Question

Please help

Please help to fill out nursing care plan for this patient who is Hydrocephalus with VP shunt. I give you 2 nursing diagnoses so help me to finish all another part. You can change nursing diagnosis if you think which better diagnosis for this patient

Nursing Care Plan

Patient Medical Diagnosis: Hydrocephalus with VP shunt

I. Nursing Diagnosis #1: Ineffective breathing pattern R/T disease process, tracheal dependency,

1. Assessment Data (include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)

a.

b.

C.

Goals & Outcome

(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable ; time- specific; and reasonable.)

Statement #l

Statement #2

Nursing interventions

(List at least three nursing or collaborative interventions with rationale for each goal & outcome.)

1.

2.

3.

1.

2.

3.

Rationale

(Provide reason why intervention is

indicated/therapeutic; provide references.)

Outcome Evaluation & Replanning

(Was goal met? How would you revise the plan of care according the patient's response to current plan ?)

Outcome#l

Outcome#2

II. Nursing diagnosis # 2: Potential for nutrition deficits R/T reliance on tube feeding

1. Etiology of problem
2. Subjective data
3. Objective data
4. Patient goals outcome
   1. Short terms goals
   2. Long terms goals

Answer 1

Assessment Nursing diagnosis Goal 1. Sub data :- Patient says, it breathe properly" Patient says, "I feel hised" pt says, . am i ok?" Ineffective breathing Sallern R/T disease process, Iracheal dependency: The client will establish an effective respinateny battern establish Intervention Rationale Evaluation Physical To • examination evaluate After (chest aus. breath some times cultation) Sounds client was has to be properly. able to done : an effective Positioning . Seme д рші ел 's respiratory (Semi fowler) bo - Position futtern must begiren. 'helf ro ease 1. breathing . • Oxygen for administration preventing beres dependent cyanosis. client. Psycological .. for : a reducing Supberst should client's a anxiety obi data :- Patient is howing dyspnea. Patient looks pale and brush . ftis capillary refill time is 4 Sec. be giren

Assessment Vinesing - Goal diagnosis Intervention Rabenale Evaluation Subdata .pl says, " I can't eat • Nutrition level of the client Potential bors nutrition dehat RIT vieliance on tube 9. food ” .PL says, when this tube will be vreme red?" Nubitional Staleis the client has to be assessed . To know the nutrition deficit level. و ادب Client's nutrition level is maintained to some extent. maintained . feeding obi dala pt looks malnutritious. • pt looks annons • Patency of . To give . nasogastric combent tube has to to the be maintained. Client. • Inmoduction . This of food through will mouth should chances of beintio durel, veemomeing with physician's Notube.t order: enhance o