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Write a CARE PLAN - on patient with Malnutrition, Quadriplegic secondary to Motor vehicle accident. Pt....

Write a CARE PLAN - on patient with Malnutrition, Quadriplegic secondary to Motor vehicle accident.

Pt. demographics -----

Pt. is always in Fetal position , has bil heel wounds and has seizure precautions, has a history of pneumonia, asthama, klebisella

Pt. cannot verbalize anything.

Pt. vitals - temp.- 98.0*F , pulse - 106, respirations - 18, bp- 133/66, spo2- 98 AAO x 0

Write a care plan -

3 Goals needed (long term and short term)

3 Nursing diagnosis with rationale

5 Nursing intervention for each Nursing Diagnosis.

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Answer #1

# 3 goals needed are :-

- Movement of the upper and lower limbs (long term goal)

- Achievement of proper nutrition ( long term goal)

- Healing of the heel wound

# Nursing diagnosis :-

1. Deficit upper and lower limbs movement related to quadriplegia

2. Malnutrition related to inability to poor intake

3. Risk for pressure ulcer related to bedriddeness

# Nursing Interventions :-

1. Deficit upper and lower limbs movement related to quadriplegia :-

- Assess the basic movements of the patient

- Encourage to express their feelings regarding inability to move and providing emotional support

- Providing support in activity of daily living

- Taking help from the physiotherapistfor the proper exercise of patient and encouraging the patient to do exercises regularly

- Teaching patient about the importance of medication compliance and follow ups

2. Malnutrition related to poor intake of food :-

- Assess the nutritional status of the patient

- In consultation with the dietician make a proper diet chart which is according to the tastes and preferences of patient

- Helping the patient to have food

- Helping the patient to do his activity of daily living

- Conducting a nutritional follow up

3. Risk for pressure ulcer related to bed ridden :-

- Assess the skin integrity of the patient in each shift

- Maintain well hydrated skin ,avoid moisture accumulation

- Change the position of the patient every two hourly

- Use of supportive devices like pillow , sand bag etc to maintain correct position

- Providing proper wound care if any bed sore present by the following the aseptic technique .

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