Please make some edits below on the 2 care plan and also make a care plan on Atrial fibrillation on the last template.
Below are the instructions for the first 2 care plans. Same thing for atrial fibrillation. Also, follow the rubric and make sure all care plans have all the following information.
You are supposed to have (2) interventions for each “goal”. I do not see interventions for your “long term falls goal”.
Long term COPD goal only has (1) intervention. Make care plan for atrial fibrillation and do the same
I would suggest you number your goals 1, 2, 3 and then for Goal 1 – label your interventions 1a and 1b. etc. just to ensure you have enough.
You need to fix your nursing diagnosis, they should all say Related To and As Evidenced By.
Ex: Nursing Diagnosis: Actual: Ineffective airway clearance due to COPD, bronchopneumonia, and increased sputum production (you are missing related to and As Evidenced by).
If I were to re-write that: Ineffective airway clearance related to COPD and bronchopneumonia as evidenced by dyspnea wheezing, productive cough and 02 sat of 77% on room air.
According to your patient information at the top, the client did not have increased secretions but, then in your assessment he did.
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