Published Nov 4, 2017
acisojdarnoc
1 Post
Hi! So I am working on a individualized care plan for my patient diagnosed with pneumonia. I am having a very hard time coming up with relevant nursing diagnoses for this patient as she does not have the typical pneumonia characteristics.
She is very independent, young, ambulates very well, former smoker, O2 sats 94% or better with all VS. My first day working with her she had crackles in her left lower lobe then the next day began to have crackles in the upper left lobe with expiratory wheezes. She had ONE "loose" stool and was immediately placed in C-Diff enteric precautions.
I have ineffective airway clearance for one of my four required diagnoses (which I have completed).
I have:
Risk for vascular trauma r/t frequent IV fluids and antibiotics
Risk for C-Diff infection r/t long use of antibiotic therapy
and,
Social isolation r/t enteric precautions ??
**My clinical instructor does not care/require a full blow nursing diagnoses (unless it seems hard to relate, then she wants some form of explanation) but wants clear SMART goals, interventions, and evaluations. That's the part I am struggling with!
I have found what I want to talk about but cannot come up with goals and therefore can't come up with anything else. Anyone?? Help!