NR 325 Care Plan 2 Diagnosis

Name

Chamberlain University

NR-325 Adult Health II

Prof. Name

Date

Care Plan for Nursing Diagnoses and Patient Goals

This care plan addresses three main nursing diagnoses with specified goals, interventions, rationales, and evaluations. Each diagnosis is approached with a focus on patient comfort, skin integrity, and hygiene, aligning with the principles of end-of-life and supportive care. Given that the patient is a Ward of the State, the plan does not incorporate significant family involvement or patient education. Instead, the focus remains on providing high-quality, compassionate care to meet the patient’s needs.

Table 1: Nursing Diagnoses, Goals, Actions, and Evaluations

Nursing Diagnosis	Goals	Nursing Actions, Rationales, and Evaluations
End of Life Care R/T: Impending death, AEB: Evaluation for Hospice	Short-Term Goal: Communicate prognosis and uncertainty. Long-Term Goal: Adjust care for maximum patient comfort.	Nursing Actions: – Help patient live as fully as possible with minimal pain. – Commit to high-quality, patient-centered care. – Ensure a peaceful end-of-life experience. Rationale: – Commitment to quality care enhances patient comfort and reduces distress. – Keeping the patient pain-free promotes a peaceful end-of-life experience. Evaluation: – Patient appears comfortable and free from visible pain signs.
Impaired Skin Integrity R/T: Skin breakdown, AEB: Pressure ulcers	Short-Term Goal: Prevent skin moisture. Long-Term Goal: Avoid further skin breakdown.	Nursing Actions: – Assess the impaired skin site regularly. – Apply measures to keep skin dry and moisture-free. – Notify PCP if ulcers worsen. Rationale: – Regular assessment monitors ulcer progression and necessary care adjustments. – Keeping the skin clean and dry lowers bacterial presence and prevents moisture-related issues. Evaluation: – Unable to observe outcomes directly.
Self Care Deficit R/T: Impaired mobility, AEB: Immobility/bedridden	Short-Term Goal: Maintain hygiene. Long-Term Goal: Encourage daily hygiene routine.	Nursing Actions: – Respect patient’s privacy during care activities. – Ensure patient comfort during positioning for hygiene/oral care. Rationale: – Respecting privacy upholds patient dignity. – Comfort during care activities minimizes pain, encouraging compliance. Evaluation: – Observed patient comfort and pain-free state during hygiene routines.

Nursing Diagnosis

Goals

Nursing Actions, Rationales, and Evaluations

End of Life Care
R/T: Impending death, AEB: Evaluation for Hospice

Short-Term Goal: Communicate prognosis and uncertainty.
Long-Term Goal: Adjust care for maximum patient comfort.

Nursing Actions:
– Help patient live as fully as possible with minimal pain.
– Commit to high-quality, patient-centered care.
– Ensure a peaceful end-of-life experience.

Rationale:
– Commitment to quality care enhances patient comfort and reduces distress.
– Keeping the patient pain-free promotes a peaceful end-of-life experience.

Evaluation:
– Patient appears comfortable and free from visible pain signs.

Impaired Skin Integrity
R/T: Skin breakdown, AEB: Pressure ulcers

Short-Term Goal: Prevent skin moisture.
Long-Term Goal: Avoid further skin breakdown.

Nursing Actions:
– Assess the impaired skin site regularly.
– Apply measures to keep skin dry and moisture-free.
– Notify PCP if ulcers worsen.

Rationale:
– Regular assessment monitors ulcer progression and necessary care adjustments.
– Keeping the skin clean and dry lowers bacterial presence and prevents moisture-related issues.

Evaluation:
– Unable to observe outcomes directly.

Self Care Deficit
R/T: Impaired mobility, AEB: Immobility/bedridden

Short-Term Goal: Maintain hygiene.
Long-Term Goal: Encourage daily hygiene routine.

Nursing Actions:
– Respect patient’s privacy during care activities.
– Ensure patient comfort during positioning for hygiene/oral care.

Rationale:
– Respecting privacy upholds patient dignity.
– Comfort during care activities minimizes pain, encouraging compliance.

Evaluation:
– Observed patient comfort and pain-free state during hygiene routines.

NR 325 Care Plan 2 Diagnosis

References

Deglin, J. H., & Vallerand, A. H. (2011). Davis’s drug guide for nurses (12th ed.). Philadelphia, PA: F.A. Davis.

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., … Angus, D. C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801-810. doi:10.1001/jama.2016.0287

NR 325 Care Plan 2 Diagnosis

Tromp, M., Hulscher, M., Bleeker-Rovers, C. P., Peters, L., van den Berg, D. T., Borm, G. F., … & Pickkers, P. (2010). The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A prospective before-and-after intervention study. International Journal of Nursing Studies, 47(12), 1464-1473.

November 16, 2024

How Can an Online Class Help Me in Communication?