priorities/ goals

Esme12, ASN, BSN, RN · Jan 14, 2013

There are goals......and there are goals that are more important than others....you prioritize the goals according to Maslows hierarchy of needs......usually the ABC's....place what can kill them first.

So if your patient is having difficulty swallowing due to hemaparesis/paralysis of the throat (ineffective airway clearance)....your priority is choking from paralysis of the throat, your goal would be to prevent choking by swallowing exercise, changing food texture, and the outcome is that the patient doesn't choke.

Ineffective airway clearance......the NANDA-I Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Maintaining a patent airway is essential to life.

fitore · Jan 14, 2013

I tried to use Maslow's hierarchy of needs, and I put nursing diagnosis by using that, I don't know if I've done right. by the way

these are my pt nursing dg:

actual dg:

1.Ineffective cerebral tissue perfusion

2.Ineffective airway clearance

3.Impaired physical mobility

4.Disturbed sensory perception (seeing)

5.Impaired verbal or written communication

6.Self-care deficit

7.Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

potential dg:

8.Risk for ineffective airway clearance

9.Risk for skin integrity

10.Risk for injury

fitore · Jan 14, 2013

I apologize for the mistakes you in writing because it is more difficult to translate from my own language than to write what I have in mind.

these are my nursing priorities:

1.Maintaining, improving cerebral functions: awareness, sensory functions.

2.Maximum independence in carrying out daily activities

3.Improving mobility. / Prevention, minimization of complications.

4.Increase the level of communication to the patient enabling him expressing his needs

5.Provide information about disease process/prognosis and treatment/rehabilitation needs.

6.Plan in place to meet needs after discharge

fitore · Jan 15, 2013

and these are my nursing goals.

I have a deadline to finish my case study please any help would be welcomed.

- Pt will maintain cerebral perfusion by having a BP of 20 percent less than usual highest BP obtained

- Pt will be oriented in time and space

- pt will be assisted in taking food until he will be able to do this themselves.

- pt will be fed with food which contents Vitamin, soft and take enough fluids.

- Pt will have clear airway.

The client will be able to increase the self-care.

- pt will be able to go to the bathroom by him self without nursing help.

- pt will be noticed with the procedures of setting catheter and will be noticed with the signs of urinary tract infection.

- pti will have improved mobility.

- Family members will be instructed for ROM exercises.

pt will maintain an effective level of communication before discharge.

pt will be able to discuss feelings of hopelessness in open way.

Client will have the necessary information about the treatment, receiving therapy.

Client will not be a damage of skin integrity / decubitus.

Client will not have injuries / (decrease of bed)

Client will be assisted in mobilizing his things before leaving the hospital.

Esme12, ASN, BSN, RN · Jan 15, 2013

I tried to use Maslow's hierarchy of needs, and I put nursing diagnosis by using that, I don't know if I've done right. by the way
these are my pt nursing dg:
actual dg:
1.Ineffective cerebral tissue perfusion
2.Ineffective airway clearance
3.Impaired physical mobility
4.Disturbed sensory perception (seeing)
5.Impaired verbal or written communication
6.Self-care deficit
7.Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs
potential dg:

8.Risk for ineffective airway clearance
9.Risk for skin integrity
10.Risk for injury

Since the case study is based on patient assessment/patient needs.... it's impossible for me to say what is first or second. If the pateint has ineffective airwau clearence I would ssay the is a priority....Airway, Breathing, Circulation. Circulation being last.....If they aren't breathing they aren't leaving. I would switch 1 and 2...the rest is good as far as I can see.

ps...you have an amazing command of the English language!

fitore · Jan 15, 2013

ps...you have an amazing command of the English language!

thanks for your compliment. I love English I always did.

fitore · Jan 15, 2013

Since the case study is based on patient assessment/patient needs.... it's impossible for me to say what is first or second. If the pateint has ineffective airwau clearence I would ssay the is a priority....Airway, Breathing, Circulation. Circulation being last.....If they aren't breathing they aren't leaving. I would switch 1 and 2...the rest is good as far as I can see.
!

so do you think that I have put also the nursing priorities and outcomes right order , recording to nursing dg....???

Esme12, ASN, BSN, RN · Jan 16, 2013

I do....once you switch 1 and 2. That is how we do it in the US....what does your instructors say????

fitore · Jan 16, 2013

yes I switched 1and 2.

fitore · Jan 16, 2013

I do....once you switch 1 and 2. That is how we do it in the US....what does your instructors say????

Subjective data: Client N.N 80 years old, male, widowed, weight: 71 kg and length 1.65cm, retired lives in city, in a 4-member family with average incomes.

Current data:he was admitted to Hospital on.... . N. N.’s son found him lying on the floor confused, and soaked in urine.

Objective data: When W. K. was admitted to the hospital, laboratory findings were all normal.

His vitals signs were all normal except BP: 143/86

oxygen levels between 95% and 100%

I tried to write some of key things.

I hope that his will give you a better reflection of my case.

once again, thank you for and sharing your valuable time to help me.

Esme12, ASN, BSN, RN · Jan 16, 2013

now what was his assessment...what did they find...where was the CVA...what is your assessment in a short paragraph. Where are you in your program?