So I’m required to do three different care plans on 1 patient. I need a risk, an actual, and a psychosocial. Each care plan must have two short term goals with 3 interventions each and a long term goal(no interventions) I have an actual, I’m struggling with my risk and have no idea for psychosocial. Here’s the rundown on my patient....
87 year old women, dementia only oriented to name (first) , diabetes type 2 (controlled), hypertension (controlled w/o meds), and hyperlipidemia.
patient came to ER on 7/1 after jumping (yes jumping) over a fence, where she landed on her ankle. Patient was found crawling back to the home by police and family. She suffered from an open tibia fracture. Cultures from wound revealed E.Coli in the wound. Patient sent to OR for I&D and external fixator placement. Currently has a wound vac in place and is on bed rest. Patient has also been to the OR 6 times since admission for I&D and fixator adjustments. OR on 7/11 for removal of external fixator and placement of internal fixator. Hemoglobin dropped to 7.3 had a transfusion on 7/3 hemoglobin level staying around 8.4 no other pertinent abnormal lab findings. PICC line in place for continuous iv antibiotic therapy. Line is patent with no abnormalities.
slightly diminished lung sounds (bilaterally, no accessory use or dyspnea)
no other wounds or sores noted
hard of hearing
patient is taking enoxaprin, nametadine, cubicin, and probiotic.
patient lives with her daughter and daughters SO, who are her caregivers. One story house with three steps to get in door. Upon discharge will be going to a SNF. Daughter and SO state she sometimes wanders because she is looking for her mother.
Due to her dementia patient usually answers with one word yes or no, seems to mimic the emotion of the person speaking to her.
care plans so far are:
impaired tissue perfusion r/t trauma of right ankle
risk for venous thromboembolism r/t immobility, poor tissue perfusion
and nothing for psychosocial help please!!!! I don’t know if I’m even on the right track with the other two honestly!!!!