Hi! Please help me fill the rest

Hi! Please help me fill the rest out of my nursing diagnoses in relation to what I already have ( as I need minimum 6 interventions and rationale). Most of it is filled out but some isn’t (will have ???). Maybe the goal and evaluation as well, if needed. I attached the case study in reference for the nursing diagnoses. Thank you so much. Please feel free to ask me any questions if needed 🙂 ———————————————————————————– Case study 2: Susan Rossi is a 76 year old Italian women who has just been admitted to an Aged care facility. She has Multiple Sclerosis, she has very poor memory and English is her second language. Her past Medical History includes very limited Range of movement (ROM) of both lower legs, Percutaneous Endoscopic Gastrostomy (PEG) tube with TDS bolus feeds. She also has limited ROM with her left shoulder. She has been tolerating small amounts of level 3 thickened fluids, but her PEG feeds are causing nausea and diahorrea. Due to Multiple Sclerosis she is no longer able to ambulate and is non-weight bearing. She is incontinent wears pads and is refusing IDC, she therefore has developed severe excoriation to her groin which is now painful and bleeding. She has a very supportive family and grandchildren that come and visit her every day at lunch time. Nursing Care Plan Nursing Diagnosis (NANDA diagnosis): Objective: (+) pain in her groin, limited range of movement of both lower legs, limited ROM with her left shoulder with Percutaneous Endoscopic Gastrostomy (PEG) tube, she is incontinent and wears pads. Impaired Urinary Elimination related to Neuromuscular impairment as evidenced by incontinence. Goals/Expected Outcome Short term: After 8 hours of nursing intervention, the patient will be able to verbalize understanding of the condition and demonstrate improvement in urine elimination as evidenced by fewer episodes of incontinence. Long term: After 2-3 days of nursing intervention, the patient will be able to return to normal voiding pattern as evidenced by no episodes of incontinence and improved elimination. Interventions/Actions Rationale 1. Take note of any claims regarding the frequency, urgency, burning, incontinence, nocturia, and size or force of the urine stream. Urinate, then feel your bladder. Gives information on the level of elimination interference or may be a sign of a bladder infection. 2. Implement a bladder training program or timed urination as necessary. Reduces the occurrence of incontinence and bladder infections while helping to restore proper bladder function. 3. Encourage drinking enough water, abstaining from caffeine and aspartame, and minimizing intake in the late evening and before bed. Suggest consuming vitamin C or cranberry juice. A healthy amount of fluid encourages urine production and helps fight illness. 4. Promote continued mobility. Decrease the risk of developing UTI. 5.??? ??? 6.??? ??? Evaluation of results: Short term: After 8 hours of nursing intervention, the patient will be able to verbalize understanding of the condition and demonstrate improvement in urine elimination as evidenced by fewer episodes of incontinence. Long term: After 2-3 days of nursing intervention, the patient will be able to return to normal voiding pattern as evidenced by no episodes of incontinence and improved elimination. Nursing Care Plan Nursing Diagnosis (NANDA diagnosis): Objective: (+) pain in her groin, limited range of movement of both lower legs, limited ROM with her left shoulder with Percutaneous Endoscopic Gastrostomy (PEG) tube, she is incontinent and wears pads. Fatigue related to decreased energy production, increased energy requirements to perform activities as evidenced by inability to maintain usual routines; decreased performance. Goals/Expected Outcome After 8 hours of nursing intervention, the patient will identify the risk factors and individual actions affecting fatigue, identify alternatives to help maintain desired activity level, participate in a recommended treatment program, and report an improved sense of energy. Interventions/Actions Rationale 1. Check vital signs. For baseline data. 2. Recognize and accept the presence of fatigue. Knowledge of these factors provides an opportunity to develop effective measures to maintain or improve mobility. 3. Accept the patient’s inability to engage in activities. Capacity can change at any time. The potential to encourage independence while supporting variations in the amount of care needed is made possible by accepting the patient’s assessment of daily variations in skills without passing judgment. 4. Identify whether in need of mobility help. Give out wheelchairs, walkers, or braces. Review the safety aspects. Mobility aids can decrease fatigue, enhancing independence and comfort as well as safety. 5. Support physical therapy. Use massaged and calming baths to make patients more comfortable. Reduces fatigue and promotes a sense of wellness. 6.??? ??? Evaluation of results: After 8 hours of nursing intervention, the patient identify the risk factor and individual actions affecting fatigue, identify alternative to help maintain desired activity level, participate in recommended tre Nursing Care Plan Nursing Diagnosis (NANDA diagnosis): Objective: (+) pain in her groin, limited range of movement of both lower legs, limited ROM with her left shoulder with Percutaneous Endoscopic Gastrostomy (PEG) tube, she is incontinent and wears pads. Self-Care Deficit related to Memory loss. Goals/Expected Outcome After 8 hours of nursing intervention, the patient will be able to perform self-care activities within the level of his own ability. Interventions/Actions Rationale 1. Assess the patient’s overall condition. To determine patient capability to perform ADL. 2. To the best of their abilities, as determined by the patient, encourage the patient to practice self-care. Wait till the patient is ready. Encourages self-reliance and a sense of control; may lessen feelings of hopelessness. 