My first pt for LTC clinical and 1st care plan

Daytonite, BSN, RN · Nov 17, 2009

i'm referring to bathing/hygiene self-care deficit in most of the comments i make.

identified problem: self -care deficit related to progression of disease as evidenced, by incontinent of bladder and bowel, and being unable to bathe self. (maslow's-safety)

this is not an official nanda diagnosis. you need to specifically identify the self care deficit involved. based on your evidence there are really 3 diagnoses here:
- bathing/hygiene self-care deficit
- total urinary incontinence
- bowel incontinence
[*]toileting self-care deficit does not necessarily mean that the patient is incontinent. incontinence becomes a result of the deficit. the definition of this diagnosis is impaired ability to perform or complete own toileting activities (page 156, nanda international nursing diagnoses: definitions and classifications 2009-2011). the evidence (symptoms) of this are things like not able to get to or find the bathroom, can't get their clothes manipulated in order to toilet, unable to sit down or rise up from the commode, can't or doesn't remember how to use toilet paper.

expected outcome: the patient will have no skin breakdown due to bowel or bladder incontinence, and will be clean and have no body odors for the next month.

this is an inappropriate outcome for bathing/hygiene self-care deficit or toileting self-care deficit,
nursing approaches/actions

rationale

assess the patient's ability to perform adl's and observe patients emotional state and behavior.
- no. this would have already been done before the diagnosis was made.
[*]assess the patient for skin breakdown and help reposition patient every 2 hours.
- this is only appropriate for a diagnosis of total urinary incontinence, bowel incontinence or risk for impaired skin integrity
[*]cleanse the patient after any incontinent episode, may also apply protective ointment.
- this is only appropriate for a diagnosis of total urinary incontinence, bowel incontinence or risk for impaired skin integrity
[*]encourage the patient to do as much as possible.
- to do what? be specific and state exactly what they should be doing. if they can hold a washcloth but can't rub the soap on it and then use it to scrub, lets say, their arms and legs, then state that you are to monitor or stand with the patient and assist them to wash their arms and legs.
[*]establish the goal of bathing as being a pleasant experience-plan for client preferences in timing, type and length, water temperature, and with silence or music
- remove "establish the goal of bathing as being a pleasant experience"
[*]use gentle touch when bathing a client; avoid vigorous scrubbing motions.

actual outcome:

pt has been bathed and kept clean, dry, and odor free. no skin breakdown occurred. the patient had his basic needs met with minimal incidences of agitation.

skin breakdown is an inappropriate goal for a bathing/hygiene self-care deficit diagnosis. you are not evaluating basic needs. you are evaluating the patient's specific symptoms of bathing/hygiene self-care deficit (impaired ability to perform or complete bathing/hygiene activities for self--page 153, nanda international nursing diagnoses: definitions and classifications 2009-2011) that earned them this nursing problem.
where did these incidences of agitation come from? that's kind of important to note as a defining characteristic (evidence) of the patient's bathing/hygiene self-care deficit. if the patient becomes agitated at the site of the shower room (been there--i worked in ltc) and refuses to go in or remove their clothes and gets agitated and starts getting belligerent, that's a defining characteristic (an aeb item) of this diagnosis. you need to have nursing interventions for this. we used to talk calmly to the patients and not tell them we were taking them to the shower room--pretty much distracted them and ushered them into the shower room before they knew what hit them and then sweet talked them once they were in there using any subject we knew would calm them down and showered them fast.

evaluation of care: (how did my care influence the actual outcome?)

after noting that pt was able to turn and adjust himself, also noticed that as long as pt had some say in when his bath/self care was given he was more willing to help. pt had no skin breakdown and was repositioned every 2 hrs. pt did not require any protective ointment after being cleansed.

again, turning and adjusting himself, having no skin breakdown, repositioning and use of protective ointment has nothing to do with a bathing/hygiene self-care deficit
as long as pt had some say in when his bath/self care was given he was more willing to help is all that you can use here.

revised approaches/actions:

this is where you change or add nursing interventions. you decide if some of your interventions weren't so good, so you change or delete them. you can add new ones if you like based on how the patient responded. not all your interventions are going to work all the time. that's why we revise care plans. in the old days we wrote care plans in pencil because we were constantly changing them.

continue plan of care.

a plan of care has to have a rational flow to it. there must be a nursing diagnostic statement that gives the snapshot of what is going on so the person who reads it gets a picture of the situation: the problem--what caused it--the symptoms. the nursing interventions primarily target the symptoms. occasionally we can also go after what caused the problem, but not always. treat those symptoms. those are what your nursing interventions are for. your outcomes are going to reflect what you predict is going to happen as a result of your nursing interventions being followed. there are 3 possibilities:

improvement of the patient's condition/symptom
stabilization of the patient's condition/symptom
support for the deterioration of the patient's condition/symptom

your evaluation is going to tell you which of the 3 happened because when you do an evaluation you are, in essence, assessing the patient again for those symptoms of the nursing problem in question. this is a more narrowed assessment because you are now just focused on this specific nursing problem. you are assessing if your solutions worked or not and preparing to make adjustments in the plan. it has to all make sense when someone reads what you wrote.

give this another try.

1mrskuykendall · Nov 24, 2009

Thanks for the advice I just got my grade back for my care plan...I got a 99%!! I was sooo happy.