PLEASE HELP TO DEVELOP CARE PLAN FOR GIVEN CASE\'S PT 1.Priority nursing diagnos
ID: 136957 • Letter: P
Question
PLEASE HELP TO DEVELOP CARE PLAN FOR GIVEN CASE'S PT
1.Priority nursing diagnosis (problem , related to...). Objective data AMB /AEB
2.Least at least 2 realistic goals and outcomes
3.Interventions r/t (Sprecific , realistic , measurable)
4.Rationale
5.Evaluation of goal/outcome (met , not met , any changes to do)
It is the fourth day following Mrs. Baptista’s abdominal surgery. She is progressing well, is ambulating several times a day, has been providing for her own hygienic needs and planning on going home tomorrow. During your early morning assessment, you note that Mrs. Baptista’s hair is oily and matted and she has an unpleasant body odor. Her dentures in a container at the bedside are in need of cleaning. You check her abdominal incision and verify that there is no drainage, redness or signs of infection. You inquire about her ability to take care of her own bath and personal needs, and offer to assist her with her bath. She replies that she had a bath yesterday and doesn’t feel that she needs one today, and request to omit her personal care for Today.
Explanation / Answer
Answer 1) The priority nursing diagnosis is Self Care Deficit related to unwillingness of the patient to perform self care which is evidenced by the patients refusal to take a bath.
This deficit may be the effect of the temporary limitations like those in post operative period who is recovering, or due to gradual deterioration which reduces the patient's ability or willingness to perform activities for self care. It can also be seen in patients who have depression who do not like to enage in self care activities.
Answer 2) Goals and outcomes for self care deficit:
Answer 3) Interventions to implemented to help Mrs. Baptista in performing her self care:
Answer 5) Evaluation of the outcomes:
When evaluated, Mrs Baptista have shown improvement in her performance towards self care. Half of the goals are met whereas half is still partially met. She may require further motivation and encourage to boost her morale and confidence. Also the nurse should try to find if the patient is depressive which often develops with post operative period. Be an active listener to patient's concern and try to allievate her fears and be responsive to her concerns. Also involve her family members for positive outcomes.
S.No Nursing intervention Rationale 1. Establish short term goals with the patient. Setting realistic goals will reduce frustation 2. Explain the patient to accept the need for amount of dependence Patient will need help to determine which is the safe limit to be independent and when to seek assistance 3. Give positiev reinforcement to all the attempts This is encourage the ongoing process as the patient often fail to recognize their progress 4. Provide supervision for each activity untill the patient can effectively perform his care activities independently in a safe environment. This is to ensure safety of the patient. 5. Boost maximum independence This is one of the important goal of rehabilitation. 6. Apply regular routines and provide adequate time to complete the task This will help to patient to organize and carry out self care activities. 7. Encourage patient to use corrective lenses or assistive devices as prescribed Patient often hesitate to take bath due to poor vision or using assistive devices. 8. Provide the preferred temperature of water to the patient. This is ensure patient safety from burns. 9. Provide privacy for bathing rountine This will foster a sense of comfort and cooperation in patient. It increases the self confidence of the patient. 10. Provide security in bathrooms like handle bars,floor is not slippery etc. This is to ensure the patient safety from falls. 11. Encourage regular bathing and brushing of teeths. Encourage to maintain adequate oral hygiene that includes cleaning of dentures. Oral and skin hygiene is important as it will prevent infection transmission of surface organism to blood stream .Related Questions
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