refreshernurse

Daytonite, Thank you so much for your help! I'm going to sit down with this and I'll think it all through and repost when I come up with my answers. I sure do appreciate you taking the time to help me actually learn!

Hi There, I am new to this site, but I am hoping to find some help with a case study. I am an RN doing a refresher course and it's been so long since I have done a care plan. Now I am doing this distance refresher course and I have to come up with 3 nursing diagnoses and then an immediate, intermediate and long term goal for the patient for each diagnosis. Maybe I am thinking to hard, but I just feel like I am doing it wrong. Any help would be greatly appreciated. Also, the diagnoses must be actual rather than potential. Ok, here goes: an 84 y/o female living independently until a recent accident underwent a TKR 2 days ago. since surgery she's been refusing meals. foley still in place on 2nd post-op day and urine draining is concentrated amber. according to the pathway for TKR her foley should have been removed on first post-op day. she is a widow, no children. active in church but worried about going home and living alone. Assessment info: *T 99, P 82 and reg, Resp 16 and reg, lungs CTA (height 5'2" wt 175) * IV of D5W @ 100ml/hr without redness or swelling. She's refusing meals stating, "I don't feel much like eating and this is a good time to get rid of some unwanted pound". * dsg on knee clean, dry and intact *she is doing required exercises @ bedside and when transported to PT *She is reluctant to move about in bed and her elbows and heels are becoming reddened So I thought the diagnoses might be: 1. Impaired tissue integrity r/t impaired physical mobility AEB reddened areas on bony prominences. Immediate goal: tissue will remain intact and not progress to stage II for duration of her hospitalization Intermediate goal: maintain sufficient fluid intake for adequate hydration (2500ml/day) Long term goal: Pt will be able to verbalize importance of skin care and nutrition in maintaining tissue integrity prior to d/c. 2. nutritional requirements: less than body requirements AEB pt's refusal of meals. Immediate goal: Pt will begin to eat at least ½ of each meal provided within 24 hours. Intermediate goal: Pt will be able to describe a plan for making healthy food choices/ meals by d/c Long term goal: I am having trouble with this one 3. I am having trouble coming up with a 3rd. I feel like I am thinking too hard about this and just freezing up in my head. The goals must be patient centered, measurable, realistic. Again, thank you for any suggestions you might have for how to think about this or what direction to take.