My First Care Plan - can you take a look?

  1. I am an LPN student and in Fundamentals. This is our first care plan and it is basic based on a resident in LTC. This is my first diagnosis with 1 short goal and 6 interventions. Looking for a review. Thanks so much!

    Nursing Care Plan Form
    Student Name: Date: 7/6/2013
    Patient Identifier: WB Patient Medical Diagnosis: Severe Peripheral Neuropathy
    Nursing Diagnosis (use PES/PE format): Impaired physical mobility/risk for falls related to neuromuscular impairment as evidenced by
    Assessment Data

    (Include at least two subjective and/ objective pieces of data that lead to the nursing diagnosis)
    Goals & Outcome

    (One statement is required for each nursing diagnosis. Must be Patient focused; measurable; time-specific; and reasonable.)
    Nursing Interventions

    (List six nursing interventions listed for each goal.)

    (Provide reason why intervention is indicated/therapeutic; provide references.) Use 3 different sources..
    Outcome Evaluation
    (Was goal met?)Indicate met or not met with data. If not met could you revise according to patient's response.

    1. Resident states that she "cannot feel" her feet.

    2. Bilateral hand pain described by patient as "burning and tingling". Resident states pain is at a level 4 from a scale of 1-10.

    Objective. ROM.

    2. Use of wheelchair for ADL's.

    Statement #1

    Resident will not fall during my shift.

    1.Student will provide supportive and well- fitting shoes for resident.

    2.Student will provide a safe environment by putting bed rails up, bed in down position and keep necessary items close by.

    3. Student will remove clutter, wires & cords from pathways. Keep floors dry.

    4. Student will encourage resident to participate in a program of regular exercise and gait training.

    5. Student will help resident plan activities and visits with adequate rest periods as necessary.

    6. Student will answer call light immediately.

    1.Assist client to walk with a firm step, maintains sense of balance and prevents slipping.

    Doenges, Moohouse & Murr, Nursing Care Plans 8th Edition, page 816

    2. These measures promote a safe secure environment and may reduce risk for falls.

    Nursing Care Plans Diagnoses, Interventions and Outcomes, 7th Edition Kindle Version location 9369

    3.Reduces risk of falling and injuring self.

    Doenges, Moohouse & Murr, Nursing Care Plans 8th Edition, page 816

    4. Evidence suggests that people who engage in regular exercise and activity will strengthen muscles, improve balance, and increase bone density. Increased physical conditioning reduces the risk for falls and limits injury that is sustained when a fall occurs.

    Gulanick & Myers, Nursing Care Plans, 8th Edition page 61

    5. Can limit or prevent fatigue; conserve energy for continued participation.

    Doenges, Moohouse & Murr, Nursing Care Plans 8th Edition, page 816

    6. Patients who experience delay in having their call lights answered are more likely to get out of bed without assistance. This behavior, especially if they need to go to the bathroom, will increase their risk of falls.

    Gulanick & Myers, Nursing Care Plans, 8th Edition page 61

    Outcome #1
    0930 resident is assisted in getting dressed and provided with supportive shoes. Goal met.

    0725 resident is at rest and would like to stay in bed due to lack of sleep. Student implements that bed rails are up and her items are close by. Goal met.

    0725 Student clears pathway and removes water from the floor. Goal met.

    Outcome #4
    Resident participated in schedule PT. Resident was pleased and anticipated her next PT.
    Goal met.

    Outcome #5
    Resident expressed interest in activities of Bingo and PT. Student and Resident made a plan to participate in both activities with adequate rest between. Goal Met.

    Outcome #6
    1030 Student responded to call light from Resident's room. Helped resident with transfer from bed to wheelchair to toilet and return with no incident. Goal met.
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    About RedHeaded2bNurse16

    Joined: Jan '13; Posts: 98; Likes: 36


  3. by   megan005
    The only thing that I notice is that you mention that one of your goals is proper footwear and to assist with walking and later you state the pt uses a wheelchair. Maybe change walking to transferring? I also might expand on limited ROM, (is it in the feet or hands or both)? Remember to think about the psychological and social impacts the dagnosis might have. But over all I would say its pretty good
  4. by   RedHeaded2bNurse16
    Thank you so much for your advice!
  5. by   helen09
    Additional assessment needed to support patient is at Risk for Fall -- leg strength on 0-5 scale, can lift leg 2 inches off bed while laying down( if cannot, better not have pt walk). Rest is good
  6. by   RedHeaded2bNurse16
    Thanks for all your pointers! I got a 100 on it!