Attached instructions w. rubric, smart goal instructions and example, patient information and clinical paperwork completed for the patient including care plan containing nursing diagnosis & three interventions needed for this assignment. I completed the first part of this assignment (The Worksheets) and attached it as well. The worksheets and the write up go hand in hand. She changed it from analyzing the food pyramid to MYPLATE instead, so that would need to be a reference. Patient is 65 years old, has dysphagia and is on a mechanical soft diet. He consumes 100% of each meal provided by the care center. Constipation is going to the focus. It seems as though the patient is not consuming enough dietary fiber due to chronic constipation and receiving Colace BID. The nursing diagnosis I submitted is “Constipation related to sedentary lifestyle as evidenced by inability to have a bowel movement in three days.” My instructor already approved it and the three interventions I wrote on the care plan. The smart goal put revolve around constipation also. The lab data of the write up can not be left blank. The patient did not have labs in the chart, but normal lab values for a patient with hyperlipidemia must be included in that section such as triglycerides, cholesterol, hdl, and ldl. Please let me know if you have any questions!
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