3. Allow as much independence as you can while providing assistance based on the severity of the condition. Participating in one’s own care helps reduce frustration about independence loss. 4. Note presence of fatigue. MS patients’ fatigue can be extremely disabling and seriously affect their ability to perform ADLs. 5. Encourage scheduling activities in the morning or at a time when you are at your most energetic. ADLs require a lot of energy from patients with MS, raising the possibility of fatigue, which frequently worsens during the day. 6.??? ??? Evaluation of results: After 8 hours of nursing intervention, the patient was able to perform self-care activities within the level of her own ability. Nursing Care Plan Nursing Diagnosis (NANDA diagnosis): Objective: (+) pain in her groin, limited range of movement of both lower legs, limited ROM with her left shoulder with Percutaneous Endoscopic Gastrostomy (PEG) tube, she is incontinent and wears pads. Risk for Ineffective Coping related to short-term memory loss. Goals/Expected Outcome After 8 hours of nursing intervention, the patient will be able to verbalize awareness of her own capabilities/strengths. Interventions/Actions Rationale 1. Assess the patient’s comprehension of the current circumstance and past problem-solving strategies. Help determine personal resources and the need for aid while offering a hint as to how a patient might handle what is taking place right now. 2. Maintain an honest, reality-oriented relationship. Lessens uncertainty and the uncomfortable, frustrating struggles that come with adjusting to a new environment or way of life. 3. Keep an eye out for non-verbal cues including posture, eye contact, motions, gestures, and touch. Verify meaning with the patient as necessary by comparing it to the verbal content. May reveal valuable details about the patient’s emotions, but verification is necessary to make sure the communication is accurate. 4. Provide clues for orientation: calendars, clocks, notecards, organizers. These act as concrete cues to help with recognition, fill memory gaps and help the patient deal with the issue. 5.??? ??? 6.??? ??? Evaluation of results: After 8 hours of nursing intervention, the patient verbalize awareness of her own capabilities/strengths. Nursing Care Plan Nursing Diagnosis (NANDA diagnosis): Objective: (+) pain in her groin, limited range of movement of both lower legs, limited ROM with her left shoulder with Percutaneous Endoscopic Gastrostomy (PEG) tube, she is incontinent and wears pads. Impaired physical mobility related to discomfort and pain. Goals/Expected Outcome After 8 hours of nursing intervention, the patient will be able to evaluate pain and quality of management. Interventions/Actions Rationale 1. Assess the strength to perform ROM to all joints. This evaluation gives information about the severity of any physical issues and directs therapy. 2. Food requirements should be watched in relation to immobility. Good nutrition also gives the required energy for participating in exercise or rehabilitative activities. 3. Analyze the demand for assistive devices. Using wheelchairs, canes, transfer bars, and other aids properly can increase activity and reduce the risk of falling. 4. Assess the safety of the environment. Throw rugs, kids’ toys, and pets can all act as obstructions that further limit and control someone’s capacity to move around safely. Evaluate the patient’s or the caregiver’s knowledge of immobility and its effects. Patients who are temporarily immobile must also take into account the potential of immobility-related adverse effects such as muscle weakening and skin deterioration. 6. ??? ??? Evaluation of results: After 8 hours of nursing intervention, the patient was able to evaluate pain and quality of management. Nursing Care Plan Nursing Diagnosis (NANDA diagnosis): Objective: (+) pain in her groin, limited range of movement of both lower legs, limited ROM with her left shoulder with Percutaneous Endoscopic Gastrostomy (PEG) tube, she is incontinent and wears pads. Powerlessness/Hopelessness related to illness-related regimen, unpredictability of the disease. Goals/Expected Outcome After 8 hours of nursing intervention, the patient will be able to make use of coping mechanisms to counteract feelings of hopelessness. Interventions/Actions Rationale 1. Take note of any actions that suggest helplessness or hopelessness. Desperate remarks may be made by the sick. How a patient responds to a circumstance in life depends on how convinced they are that their position is hopeless and that there is nothing they can do to change it. 2. Express hope for the patient while acknowledging the reality of the situation. Despite a potentially dismal prognosis, remissions can happen, and since the future cannot be foretold, optimism for some degree of quality of life should be encouraged. 3. Encourage and aid the patient in activities they would like to partake in within the scope of their capacities. Staying active and interacting with others counteract the feeling of helplessness. 4. Openly discuss needs with the patient or SO, and establish routines that both parties will follow to address those requirements. Helps deal with manipulative behaviour when the patient feels powerless and not listened to. 5. ??? ??? 6. ??? ??? Evaluation of results: After 8 hours of nursing intervention, the patient was able to make use of coping mechanisms to counteract feelings of hopelessness.

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