My first care plan

  1. Hi everyone,

    I just did my first care plan and wanted some feedback:

    Clinical Assessment Data- Care Plan

    Nursing Diagnosis: Self care deficit (bathing) related to impaired mobility status (weak leg muscles) as evidenced by inability to access shower, regulate bath water, wash entire body, dry body

    Nursing interventions and scientific rationales:

    1. Encourage client to perform as much self care/bathing that she can do safely and assist with washing hard to reach areas (back, lower legs and feet, and perineal)- Allow client some independence while providing needed personal care assistance.
    2. Respect client privacy while bathing-Privacy is a client's right.
    3. Make sure bathing accessories like towels, wash cloths,and soap are within reach-Prevent client from falling while reaching for accessories.14

    Short term goal: Client will demonstrate how to safely perform self care/bathing to the best of her abilities after 1 week.

    Evaluation: Ask client why it is important to practice safety when bathing and what safety measures she should follow.

    Long term goal: Encourage client tocontinue to implement safe measures for performing self care/bathing.

    Evaluation: Observe client behavior while bathing and take note when she is practicing safe self care/bathing.

    14Kozier, Barabra Glenora, Erb Berman, Audrey Snyder, Shiree J Kozier and Erb's Fundamentals of Nursing, (Prentice Hall New Jersey 2008) pp 745-748

    What you are seeing here is just one page of a 14 page 'complete plan' which included pt information, lab data, medications, disease pathophysiology.....

    I honestly don't mind the care plans....I, dare I say, enjoyed doing it. Maybe it's because I have a degree in Communication (journalism)!
  2. Visit RadioJenn profile page

    About RadioJenn

    Joined: Sep '09; Posts: 21; Likes: 9


  3. by   TurismoDreamin
    For some reason, I feel like there's something else that should be addressed as a...priority.
  4. by   9livesRN
    self care deficit sound like a good plan, but in my opinion, you could explore the impaired mobility, since it is a broad diagnosis and you could even ad at risk for!

    I have used the same book as you have and it is not a bad book at all, I love mynursing lab!

    you could use more then 1 diagnosis, and add impaired mobility as evidenced by weakened leg muscles at risk for skin breakdown, short term, turn q2 long term prevent bedsores.

    Or even self impaired body image, or self esteem, since the patient can not walk around and perform ADL's,

    Let me tell you that you did a great job on your first time around!!!
  5. by   RadioJenn
    Oh the assignment called for three diagnoses. Here are the other two:

    Thanks for the compliment!

    Clinical assessment data-care plan

    Nursing diagnosis: Risk for falls related to previous fall, wheelchair use, over 65, use of antihypertensive agents, dementia, impaired physical mobility (decreased lower leg strength)

    Nursing interventions and scientific rationale

    1. Keep bed in low position-Client can move in and out of bed easily
    2. Reduce poor lighting or glare- Prevent client from squinting and impairing vision
    3. Instruct client on how to use call bell and keep call bell near bed-Client will know he/she can get assistance and can prevent accidental falls.
    4. Wear non-skid footwear-Prevent a slippery surface when client is standing
    5. Keep furniture like bedside tables near bed- So client does not reach and lose balance
    6. Use guard rails around toilet in bathroom - Prevent serious injury when getting on and off toilet. Client could band head against porcelain sink or toilet.
    7. Evaluate cognitive status of client-See that patient can understand their limitations and dangers12

    Short term goal: Client will reiterate what safety measures are in place to prevent falls and how to ask for help with mobility in 5 days

    Evaluation: Ask client what safety measures are being used to prevent falls and if she/he understands what they are and why they are needed.

    Long term goal: Client will continue to understand and implement safety measures to avoid falls.

    Evaluation: Client will be free from bruising and injuries resulting from falls

    12Kozier, Barabra Glenora, Erb Berman, Audrey Snyder, Shiree J Kozier and Erb's Fundamentals of Nursing, (Prentice Hall New Jersey 2008) p 723


    Clinical Assessment Data-Care plan

    Nursing Diagnosis: Impaired skin integrity due to extremes in age, impaired circulation, mechanical factors as evidenced by stage II pressure ulcer (sacrum)

    Nursing Interventions and scientific rationale:

    1. Reposition client every 2 hours-Relieve direct pressure and promote healing
    2. Use proper lifting and moving techniques-Reduce friction on skin and chances of skin trauma
    3. Teach client to move- Relieve pressure on wound area and promote circulation
    4. Keep client bed flat or Fowler's position-Reduce shearing force and chances of skin trauma
    5. Clean and dress wound every day-Prevent microorganisms entering wound area and prevent the transmission of blood borne pathogens
    6. Promote adequate nutrition and fluid intake-Proteins, Vitamins A-C-B, and zinc help skin repair itself13

    Short term goal: Wound will continue to healing process after 3 weeks

    Evaluation: Check sacral area for signs of wound healing

    Long term goal: Client will maintain skin integrity and be free from pressure ulcers

    Evaluation: Evaluate diet for proper nutrition and fluid intake, check skin status over bony prominence areas

    13Kozier, Barabra Glenora, Erb Berman, Audrey Snyder, Shiree J Kozier and Erb's Fundamentals of Nursing, (Prentice Hall New Jersey 2008) pp 917-920 & p935
  6. by   9livesRN
    keep up the good work