Nursing Care Plan

ASSESSMENT DATA: SUBJECTIVE & OBJECTIVE List focused system data that is pertinent to this diagnosis. NURSING DIAGNOSIS 1. Problem, related to, as evidenced by or Risk for, related to SUBJECTIVE DATA Daughter states she is unable to care for herself at home. She is easily fatigued, Nursing Dx: impaired skin integrity OBJECTIVE DATA Albumin levels is 3.4 g/dL, Prealbumin 14.7 mg/dL, BMI 35.1 which obese, pressure ulcer on right medical malleolus, deep vein thrombosis, chronic obstructive pulmonary disease, bilaterally 2+ edema, unsteady gait, she has a brown hyperpigmentation on both lower legs, 80 years old female, Braden Scale is 16, BP OUTCOME CRITERIANURSING INTERVENTIONS 2 SMART goals (Can be long term or 3 interventions per short term. goal (In your own words) EVALUATION Did your patient meet the goal and if not why? (Met/Progressing/Not met) (Can include assess/monitor, skill, teaching) Related to: insufficient venous return As Evidenced By: venous stasis ulcer, Ulcer assessment: shallow, 1inch width, mostly pink/red, no signs of necrosis; brown hyperpigmentation on both lower legs, bilaterally 2+ edema, age 80 years old, 1.Patient will demonstrate to ambulate for 200 meters by the end of the shift. 1. Nurse will assist with ambulation twice a day. 2. Nurse will educate the importance of ambulation. 3 Nurse will assess physical therapy understanding. 1. Patient met the goal if they were able to demonstrate how to ambulate 200 meters by discharge. Goal was not met if the patient was not able to ambulate by discharge. 2. Patient will describe 3 important reasons of to wear compression stockings in relation to insufficient venous return by discharge. 1. Nurse will educate the importance of compression stockings. 2. Nurse will demonstrate how to apply compression stockings properly. 3. Nurse will assess for edema. 2. Patient met the goal by describing 3 important reasons to wear compression stockings in relation to insufficient venous return by discharge 122/80 mg/Hg, pulse: 95 beats/min, oxygen 94%, respiration: 19 breaths/min, temperature: 97 degrees F, Ulcer assessment: shallow, 1-inch width, mostly pink/red, no signs of necrosis ASSESSMENT DATA: SUBJECTIVE & OBJECTIVE List focused system data that is pertinent to this diagnosis. NURSING DIAGNOSIS 1OUTCOME CRITERIANURSING INTERVENTIONS Problem, related to, as 2 SMART goals 3 interventions per goal (Can be long term or evidenced by (In your own words) short term. (Can include assess/monitor, or skill, teaching) Risk for, related to EVALUATION SUBJECTIVE DATA Daughter states she has unhealthy diet, she is easily fatigued, she has inadequate selfcare. Nursing Dx: Imbalanced nutrition 1. Patient met goal if the patient was able to identify and eat one protein option as a snack by end of the shift Related to: poor dietary decisions 1.Paitent will choose one protein option as a snack by the end of the shift. 1. Nurse will educate patient on proper nutrition options for protein. 2. Nurse will request an order for a nutritionist Did your patient meet the goal and if not why? (Met/Progressing/Not met) As Evidenced By: OBJECTIVE DATA She was prescribed 1 She was prescribed 1 multivitamin and multivitamin and protein supplement 2x protein supplement 2x daily. Albumin: 3.4 daily. She is obese with g/dL, Pre-albumin: 14.7 a BMI of 35.1, mg/dL C, inadequate Albumin: 3.4 g/dL, Pre- self-care as professed albumin: 14.7 mg/dL C, by her daughter, She is age 80, unstady gait obese with a BMI of 35.1, consult from physician. 3 Nurse will assess if client has difficulty chewing or swallowing. 2. Patient will identify three reasons why a balanced meal is important to maintain a healthy lifestyle by discharge. 1. Nurse will educate patient on what consists of a balanced meal. 2. Nurse discussed with patient a proper goal weight. 3 Nurse will assess clients dietary nutrition history noting the areas of malnutrition. 2. Patient met the goal if the patient is able to identify three reasons why a balanced meal is important to maintain a healthy lifestyle.