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NURSING CARE PLAN #1

CUES NURSING OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION


DIAGNOSIS
SUBJECTIVE Self-Care Deficit Short Term Goal: 1. Assess patients strength 1. The patient may only need Short Term Goal:
CUES: related to Within 4 hours of to accomplish ADL’s with some self care measures After 4 hours of
Flat affect Cognitive nursing intervention efficiently 2. Various etiological factors may nursing
No verbal response Impairment the patient will be able 2. Determine the specific need more explicit intervention the
to execute self-care cause of each deficit, interventions to enable self- patient was able to
OBJECTIVE measures to outmost such as weakness, care execute self-care
CUES: capability cognitive impaired 3. This may imply the demand measures to
Inability to bathe/ 3. Monitor impulsive for supplementary outmost capability
groom self Long Term Goal: behavior and actions interventions and management
independently Within 1 week of indicative of altered- to guarantee safety and Long Term Goal:
Poor personal nursing intervention judgment security Within 1 week of
hygiene the patient will be able 4. Established short term 4. Helping the patient by setting nursing
Dry/Flakes skin to develop effective goals with the patient realistic goals will reduce intervention the
observed skills in performing 5. Present positive frustration patient was able to
ADL’s/self-care reinforcement for all 5. External resources of positive develop effective
measures activities attempted, note reinforcement may promote skills in
independently partial achievements ongoing efforts. Patients often performing
6. Render supervision for have difficulty seeing progress ADL’s/self-care
each activity until the 6. The patient’s ability to perform measures
patient exhibits skill self-care measured may change independently as
effectively and is overtime and will need to be evidenced by
independently assessing regularly. patient initiating to
7. Implement measure to 7. An appropriate level of perform
promote independence, assistive care can prevent ALD’s/self-care
but intervene when the injury from activities without measures
patient cannot function causing frustration effectively.
8. Boost maximum 8. The goal of rehabilitation is
confidence, instruct the one of achieving the highest
patient on how to level of independence possible
perform self-care 9. An established routine
measure becomes route and require less
9. Established regular efforts. This helps patients
routines and allow organize and carry out self-
adequate time for the care skill
patient to complete task 10. A plan that balances periods of
10. Mange regular activities activity with periods of rest
so the patient is rested can help the patient complete
before the activity the desired activity without
fatigue and frustration.

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