i am sorry, i didn't mean to sound pretentious in my reply...i just copied and pasted the gordons info.
i appreciate your help, here is some more info as well as what i have so far:
medical dx: dementia, pneumonia, hypertension, atrial fibrillation, situational depression. resident has limited mobility-wheelchair bound, unable to stand unassisted. her skin is intact-warm pink and dry. a&o x1 sometimes 2 (to person and occasionaly place) she has excellent long term memory but drifts from past to present during conversation sometimes. she is incontinent of bowel and bladder. the reason i chose self-care deficit is that is what is keeping her at the facility. she is unable to perform adl's unassisted. i understand i need to find one specific adl to pinpoint? such as "bathing or toileting?" we did care plans at the very beginning of the semester and now our big assignment for the end of semester is....a care plan! here is what i have thus far:
self care deficit r/t cognitive decline, aeb inability to independently and appropriately bathe.
signs and symptoms
memory problems; forgetfulness (gfhp #5 cognitive/perceptual)
loss of bladder or bowel control (gfhp #3 elimination)
change in personality and mood, such as depression (gfhp #1 health maintenance management)
resident will perform self-care bathing (with assistance as needed) 3x by april 21, 2009
resident will regulate water temperature by verbalization to the nursing student and assistive personell and wash upper body with assistance when needed (to facilitate independence and provide appropriate help in hygiene) every tuesday during her bath.
1. the student nurse will provide appropriate cognitive-enhancement techniques and social engagement.
2. the student nurse will ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
3. the student nurse will work to maximize the resident's functional capacity, but ensure to meet resident's needs when she is unable to meet her own needs.
the student nurse will provide appropriate cognitive-enhancement techniques and social engagement
1. the resident actively and enthusiastically engages in conversation with the nurses aid. resident enjoys talking about past events and was able to recall recent events of the day. resident is relaxed and calm during the conversation aeb smiling and laughing appropriately thoughout the conversation.
the student nurse will ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
2. the resident drank all of her juice that was given to her from the dietary aide. resident stated "that feels better" when pillow was adjusted below her head. resident states a "0" on a scale of "0-10" for pain.
the student nurse will work to maximize the resident's functional capacity, but ensure to meet resident's needs when she is unable to meet her own needs.
3. the resident was able to bathe her upper body with minimal assistance (assistance was needed to wash and dry under the breast tissue). resident was able to comb her hair and pick out a hat to wear.
again, i appreciate your help!