Published Feb 26, 2010
RadioJenn
21 Posts
Hi everyone,
I just did my first care plan and wanted some feedback:
Clinical Assessment Data- Care Plan
Nursing Diagnosis: Self care deficit (bathing) related to impaired mobility status (weak leg muscles) as evidenced by inability to access shower, regulate bath water, wash entire body, dry body
Nursing interventions and scientific rationales:
Short term goal: Client will demonstrate how to safely perform self care/bathing to the best of her abilities after 1 week.
Evaluation: Ask client why it is important to practice safety when bathing and what safety measures she should follow.
Long term goal: Encourage client tocontinue to implement safe measures for performing self care/bathing.
Evaluation: Observe client behavior while bathing and take note when she is practicing safe self care/bathing.
14Kozier, Barabra Glenora, Erb Berman, Audrey Snyder, Shiree J Kozier and Erb's Fundamentals of Nursing, (Prentice Hall New Jersey 2008) pp 745-748
What you are seeing here is just one page of a 14 page 'complete plan' which included pt information, lab data, medications, disease pathophysiology.....
I honestly don't mind the care plans....I, dare I say, enjoyed doing it. Maybe it's because I have a degree in Communication (journalism)!:)
TurismoDreamin
40 Posts
For some reason, I feel like there's something else that should be addressed as a...priority.
9livesRN, BSN, RN
1,570 Posts
self care deficit sound like a good plan, but in my opinion, you could explore the impaired mobility, since it is a broad diagnosis and you could even ad at risk for!
I have used the same book as you have and it is not a bad book at all, I love mynursing lab!
you could use more then 1 diagnosis, and add impaired mobility as evidenced by weakened leg muscles at risk for skin breakdown, short term, turn q2 long term prevent bedsores.
Or even self impaired body image, or self esteem, since the patient can not walk around and perform ADL's,
Let me tell you that you did a great job on your first time around!!!
Oh the assignment called for three diagnoses. Here are the other two:
Thanks for the compliment!
Clinical assessment data-care plan
Nursing diagnosis: Risk for falls related to previous fall, wheelchair use, over 65, use of antihypertensive agents, dementia, impaired physical mobility (decreased lower leg strength)
Nursing interventions and scientific rationale
Short term goal: Client will reiterate what safety measures are in place to prevent falls and how to ask for help with mobility in 5 days
Evaluation: Ask client what safety measures are being used to prevent falls and if she/he understands what they are and why they are needed.
Long term goal: Client will continue to understand and implement safety measures to avoid falls.
Evaluation: Client will be free from bruising and injuries resulting from falls
12Kozier, Barabra Glenora, Erb Berman, Audrey Snyder, Shiree J Kozier and Erb's Fundamentals of Nursing, (Prentice Hall New Jersey 2008) p 723
and....
Clinical Assessment Data-Care plan
Nursing Diagnosis: Impaired skin integrity due to extremes in age, impaired circulation, mechanical factors as evidenced by stage II pressure ulcer (sacrum)
Nursing Interventions and scientific rationale:
Short term goal: Wound will continue to healing process after 3 weeks
Evaluation: Check sacral area for signs of wound healing
Long term goal: Client will maintain skin integrity and be free from pressure ulcers
Evaluation: Evaluate diet for proper nutrition and fluid intake, check skin status over bony prominence areas
13Kozier, Barabra Glenora, Erb Berman, Audrey Snyder, Shiree J Kozier and Erb's Fundamentals of Nursing, (Prentice Hall New Jersey 2008) pp 917-920 & p935