Nursing Care Plan Template

Initials: VM

Significant Medical Diagnoses: Dementia, aphasia, dysphagia

Safety Considerations: fully dependent, frail, aspiration, falls

Activity level and restrictions: cannot perform any ADL’s by himself, confined to geriatric chair
and bed

Activities of Daily Living: None

Assessment of issue (NANDA Nursing Diagnosis):

1) Risk for aspiration related to lack of ability to feed himself and to verbally
communicate

2) Risk for impaired skin integrity related to immobility and lack of cognitive
functioning, proven by multiple pressure ulcers
1) Risk for aspiration related to lack of ability to feed himself and to verbally communicate
Assessment Data Planning or Client Nursing Rationale for Evaluation or
Outcomes Interventions or Interventions result of the
Plan intervention
Issue of Short term by the Have one support Worker can pay Resident’s needs
exploration: end of shift: worker feeding more attention to will be able to be
SMART just this resident the resident and better met and as a
Aspiration his needs if she is result feeding time
Resident is able to only in charge of will not cause as
be fed orally and feeding him, can much stress, and
Subjective data: without the use of also identify if be more enjoyable
Resident can nasogastric tubes there is a possible for the resident.
sometimes grunt or other aids problem quicker
what sounds like
“no” when he does
not want to eat but
is not always able Keep resident Allows for better Less events
to do this and this sitting at 90 swallowing and involving
is not always clear degrees while decreases risk of aspiration occur
Will not open Longer term: feeding at all times aspiration due to the better
mouth sometimes posture and slower
with no indication Resident has clear feeding rate of
of why breath sounds and resident
is free of
aspiration signs
and risk for
Objective data: aspiration is Feed resident at a This ensures Lower risk of
Resident is decreased slower rate resident has time aspiration and
coughing often to swallow food therefore fewer
when being fed and is ready for aspiration events
and is not able to another bite even or fears
communicate though he cannot
when he is ready verbalize this need
to continue
feeding or when to
stop other than
when he is
coughing
Does not open
mouth wide when
being fed making
it hard to get food
into the mouth and
to tell if resident is
pocketing
2) Risk for impaired skin integrity related to immobility and lack of cognitive functioning,
proven by multiple pressure ulcers
Assessment Data Planning or Client Nursing Rationale for Evaluation or
Outcomes Interventions or Interventions result of the
Plan intervention
Issue of Short term by the Assess bony Bony prominences Less pressure
exploration: end of shift: prominences and are at higher risk ulcer stage
SMART take appropriate for producing advancement due
Pressure Ulcer risk measures if early pressure ulcers, to early
Resident will get stage pressure taking early assessment
stage-appropriate ulcers are measures can
wound care for discovered reduce the time it
Subjective data: current pressure takes to heal and
Resident has ulcers prevent ulcers
difficult time from progressing
verbalizing pain or to higher stages
discomfort

Rotate resident no Reduces the Less pressure

Longer term: less than every amount of pressure ulcer occurrence
two hours on certain areas of due to frequent
Resident will the body changes in
Objective data: experience healing position and
Resident has a of pressure ulcers pressure changes
Braden scale score and less
of 4 (very high occurrence of
risk for pressure sores Provide resident Allows pressure to Less chance of
ulcers) with air bed be distributed pressure ulcers
Skin has many throughout due to the
folds that can resident’s body increased
contribute to the more effectively distribution of
high risk of ulcers pressure