses on the help with care plans thread. if you look at it you will see that a list of the patient's signs and symptoms which is derived from reading about their medical disease must be present. you cannot avoid doing this.

pain related to inflammatory response in affected vein aeb _________

• where the pain is located
  
  
• how long it lasts
  
  
• how often it occurs
  
  
• a description of it (sharp, dull, stabbing, aching, burning, throbbing)
  
  
  • have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain (is this patient able to speak?)
    
    
  [*]what triggers the pain
  [*]what relieves the pain
  [*]observe their physical responses
  • behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
    
    
  • sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
    
    
  • parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
    
    

my expected outcome is tissue perfussion will be improved as evidenced by decreased edema and fewer feeling of discomfort.

my nursing intervensions are:

1.implement measures based on th client's individual risk factors to prevent hazards of immobility

2.managing venous stasis ulcers that involves healing the ulcer and to prevent recurrence

3.skin should be inspected daily and wash gently with warm water and soap

interventions for pain are things such as:

• assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
  
• assess and document where the pain is located and what, if anything, makes it worse or better
  
• observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
  
• give pain medication as ordered
  
• monitor for side effects of narcotic therapy: respiratory depression, constipation, nausea/vomiting