Nursing Care Plan Using Neuman’s Model Nursing Diagnosis using NANDA diagnoses terminology| Measurable Goals| Nursing Outcomes (interventions)| Level(s) of Prevention for each Intervention| Self-care deficit r/t physical limitations and frustration over loss of independence AEB in ability to perform ADL’s such as bathing, grooming, hygiene, and dressing. | Patient will be dressed and out of bed for therapy daily over the next 30 days. Ace will be free of skin breakdown for the next 60 days. Pt will assist with ADL’s to the highest degree possible over the next 30 days.
Ace with bathe and dress self with min-assist/supervision and cues in 90 days. | 1. Encourage patient to be accountable for specific aspects of care (i. e. brush teeth daily)2. Set up grooming items and encourage participation3. Assist with ADL’s if Ace is unable4. Encourage, cue and assist to select clothing and dress appropriately daily5. Ambulate pt with assist (as directed by PT)6. Monitor for c/o discomfort, foul smelling, and discolored urine 7. Assist with and encourage good peri-care with each toileting 8.
Educate pt on breaking tasks into small steps. Limit choices to two, and provide reminder and cues during tasks | 1. Primary2. Secondary4. Primary5. Secondary6. Primary7. Primary8. Teritary | Risk for impaired skin integrity R/T immobility, mechanical pressure & sheer. | Ace will be turned/repositioned Q 2 hrs. with assist of 1-2 people. Ace will complete transfers with min-mod assist of 1 as required. Ace will be out of bed daily, as tolerated, transfers will be with assist of 1-2 staff as required. | 1.
While in bed staff with assist Ace to turn/reposition self-using pillows and wedges to maintain position. 2. Place call light w/in easy reach3. PT to educate Ace on assistive devices4. Remind and encourage Ace to call for assistance when needed5. Ace will be out of bed to chair daily as tolerated | 1. Primary2. Secondary3. Primary4. Secondary5. Teritary| Impaired physical mobility related to neuromuscular impairment r/t Hypertension, Occlusion within vessels of the brain parenchyma disruption of blood supply in the brain area, tissue and cell necrosis. Ace will be free of injury for next 30 days. | 1. Change position Q 2 hrs. 2. Teaching related to ambulation and transfers by PT/OT and nursing. 3. Evaluation and education of assistive devices as directed by therapies. 4. Education on diet, nutrition and speech consult 5. Encourage use of non-skid shoes/footwear6. Provides safety measures (side rails up, using pillows to support body part) | 1. Primary2. Tertiary3. Tertiary4. Primary5. Secondary6. Primary|
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