Care Plan Assistance

your goal needs to reflect your interventions, in other words, your goal is what you anticipate will happen as a result of your interventions being performed. because there are problems with your diagnostic statement and interventions, your goal will not work.

diagnosis: self care deficit(bathing, dressing, toileting) related to memory deficit as evidenced by inability to perform adl's independently

• interventions:
  
  • assess patient - should have already been done prior to determining the problem (nursing diagnosis) otherwise, how would you have found all the evidence that the problem exists. assessment is step #1 of the nursing process. doing interventions for the nursing problem is all the way down at step #3.
    
  • identify degree of impairment - a nice idea. i worked in long term care for years. i've never heard of any specific scale that rates a degree of impairment for any of these 3 self-care deficits.
    
  • develop plan of care and schedule for adl's - this is mumbo jumbo. that is what this whole assignment is--develop a care plan. now, "schedule for adl's" is getting close to treating the situation. but how, specifically? in ltc we put everyone on a shower schedule. twice a week they were scheduled for a shower on a specific day and shift. when living at my brother's home my elderly mom got showered in the evenings when my brother was home and could help her so she was safe from falling. in ltc clothes were marked with the patient's names and aides assisted the patients with dressing. toileting of the patients was done by the aides q2h.
    
  • allow ample time to complete activities - what does this have to do with memory and forgetfulness?
    
  • identify community resources - how are community resources going to help with a forgetful patient who isn't bathing, dressing or toileting correctly?
    
  • give family information about respite care, home health, social services, occupational therapy - why would these services even be necessary? this diagnosis is about the patient not bathing, dressing or toileting because of memory problems.
    
  • keep journal/list of activities - this, again, is assessment, or maybe evaluation to see if strategies are working. the only thing that is feasible to track would be incontinence. if the patient is incontinent use a different diagnosis such as total urinary incontinence.
    

• goal: within one day the patient will be appropriately dressed for the time of day in clean clothing.
  
• interventions:
  
  • at bedtime, one person will accompany patient to bedroom and assist them in choosing pajamas and then helping them dress for bed
    
  • when patient is ready for bed, the clothing the patient wore during the day will be removed and placed in the laundry by the person assisting the patient
    
  • a new clean change of underwear and clothing for the next day can be selected and placed out for the patient for the next day. this can be done with the patient helping.