reba77

Thanks alot.... I will try those:yeah:

Any input would be appreciated

I have to do two care plans on a pt I have never seen just the chart. each care plan must have 2 short term and 2 long term goals pt info- 81 y/o w/m diag- periventricular leukoencephalopathy with brain atropy and calcified right vetebral artery muscle weakness ( dressing, balance, gait and strength tested fair/poor), episodes of syncope and collapse, dysphagia (occasionally) hx of seizure disorder. I was thinking of using- Risk for fall r/t PVL aeb muscle weakness, episodes of sycope and collapse, hx of seizure disorder STG- Pt will not fall during my 8 hour shift STG- Pt will be learn how to use assistive devices such as wheelchair and pull bars by the end of my 8 hour shift LTG-Pt will be able to transfer from bed to wheelchair with min. or no assistance by the end of 3 months. LTG- ?????? (not sure) Impaired Verbal Communication r/t PVL aeb muscle weakness, poor oral motor skills, dysphagia STG- Pt will be able to use alternative methods of communication effectively by the end of my 8 hour shift STG- Pt will demonstrate understanding by nodding head yes/no by the end of my 8 hour shift LTG- Pt will be able to say simple words such as yes, no, help, in the next 2 months LTG- ???? (not sure) please let me know if the above is ok and any suggestions would be helpful

can someone please look at the following care plan and see if I need to change anything.... any input would be helpful...thanksNursing Diagnosis & Patient Goals Implementation Rationale Evaluation Nursing Assessment(must be timed & measured) (must have a reference)(subjective & objective)Fluid & Electrolyte ImbalanceSTG#1 R/T Diverticulitis Pain will be at a tolerable level#1 #1 #1 AEB per pt. (3 on a scale of 0-10)Assess presence/ descriptionChanges in the severity &States "stomach keeps * bloody diarrhea by the end of my shift.of painnature of the pain may indicatecramping" while holding abd.* vomiting a life-threatening condition such * pt stated "pain was 8 on 0-10 as perforation of the GI tractscale after eating 4 servings of salad. #2 #2 * abnormal labs Admin. Pain meds as prescribed Pt states pain is a 1 on a * WBC- 15.8 (4.5-11.0) by Dr. (Demerol 50mg IM)med will decrease pain to 0-10 scale. * H & H 12.8 (13.5- 17.5) level pt can tolerate 38.0 ( 40-51) STG#2 * K - 3.5 (3.6-5.2) Will control vomiting during #1 #1 #1 my shift. Offer cold water, ice chips, These fluids help hydrate. Was able to have 2 popsicles room temp broth, or bouillionFluids with extreme temp may and room temp chicken broth if tolerated and approp per dietbe diff. to tolerate. for supper, tolerated well states " it didn’t hurt my stomach to eat this time" #2 #2 #2 Administer antiemetics as Most antiemetics act by raising Pt had no episodes of vomiting ordered.(Zofran 4 mg IV)the threshold of the chemoreceptors during my shift. Was given trigger zone to stimulation.Zofran @ 1600. LTG#1 Abnormal labs will be WNL#1 #1 #1 before discharge. Admin D5 1/2 NC- KCL 20 mEql Will hydrate pt & help increase On discharge K- 4.2 * WBC- 15.8 (4.5-11.0)as ordered. low K. H&H 15.2 and 44 * H & H 12.8 (13.5- 17.5) 38.0 ( 40-51) #2 #2 #2 * K - 3.5 (3.6-5.2) Monitor H&H and K levelsMany individuals with GI bleeding Lab levels were checked have longstanding nutritional deficits daily till discharge. that result in an altered coagulation profile because of the liver's inability to produce adequate vit K H&H are monitored as indicators of both blood loss and hydration status LTG#2 Pt will understand proper diet#1 #1 #1 for Diverticulitis ( High-protein, Consult dietician to reviewHigh- protein, low-residue diets Pt was given papers for properlow- residue diet) nutritional Hx. How to perform are recommended to max.adsorptiondiet. Verbalized understanding calorie count, and assist with menu selections. #2 #2 #2 Encourage use of vitamins andThese compensate for defec.Pt verbalized understanding of mineral supplements as ordered need to take K supplements.

I need help please. I have two care plans Im working on. I cant figure out 2 STG and 2 LTG. 1. Risk for Deficient Fluid Volume R/T SBO and diverticulitis AEB bloody diarrhea, vomiting, NPO, NG tube with brown liquid in suction canister. 2. Risk for Injury R/T alcohol withdrawal AEB not oriented to place, and combative