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

The following care plan highlights three priority nursing diagnoses with their respective goals, interventions, rationales, and evaluation measures. The plan emphasizes patient comfort, maintenance of skin integrity, and assistance with hygiene. Considering the patient is a Ward of the State, there is minimal family involvement and limited patient education. Therefore, the plan focuses primarily on ensuring compassionate, evidence-based, and patient-centered care that addresses the individual’s immediate health needs while promoting dignity and comfort.

Table 1: Nursing Diagnoses, Goals, Actions, Rationales, and Evaluations

Nursing Diagnosis	Goals	Nursing Actions	Rationales	Evaluation
End-of-Life Care Related to: Impending death As evidenced by: Evaluation for Hospice	Short-Term Goal: Communicate prognosis clearly and address uncertainty with the patient. Long-Term Goal: Provide maximum comfort and ensure dignity during the end-of-life process.	– Facilitate open communication regarding prognosis and care preferences. – Deliver care focused on comfort measures, including effective pain control. – Create a peaceful, supportive environment during end-of-life care.	– Clear communication reduces anxiety and promotes understanding of care decisions. – Comfort-centered care enhances quality of life in terminal stages. – A calm environment ensures emotional and physical ease.	– Patient demonstrates signs of relaxation and reduced discomfort. – Minimal or no visible expressions of pain or distress.
Impaired Skin Integrity Related to: Skin breakdown As evidenced by: Pressure ulcers	Short-Term Goal: Maintain skin dryness and prevent further irritation. Long-Term Goal: Prevent worsening of pressure ulcers and promote healing.	– Inspect skin regularly for breakdown or new lesions. – Reposition patient at regular intervals to relieve pressure. – Keep skin clean, dry, and protected with barrier creams. – Notify primary care provider if ulceration worsens.	– Continuous monitoring allows early detection of deterioration. – Repositioning minimizes prolonged pressure and enhances circulation. – Moisture control prevents maceration and bacterial growth. – Early medical intervention reduces risk of complications.	– No new skin breakdown observed. – Patient’s skin remains dry and protected. – Existing ulcers show no signs of worsening.
Self-Care Deficit Related to: Impaired mobility As evidenced by: Bedridden state	Short-Term Goal: Assist patient in maintaining daily hygiene practices. Long-Term Goal: Support the establishment of a consistent hygiene routine that respects patient dignity.	– Provide complete assistance with hygiene activities, such as bathing and oral care. – Respect privacy by maintaining dignity during care activities. – Position patient carefully to reduce pain and enhance comfort during hygiene care.	– Hygiene care prevents infections and improves physical well-being. – Maintaining privacy upholds dignity, an essential part of holistic care. – Comfort during repositioning encourages patient cooperation and minimizes distress.	– Patient shows signs of comfort during hygiene activities. – No evidence of discomfort, resistance, or increased pain noted.

This care plan demonstrates the importance of tailoring interventions to meet the needs of vulnerable patients, especially those with limited autonomy or family support. Emphasis on end-of-life comfort, skin integrity preservation, and hygiene support ensures that the patient receives compassionate, dignified care consistent with best nursing practices. By focusing on both immediate and long-term goals, nurses can improve patient outcomes and reduce distress during challenging stages of illness.

References

Deglin, J. H., & Vallerand, A. H. (2011). Davis’s drug guide for nurses (12th ed.). 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

NR 325 Care Plan 2 Diagnosis

Tromp, M., Hulscher, M., Bleeker-Rovers, C. P., Peters, L., van den Berg, D. T., Borm, G. F., … & Pickkers, P. (2010). The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A prospective before-and-after intervention study. International Journal of Nursing Studies, 47(12), 1464–1473. https://doi.org/10.1016/j.ijnurstu.2010.03.009