Care Plan: Nursing Diagnosis List

Student Patient initials. Date of Care Room

Identify all actual and high-risk nursing diagnoses for the chosen patient. Number diagnoses listed in order of priority (1 = greatest). Continue list on back of sheet prn. A minimum of six diagnoses are required to achieve full grade points for this section. Number

1 2. 3. 4. 5. 6.

Nursing Diagnosis Bowel incontinence r/t toileting self-care deficit AEB inability to recognize occurrence of defection. Risk for impaired skin integrity r/t impaired mobility & toileting self-care deficit. Impaired transfer ability r/t loss of muscle function & control AEB insufficient muscle strength. Impaired social interaction r/t limited physical mobility AEB patient refused to be assisted out of bed. Interrupted family processes r/t family roles shifted AEB family reporting to staff the difficulty adjusting to the changes since patient had accident. Self-care deficit: hygiene r/t SCI AEB patient unable to bathe, dress, or carry out proper toileting hygiene.

Ivy Tech Community College Nursing Programs CARE PLAN Date Name: Pt. Initials:. Room NURSING DIAGNOSIS : (Problem Statement actual or potential problem): Number Nursing Diagnosis

1 2. 3. 4. 5. 6.

Bowel incontinence r/t toileting self-care deficit AEB inability to recognize occurrence of defection. Risk for impaired skin integrity r/t impaired mobility & toileting self-care deficit. Impaired transfer ability r/t loss of muscle function & control AEB insufficient muscle strength. Impaired social interaction r/t limited physical mobility AEB patient refused to be assisted out of bed. Interrupted family processes r/t situational crisis AEB family reporting to staff the difficulty adjusting to the changes since patient had accident. Self-care deficit: hygiene r/t SCI AEB patient unable to bathe, dress, or carry out proper toileting hygiene.

EXPECTED OUTCOMES: (GOAL) (Stated as a patient behavior that is measurable, realistic, and specific include a time frame) 1. Patient family/patient will demonstrate skill in carrying out bowel care routine with the help from the nurse by the end of my shift. 2. Patient will maintain intact skin throughout my shift. 3. Patient will maintain or improve muscle strength and joint ROM throughout my shift. 4. Patient will remain free from injury thoughout my shift. 5. Family members will identify support systems to assist them by the end of my shift. 6. Patient will have self-care needs met and will have few if any complications thoughout my shift. EVALUATION: Was the goal(s) met? Yes - #2, #3, #4, 6 No - #1, #5

How do you know? #2 - by the end of my shift I had changed patients brief, assisted in bathing him, and turned him every 2 hours and he was free from any skin breakdown. #3 - patient was able to perform passive ROM. #4 - patient was free from injury throughout my entire shift. I performed hourly safety checks. Ensuring that the patients bed was low, wheels were locked, bedside table & call light was both within reach at all times. #6 - Patient was bathed, shaved, clothes changed, skin barrier ointment applied to groin and buttocks, and lotion applied to his feet. #1 & # 5 - patients family never came during the period that I was caring for him

Defining Characteristics Objective Data:

Nursing Interventions

Nursing Rationale

Immobility

Discuss with facility staff what has worked

Obstinate re: getting out of bed Encourage patient to become involved in planning out the days activities & provide emotional support & positive feedback Limited ROM Perform passive ROM exercises every 2-4 hrs Difficulty turning Ask for assistance in turning and positioning patient q 2hr

staff is more familiar with patient & can provide insight into helping patient get out of room. enhances patient compliance, selfesteem, and motivation prevent contractures & muscular atrophy to prevent skin breakdown

Subjective Data: Reports pain on movement Unwilling to be moved Provide analgesics if ordered before moving, or non-pharmacological Patient will be more compliant and pain control able to move if pain is reduced. Encourage patient feedback on what has helped him before Patient is more in control of his life.

CARE PLAN (continued)

Nursing Interventions

Nursing Rationale