o****n
发帖数: 9475 | 1 第一次graded care plan，写完了不太确定，请前辈帮忙看看
pt c/o N/V and diarrhea x 3days, Dx:Hypovolemia
3mm cool area on coccyx
24hr I/O 2000/3600
mucous membranes pink and dry, - saliva pool
ate 10 % of lunch
81% of IBW
Diabetes x20yrs
根据这些data，需要写四个nursing diagnosis，我写了：
1.Deficient fluid volume r/t active fluid volume loss AMB N/V and diarrhea x
3days, I/O(– 1600 ml) previous 24 hours, and – saliva pool
2.Imbalanced nutrition: less than body requirement r/t inability absorb
nutrients AMB ate 10 % of lunch and 81% of IBW
3.Impaired skin integrity r/t change in fluid status secondary diarrhea AMB
3 mm cool area on coccyx.
4.Risk for electrolyte imbalance r/t active fluid volume loss AMB N/V and
diarrhea x 3 days
疑问：
第3个，3 mm cool area on coccyx能做为AMB吗？
第4个，对r/t不太确定，Ackley (nursing diagnosis handbook)上没有r/t，我搬用了
Deficient fluid volume 的r/t，可以吗？ |
o****n
发帖数: 9475 | 2 还有Deficient fluid volume的care plan，大家看看有问题吗？
Deficient fluid volume r/t active fluid volume loss AMB N/V and diarrhea x
3days, I/O(– 1600 ml) previous 24 hours, and – saliva pool
OT：Patient will not have N/V in 48 hrs
NIC：
1a) Assess patient’s fluid I/O q8h, and monitor weight daily
1b) assess patient BP and pulse q4h
1c) assess patient’s dry tongue and mucous membranes q4h
1d) provide oral hygiene BID and after every vomiting
1e) administer medications as ordered
什么是administer medications as ordered的rationals？ |
a****a
发帖数: 154 | 3
I am not qianbei, just my two cents.
I think assessment should not be too much in a care plan, at least my
instrucor hates it :).Probably you wanna put encouraging fluid and potassium
-rich food, something like that.We can put teaching as well if there is
nothing else to do.
rationales of drug are reasons why dr gives it. You can put drug actions,
how it works.
【在 o****n 的大作中提到】
: 还有Deficient fluid volume的care plan，大家看看有问题吗？
: Deficient fluid volume r/t active fluid volume loss AMB N/V and diarrhea x
: 3days, I/O(– 1600 ml) previous 24 hours, and – saliva pool
: OT：Patient will not have N/V in 48 hrs
: NIC：
: 1a) Assess patient’s fluid I/O q8h, and monitor weight daily
: 1b) assess patient BP and pulse q4h
: 1c) assess patient’s dry tongue and mucous membranes q4h
: 1d) provide oral hygiene BID and after every vomiting
: 1e) administer medications as ordered
|
o****n
发帖数: 9475 | 4 谢谢MM，这个周末全耗在这几个care plan上了
potassium
【在 a****a 的大作中提到】
:
: I am not qianbei, just my two cents.
: I think assessment should not be too much in a care plan, at least my
: instrucor hates it :).Probably you wanna put encouraging fluid and potassium
: -rich food, something like that.We can put teaching as well if there is
: nothing else to do.
: rationales of drug are reasons why dr gives it. You can put drug actions,
: how it works.
|
n******e
发帖数: 40 | 5 有个写care plan 的书
找到诊断 照着书写就行
写习惯就好了
就不会费这么多时间了
呵呵 |
m*****h
发帖数: 2638 | |
m*****h
发帖数: 2638 | 7 那个diabetes x20years也可以写几个plan 出来
我很讨厌这个care plan，当初在学校写这个也很抓瞎
上班的医院用的系统，我们只用放进去past medical history，c/o，diagnosis，care
plan就出来了。 |
y*****n
发帖数: 367 | 8 这个好！省了多少时间啊。
care
【在 m*****h 的大作中提到】
: 那个diabetes x20years也可以写几个plan 出来
: 我很讨厌这个care plan，当初在学校写这个也很抓瞎
: 上班的医院用的系统，我们只用放进去past medical history，c/o，diagnosis，care
: plan就出来了。
|
o****n
发帖数: 9475 | 9 我就正在抓瞎阶段
最抓瞎的每一个intervention要找到rationale，5、6本书，桌子上摆不下，再搁床上
，轮流翻着找，找着找着，杀人的心都有了
care
【在 m*****h 的大作中提到】
: 那个diabetes x20years也可以写几个plan 出来
: 我很讨厌这个care plan，当初在学校写这个也很抓瞎
: 上班的医院用的系统，我们只用放进去past medical history，c/o，diagnosis，care
: plan就出来了。
|
P*1
发帖数: 268 | 10 You do not need to use so many refrence for rationale. I only use my med-
sur text book and fundamental of nursing textbook to look for rationales.
Once you finished one care plan, and got the feed back from your instructor,
you will know what is expected, then you will feel confident for the future
ones.
【在 o****n 的大作中提到】
: 我就正在抓瞎阶段
: 最抓瞎的每一个intervention要找到rationale，5、6本书，桌子上摆不下，再搁床上
: ，轮流翻着找，找着找着，杀人的心都有了
:
: care
|
