NORFOLK STATE UNIVERSITY DEPARTMENT OF NURSING NURSING CARE PLAN

Student __ Date _11/04/2011 Clients initials _RW__ Age _52 Nursing System _Orems partially Compensatory Instructor ___Mrs. Smith Facility __Sentara Care Plex Hospital
PLANNING IMPLEMENTATON
RATIONAL FOR NURSING ORDERS Adapting environmental factors for bathing may help prevent bathing disability and promote bathing independence (Naik & Gill, 2005). Unpadded shower chairs with large openings and no foot support are not good devices. This allows client to sink into the opening with their feet unsupported (Rader et al, 2006). Sensations that make bathing pleasant should be used for everyone to avoid behaviors that are symptoms of unpleasant bathing (Rader et al, 2006). Client behaviors labeled as aggressive are likely defensive behavior that results from feeling threatened or anxious (Perimutter & Camberg, 2004) METHODS OF NRSG ASSISTANCE

ASSESSMENT
DATA COLLECTION

NURSING DIAGNOSIS
SCD COLLABORATIVE PROBLEM PRIORITY #1 Bathing self- care deficit related to left side weakness as manifested by inability to wash body. RATIONALE PRIORITY #1 Based on Maslows Hierarchy of needs self-care deficit is a Physiologic need and is a basic need that needs to be met first (Smeltzer 5). GOAL/OBJECTIVES

EVALUATION
GOAL MET, NOT MET PARTIALLY MET

NURSING ORDERS

SUBJECTIVE DATA Client stated I cant shower anymore without assistance.

GOAL: Client will remain free of body odor. OBJECTIVES: Client will use methods to bathe safely with minimal difficulty. Client will state satisfaction with ability to use adaptive devices to bathe. Client will bathe with assistance of caregiver as needed and report satisfaction during bathing experience. Client will bathe with assistance of caregiver as needed without exhibiting aggressive behaviors. Nurse will adapt environment by placing items within easy reach, installing grab bars, lowering faucets, and using a handheld shower. Nurse will use a comfortable padded shower chair with foot support. Nurse will establish the goal of clients bathing as being pleasant experience, without the symptoms of unpleasant of unmet needs. Nurse will make bathing a soothing experience, and reduce client aggression

Nurse adapted environment by placing items within easy reach, installing grab bars, lowering faucets, and using a handheld shower. Nurse used a comfortable padded shower chair with foot support. Nurse established the goal for clients bathing as being a pleasant experience, without the symptoms of unpleasant or unmet needs. Nurse made bathing a soothing experience, and reduced client aggression.

Goal met. Client was able to bathe safely with minimal difficulty. Goal met. Client was satisfied with the bath devices. Goal met. Client reported being satisfied with bathing experience. Goal met. Client no longer exhibited aggressive behavior.

OBJECTIVE DATA BP:114/69 Pulse: 77 SpO2: 96% Respirations:14 Temp: 98.6 Intake of dinner: 0%. RN notified.