Comprehensive Care Plan
Comprehensive Care Plan
| Nursing Diagnoses | Expected Outcomes (S.M.A.R.T)
Specific, measurable, attainable, realistic, & time-oriented |
Nursing Interventions
What can you, the nurse, do to reach the goal and improve the problem? |
| Ineffective Breathing Problem | The patient will
Short-term goals: The patient will keep his head in a neutral position. The patient will elevate his position of the head and use airway adjunct (incent spirometer and pursed-lip breathing) Long-term goals: The patient will avoid and limit prone positions as indicated by the nurse. The patient will help assess respiratory functions by demonstrating appropriate behaviors supporting respiratory efforts such as taking a deep breath (Postma, 2015). |
The nurse will
1. Assist the patient in maintaining his airway and preventing aspiration. 2. Instruct and assist encourage deep breathing, while focusing the attention on the best steps of breathing. 3. Auscultate the patients breath sounds. 4. Assist the patient in controlling respiration. |
| Impaired Skin Integrity | Short-term goals: The patient will use skin hardening agents.
The patient will periodically elevate the lower extremities as advised by the nurse. Long-term goals: The patient will verbalize understanding of treatment needs. The patient will participate to the level that he will be able to prevent skin breakdown. |
1. Inspect every skin areas of the patient while noting changes such as capillary branching, redness, and swelling.
2. Cleanse the patients halo or tong insertion points, subsequently applying the antibiotic ointment as required. 3. Massage and lubricate the patients skin with lotion for enhanced circulation and skin protection, consequently reducing the risk of ulceration. 4. Provide kinetic therapy to the patient. |
| Impaired Physical Mobility | Short-term goals: The patient will regularly position his arm at a 90-degree angle, thus preventing frozen shoulder contractures.
The patient will reposition periodically either when in sleeping or sitting positions. This will help him reduce pressure areas while promoting peripheral circulation (Crawford and Harris, 2016). Long-term goals: The patient will increase the strengths of unaffected body parts. The patient will demonstrate behaviors and techniques, indicating the ability to resume activity. |
1. Continually assess the patient’s motor function by requesting him to perform various functions such as squeezing and releasing the nurse’s hands. This aspect will help the nurse evaluate the patient’s status.
2. Assist the patient to perform full range of motion (ROM) exercises on all the extremities and joints. This will enhance, restore, and maintain the patient’s muscle mobility, consequently preventing him from experiencing muscle atrophy. 3. Efficiently plan the activities for the patient, allowing him to be involved within his tolerance and ability. 4. Prepare the patient for weight-bearing activities such as maintaining an upright position using a tilt table. This will help the patient with osteoporotic changes in his long bones. While reducing incidences of infections. |
| Reflex Urinary Incontinence | Short-term goals: The patient will limit fluid intake, 2 to 3 hours before sleeping.
The patient will void before going to sleep. Long-term goals: The patient will acknowledge the application of an external catheter. The patient will void at scheduled intervals before predictable urination. This practice will reduce incontinence episodes. |
1. Catheterize the patient at various intervals, especially when he cannot engage in spontaneous voiding (Silva et al., 2019).
2. Work with the patient to establish a reasonable and manageable voiding program. This will promote additional knowledge and appropriate management, positively resonating with the patients cultural and spiritual beliefs. 3. Measuring and recording the patients urine volume after every voiding. 4. Ascertaining the patients recognition of the need to urinate. Having suffered a T3 burst fracture, the patient potentially developed neurological impairments, destroying his sensory fibers. |
References
Crawford, A., & Harris, H. (2016). Caring for adults with impaired physical mobility.Nursing2020,46(12), 36-41.
Postma, K. (2015). Respiratory Function after Spinal Cord Injury.
Silva, V. S. T. D., Torres, M. V. D. A. C. R., Silva, M. A. D. O., Freitas, O. S., Santos, P. D., Gomes, J. J., & Assis, G. M. (2019). Male External Catheter in Adults: a glance at nursing care practice.Revista brasileira de enfermagem,72(2), 450-454.
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