NR 325 Care Plan 2 Diagnosis

Student Name

Chamberlain University

NR-325 Adult Health II

Prof. Name:

Date

Care Plan for Nursing Diagnoses and Patient Goals

This care plan outlines three primary nursing diagnoses with associated goals, nursing interventions, rationales, and evaluations. It emphasizes patient comfort, skin integrity, and hygiene, particularly within the framework of end-of-life and supportive care. Considering the patient is a Ward of the State, the care plan does not involve significant family engagement or educational interventions. Instead, the focus is on ensuring high-quality, compassionate care to meet the patient’s needs effectively.

Table 1: Nursing Diagnoses, Goals, Interventions, 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: – Assist the patient in living fully with minimal pain. – Deliver high-quality, patient-centered care. – Ensure a peaceful end-of-life experience. Rationale: – Quality care promotes comfort and reduces distress. – Pain-free experiences support a peaceful end of life. Evaluation: – The patient demonstrates visible comfort and absence of pain indicators.
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: – Regularly assess impaired skin areas. – Implement measures to keep the skin dry. – Notify the PCP if ulcers worsen. Rationale: – Routine assessments monitor skin condition and support care modifications. – Maintaining dryness minimizes bacterial growth and prevents further breakdown. Evaluation: – Unable to observe direct outcomes but ensure proactive interventions are in place.
Self-Care Deficit R/T: Impaired mobility AEB: Immobility/bedridden	Short-Term Goal: Maintain hygiene. Long-Term Goal: Promote a daily hygiene routine.	Nursing Actions: – Preserve patient privacy during care. – Ensure comfort during repositioning for hygiene and oral care. Rationale: – Respecting privacy maintains dignity. – Comfort reduces pain, encouraging compliance. Evaluation: – Patient experiences pain-free and comfortable hygiene routines.

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. https://doi.org/10.1001/jama.2016.0287