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:
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.
- 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.
- Respect client privacy while bathing-Privacy is a client's right.
- Make sure bathing accessories like towels, wash cloths,and soap are within reach-Prevent client from falling while reaching for accessories.14
Kozier, 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)!