juardsrn

Ah dang it! I tried to be as vague as I could, but still listing important info. What would I need to take out? I assumed that since there isn't a city, state, or facility everything would be okay.

Ahh that's a great idea! I think she might able to blow on a feather! I didn't think something like that could be used as an intervention. I guess I was making it harder than it really is. I've just never had a patient who is quite like this one. And I'm positive it won't be my last haha Thanks for the suggestion!

I'm having an awful time writing a care plan for my patient and any help/input would be more than helpful! My nursing dx is: Potential for aspiration related to impaired swallowing as evidenced by excessive saliva production and presence of a G-tube (I know NANDA only has a "risk for aspiration", but this semester, our teacher only wants us using "potential for" in our care plans. Should I change the nursing dx to ineffective airway clearance?) Pt background: 24yo F with cerebral palsy, mental retardation, constipation, epilepsy, and also a quadriplegic. Pt also had a G-tube placed in 02/15. Vitals: (0800) - 97.0 (axillary), 60, 20, 110/68, 94% (1200) - 100.2 (axillary), 62, 18, 108/64 95% Meds: Metoclopram 5mg Baclofen 60 mg Milk of Magnesia 30 mL Docusate 50 mg Depo provera 150 mg When I noticed the spike in her temperature, I went to the pt's RN and discussed that I was scared she may have aspirated sometime after her tube feeding. Came to find out that she started her menstrual cycle and usually gets a temp on the first day (crisis averted, thankfully). I guess I have 2 questions. 1.) Would it be okay to put "the patient will demonstrate effective coughing" as a goal? The pt will only do so many commands. I doubt if I explain deep breathing and coughing exercises, she'll understand. However, when I was assessing her oral membranes and asked her to open her mouth, she was able to do that. I suppose I won't truly know unless I try, right? 2.) The patient has a prescription for Baclofen (muscle relaxant). I know in my experience, my doctor gave me a muscle relaxant to help from coughing up so much mucous all the time. Would it be safe to say that Baclofen can produce the same effects as another muscle relaxer did for me? The current nursing diagnosis book I'm using is: "Nursing Care Plans - Diagnoses, Interventions, and Outcomes" by Gulanick and Myers. I feel like I'm falling into some kind of trap on this one and missing something! The patient is at a risk for aspiration because of their excessive saliva and mucous production, their lungs sounds slightly like crackles, and they also have a presence of a g-tube. Any help would be super awesome and graciously taken!!

I hope I can feel that "pain" one day haha! Good luck with the NCLEX!!

I thought so, too. She doesn't necessarily "give" us the nursing dx, but she gives us choices to do our care plans on when they're due. For example, the care plan that is due tomorrow, the guidelines say to, "prepare a care plan on nutrition, skin impairment, or pain". So, the nursing dx is going to be "Acute/chronic pain r/t ____ AEB _____" if we decide to do it on pain (like I chose ) . I'm hoping that the further we get into the program, the more freedom we'll have with our care plans, but from the sounds of it, I think this is the way it will be until we graduate.

Lol like I said before, I was just curious. I've been completing them how she wants them to be done. Overall, I'm surprised with the feedback I've gotten from her. I was sure she was going to rip them apart, but alas, she was pleased with them!

Hi! I'm a first year nursing student obtaining my ADN! I'm currently taking a break from writing my 3rd care plan. Thankfully, I haven't had too much trouble writing them. However, I was curious how your teachers have you guys write out your care plans. Our teacher has us do the usual medical dx, nursing, dx, and sub./obj. data. Then she has us list 3 short term goals and 3 long term goals accompanied by 3 interventions for each goal (18 interventions in all). Now, this wouldn't be so bad, however, she only lets us use our Fundamentals book as a reference for our rationales. I'm not a huge fan of our book just because of the way it's laid out (we use "Fundamentals of Nursing" by Potter and Perry, 8th edition). Right now we're doing our clinicals at a local nursing home, and every patient that I've had has been nonverbal and bed bound, so I've had trouble figuring out how to start my care plans. Unfortunately, my teacher picks our diagnosis for us and we fill in the blanks based off of our assessment. So, just out of curiosity, how does your teacher have you format your care plans?