Need Assistance with Nursing Care Plan!

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Hi There! :)

I have my final Nursing Care Plan due and I am having some trouble figuring out the best way to go about this care plan. I have already completed care plans with the following nursing diagnosis: Risk for infection, Risk for constipation, Impaired Verbal Communication, and Risk for Aspiration. Therefore I have to select a different diagnosis for this final care plan.

I have an immobile, dependent patient with a PEG tube and suprapubic catheter.

I was thinking of having my nursing diagnosis be "Risk for impaired skin integrity r/t mobility deficit." However I am having trouble coming up with Patient Goals. The patient is slow to respond and a permanent resident at the facility so that eliminates all the goals that involve patient/family teaching.

Please help! Any guidance (with this nursing diagnosis or suggestions of a different one) would be greatly appreciated!!!

Thank you !!

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Specializes in LTC, Nursing Management, WCC.

How about Impaired physical mobility

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Specializes in Med Surg, Float, Travel.

Try putting yourself in the patient's shoes. If you couldn't move around & had trouble communicating needs & learning, & were at risk for skin breakdown, what would you want as goals?

I know I'd want my nurse to help me with:

-turning, coughing, deep breathing

-check & see if I need to be changed

-check around my cath & peg for drainage & keep the skin clean & in good condition around the sites

-if im A&O but just slow to respond, I'd want my nurse to ask me simple yes/no questions so I'd be able to participate in my care & communicate needs the best I can

-if I'm not able to respond at all, I'd still want my nurse to tell me what he/she is going to do prior to touching me/moving me around so I'll feel less anxious

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I would suggest finding more assessment data. You form the Dx based off of the assessment data, not the other way around. So think about what's going on. What have you noticed? Have you inspected the client? Any skin breakdown upon head-to-toe assessment? Think of subjective and objective data. Are they in any pain?

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