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Discussion

Care plan crisis

I have a care plan due next monday and I am really struggling with it. It is over self care deficit. My pt is 63 and is totally dependant for everything. The pt is bed bound, bowel and bladder incontinent, very limited ROM, and has contractures in her hands and feet. Pt has a peg tube and is on tube feedings. Everything in my care plan book is geared toward regaining independance, but that is not a realistic goal for this pt. The only thing I can think of for her to maintain would be the ROM but it is extremly limited as is and I have to have a rationale and I don't have one, other than common sense. Do any of you have any suggestions on how to go about this care paln? I am really lost on this one.

PS: The instructor assigned it, so please don't throw me under the bus for ABC's! I think risk for aspiration would be a better fit for this pt.

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    Now I have several:

    Bathing/hygiene Self Care deficit r/t (her diagnosis or symptoms)

    Dressing/grooming self-care deficit

    Feeding self care deficit

    Toileting self care deficit

    Think of maintaining skin integrity, dignity, maintaining & improving nutritional status just providing a quality life with care and compassion

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    Our Nursing Resource Center Library has dozens of Care Plan books. I just grab a big stack of random ones when I have care plans assigned and they help so much. It is one case where too much information is better!

    Your case makes me think, Risk for impaired Skin Integrity r/t immobility, incontinence, etc. My goals would be PT will be clean and dry and free of pressure sores by end of shift...

    My interventions would involve turning and positioning q 2h and maintaining clean dry skin in the perineal area and around the PEG site.

    Risk for nutritional deficit or fluid volume deficit or fluid volume excess r/t PEG feeding - I would want to monitor F&E levels, assess skin turgor, mucus membranes etc

    Self care deficit r/t immobility, PEG feeding, inability to perform oral hygiene...

    I would perform good oral hygiene on Pt, check mouth for sordes, keep lips hydrated etc.

    Risk for immobility r/t being bed bound - to avoid further contracture perform ROM exercises q 2h...

    For my rationales I just look up my interventions or one word from the Dx in my Clinical Skills textbook or Med-Surg txtbook and I can usually find a relevant citation.

    I know these are incomplete and hopefully by now you've had your lightbulb moment. I usually get over the hump just after I vent that the task is impossible!!

    Good luck!

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