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MLSruns800

MLSruns800

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  1. MLSruns800

    Care Plan Help!!!

    Whoops! I copied and pasted from my document so the red font did show up. Her comment was "Who would you collaborate with one VS? If they gather data indicating abnormals, then what would they do?" Thank you for your comments!! :) This is only my second attempt at a care plan so I am constantly questioning myself!
  2. MLSruns800

    Care Plan Help!!!

    Hello. Once again I am coming for feedback on a care plan. This was a copy and my instructor made one comment on it. (In the red font) I guess I do not understand what she is really asking..... Can anyone offer any advice or corrections they think I should make? Thanks!!! [TABLE] [TR] [TD]Nursing Diagnosis Ineffective breathing pattern related to alteration in oxygen supply as evidenced by shortness of breath, oxygen saturation of 87%, and use of accessory muscles while breathing. [/TD] [TD]Expected Outcomes Patient will establish appropriate breathing pattern evidenced by absence of hypoxia before discharge. Patient's respiration rate and pulse oximetry will return to normal/acceptable range before discharge. [/TD] [TD]Evaluation Patient showed no signs of hypoxia or respiratory distress before discharge. (Goal met) Patient's respiratory rate remained within 17-18 breaths per minute during hospitalization. Her pulse oximetry remained above 92% during hospitalization and once she was weaned off oxygen therapy. (Goal met) [/TD] [/TR] [TR] [TD]Assessment Patient reported feeling very short of breath last few days and very fatigued. Patient had oxygen saturation of 87% when arriving at emergency room on room air – patient placed on 2 liters of oxygen. Patient reported having a very sore throat. Patient's voice was very hoarse and a dry cough was noticed. Patient was using accessory muscles during respirations and had nasal flaring present. Respirations were 28 in emergency room. [/TD] [TD]Nursing Interventions Monitoring of pulse oximetry and respiratory rate. Having patient sit in chair or elevate head of bed when patient is in bed. Administer oxygen therapy as prescribed if needed. Auscultate chest and lungs. Encourage use of incentive spirometer every four hours while patient is awake. (Collaborate with respiratory therapy) Who would you collaborate with one VS? If they gather data indicating abnormals, then what would they do? [/TD] [TD]Rationale Monitoring pulse oximetry and respiratory rate verifies maintenance and improvement of oxygen saturation. Elevating the head of bed and having patient in sitting position can promote physiological and psychological ease of maximal inspiration. Administering oxygen therapy helps with management of any respiratory distress or signs and symptoms of hypoxia. Auscultating the chest and lungs help to evaluate breath sounds or fluid in lungs. Using an incentive spirometer can help you practice taking deep breaths, which can help open your airways, prevent fluid or mucus from building up in your lungs, and make it easier for you to breathe. (Source: Nursing Pocket Guide in Nursing Central App. Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 9th Edition (pg 35-36) [/TD] [/TR] [/TABLE]
  3. MLSruns800

    Nursing Care Plan HELP!

    Hello everyone. I am working on my first practice nursing care plan and I am stuck. I was wondering if anyone can give me a little insight. I obviously am not expecting anyone to do the work for me. I am just asking for any advice and opinions if I am heading in the right direction when completing my first nursing care plan for practice. So I was given a case scenario where the primary admitting diagnosis was generalized weakness. Some of my assessment findings were: Pt. reported having a hard time getting up from toilet and chairs twice this morning. Pt. reported having no strength to get dressed, eat, or take morning meds. Pt. reported feeling very weak and fatigued while trying to get out of bed so wife called EMS. Pt. reported feeling congested, having a sore throat and having cough. Dry cough present. Temperature on admission 100.1. Blood sugar was 254. Patient reports having a fall in June of 2016 resulting in sprained ankle. Patient has some right side deficit from previous stroke. I chose my nursing diagnosis to be: Activity intolerance related to generalized weakness as evidenced by inability to perform ADLs, impaired mobility, and fatigue. My (2-3) expected outcomes for my patient were: Patient will demonstrate ability to perform basic ADLs without signs of exhaustion or fatigue by discharge. Patient will ambulate 100 feet (or more if tolerated) with staff twice daily. Patient will remain free from falls during length of hospital stay (or until discharge.) My nursing interventions for my patient were: Reduce intensity level or discontinue activities if patient shows signs of overexertion. Plan cares to balance rest periods with other activities. Evaluate if patient might need additional help (PT/OT) in home after discharge. Maintain safe environment and follow fall prevention measures. My nursing evaluation: Patient demonstrated ability to dress upper and lower body, bath self, perform self oral care without showing signs of fatigue or exhaustion. (Goal/outcome met) Patient ambulated 3 times daily with staff in room and hallway to exceed 100 feet. (Goal/outcome met) Patient had no falls during hospital stay. (Goal/outcome met)