Elimination care plan

Elimination care plan - UNIVERSITY OF KENTUCKY COLLEGE OF...

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UNIVERSITY OF KENTUCKY COLLEGE OF NURSING NUR 863: PROFESSIONAL NURSING CARE ACROSS THE LIFESPAN INTERACTIVE CARE PLAN WORKSHEET Student Name: _____Macy Bundy_______ Mailbox___291_____ Patient’s Medical Diagnosis: Paraplegic, functional decline, bilateral ischial wounds, encephalitis Patient’s Initials: S.O. Sex: Male Age: 60 Wt.: 225 Ht.: 6’1” STUDENT INSTRUCTIONS: In the space below enter the subjective and objective data related to the nursing diagnosis. Are the findings normal or abnormal? If abnormal include normal values for comparison. ASSESSM ENT Subjective Data Entry - Character of stool soft - Constipation - No history of bleeding, hemorrhoids, use of laxative, or diarrhea - “It seems to get pretty full before they change it.” - “I don’t eat those foods.” Objective Data Entry BP: 118/68 (Normal) HR: 90 (Normal) RR: 14 (Normal) Temp: 98.2˚ (Normal) SaO2: 97% (Normal) Assessment: Abdomen soft, non tender, no palpable masses, normoactive bowel sounds x 4 quadrants, use of depends, stoma surrounded with erythemous and inflamed skin, colostomy full with soft stool, lack of sensation to recognize the urge to defecate, decreased muscle strength (0/5) bilaterally below T6, diet full of saturated fats, unable to change own colostomy bag, confusion with some disorientation, unable to follow through with directives, not able to listen attentively and distracted easily. (Normal= No use of depends undergarments; able to have a bowel movement
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Elimination care plan - UNIVERSITY OF KENTUCKY COLLEGE OF...

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