Help with non-comunicative patient care plan

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Hello,

I am a nursing 3 student, My program has four semesters so this is about the 14th care plan I've written.

All of my usual expected outcomes involve communication with a patient.

This client has severe cognitive delays and is unable to verbalize or follow commands. He was on the med surg unit from his LTC facility and completely dependent on his caregiver who was not there at the time of my shift.

For the first time I have really felt helpless and relied on the RN on the floor to administer the med which pt refused. (ground up anti-seizure meds in apples sauce)

Anyone have any websites or general tips on how to write a care plan when someone is unable to follow commands or verbalize his wants or needs.

Thanks in advance for any input.

-Andrew

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Specializes in FNP, Peds, Epilepsy, Mgt., Occ. Ed.

How about nonverbal expressions of pain or discomfort? Restlessness, grimacing, moaning or crying, even elevated heart rate or BP.

This patient may not be able to state that his pain is "less than 3 on a 0-10 scale," but a change from grimacing and moaning to resting quietly would express a decrease in pain or discomfort.

Look for things that can be measured more objectively: oxygen saturation, skin color/integrity, and so forth.

I'm not a care plan expert by any means but these would be things I'd be looking at.

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Impaired Verbal Communication sounds like an appropriate ND.

My CP book has lots of interventions and rationales that do not involve any verbalizations for the client.

Good Luck!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

usually, these patients are put on regular routines of care since they can't tell you what they need. they don't handle change very well. therefore, the care is anticipated and planned for. you listen and look for verbal grunting or noise or physical response to what is happening to them. as you discovered, meds were crushed and put in applesauce. sometimes the patient probably takes them and sometimes doesn't. that's about as much of a response as they are going to get from this patient--that is how he communicates he doesn't want the medication.

i would go on the internet and search for stroke care or alzheimer websites which are two conditions i can think of where the patients have these kinds of problems and see if they list some care strategies on them.

i have to tell you though that there are three major results of nursing goals

  • improvement of the patient's condition
  • stabilization of the patient's condition
  • support for the deterioration of the patient's condition

sometimes there just isn't any possibility of improvement and nursing interventions can only stabilize or support the condition that they have. :uhoh21:

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