Care Plan Help

[rescue14]

Hello,

I have a careplan due that must have 2 diagnoses. 1 goal and 3 outcomes per diagnosis with 3 interventions w/ rationale and references per outcome.

My client is bedfast, w/ right side hemiplegia, decreased function in legs bilaterally, 4 fingers amputated off one hand, has tremors, cannot speak (can nod yes or no)

He has a stage I pressure ulcer on saccral area and also has dementia

Diagnosis 1:

Impaired skin integrity R/T pressure on sacral area and immobility AEB stage I pressure ulcer on sacral area

GOAL: client's skin will remain intact

OUTCOMES:

• Client will have oral fluid intake of at least 500ml by end of shift
  
• Client will indicate any altered sensation or pain in sacral area by end of shift
  
• Client will participate in measures that will help maintain skin integrity by end of shift
  

Diagnosis 2:

Impaired bed mobility related to body weakness and deterioration AEB limited ROM in all limbs and hemiplegia

GOALS: client will increase exercise and activity in bed

OUTCOMES:

• Client will complete one ADL by end of shift w/o assistance
  
• Client will participate in exercises by end of shift
  
• No real clue
  

I haven't done any interventions yet, because I feel like I'm painting myself into a corner. I think a big problem is that the client is non-verbal, and that limits my teaching options, since the patient won't be able to acknowledge demonstrate much of what is taught.

Any help or feedback would be appreciated. I've tried looking everywhere, and am just stuck.

Thanks in advance!

[Daytonite, BSN, RN]

Good diagnoses, but before making any goals, consider what nursing interventions you will order. The reason I recommend this is because your goals are what you expect to happen as a result of the nursing interventions being performed.

[rescue14]

Thank you for your reply,

I guess that's where I need some ideas, since measurable teaching interventions are difficult since the client can't communicate orally.

[LylaRae]

I like to include a nutrition diagnosis with this type of patient.

[mommybess, BSN, RN]

You're on the right track. I have one comment regarding your first dx's goal of GOAL: client’s skin will remain intact.

It is more realistic for the goal to be: no further breakdown of client's skin

Others that you could use:

Risk of imbalanced nutrition: less than body requirements

Imbalanced nutrition: less than body requirements

Risk for aspiration

Risk for infection

Risk for falls

Risk for injury

Feeding self care deficit

Toileting self care deficit

Impared transfer ability

Impaired physical ability

Impaired verbal communication

Risk for loneliness

Powerlessness

Impaired swallowing

Disturbed sensory perception

Risk for imbalanced fluid volume