Free Self-Care Deficit Nursing Care Plan Template

Self-Care Deficit Nursing Care Plan

Patient Information:

  • Name: Lowell Quizon

  • Age: 65

  • Gender: Male

  • Diagnosis: Post-Operative Hip Replacement Surgery (Right Hip)

  • Date of Admission: January 15, 2050

  • Expected Discharge Date: January 22, 2050

Assessment of Self-Care Deficits:

  • Activities of Daily Living (ADLs) Impaired:

    • Bathing and Grooming: Unable to shower independently due to pain and limited mobility.

    • Dressing: Requires assistance with putting on pants and shoes.

    • Toileting: Needs assistance with transfers to and from the toilet.

    • Mobility: Limited ability to walk, uses walker for support.

    • Nutrition: Needs help preparing meals and reaching for food items on high shelves.

Nursing Diagnosis:

  1. Self-Care Deficit related to post-surgical pain and immobility as evidenced by inability to perform ADLs independently.

  2. Impaired physical mobility related to post-operative recovery and pain management.

  3. Risk for impaired skin integrity related to immobility and inadequate nutrition.

Goals and Outcomes:

Goal/Outcome

Expected Outcome

Interventions

Timeline

Improve ability to perform ADLs independently.

Patient will demonstrate the ability to perform basic ADLs with minimal assistance.

1. Assist patient with bathing, grooming, and dressing initially.
2. Teach patient techniques for safe transfers and self-grooming.

By January 21, 2050

Increase patient mobility to facilitate ambulation.

Patient will increase walking distance to 50 feet using walker with assistance.

1. Provide support during ambulation.
2. Monitor vital signs and pain levels during movement.

By January 20, 2050

Maintain nutritional intake and prevent skin breakdown.

Patient will maintain adequate nutrition and skin integrity.

1. Provide high-protein snacks and assistance with meals.
2. Turn and reposition the patient every 2 hours to prevent pressure ulcers.

By January 21, 2050

Nursing Interventions:

Intervention

Rationale

Expected Outcome

Evaluation Date

Provide assistance with bathing and dressing.

Assists patient in regaining independence while managing post-surgical limitations.

Improved patient participation in ADLs.

January 20, 2050

Assist with meal preparation and feeding.

Ensures the patient receives adequate nutrition to promote healing.

Patient will maintain nutritional intake.

January 20, 2050

Encourage ambulation with a walker and assistance.

Promotes mobility and circulation, preventing complications such as blood clots.

Increased ambulation distance.

January 19, 2050

Reposition patient every 2 hours.

Reduces risk of pressure ulcers and promotes skin integrity.

Skin remains intact without signs of pressure injury.

January 21, 2050

Provide education on proper use of mobility aids and self-care techniques.

Enhances patient’s confidence in performing ADLs independently.

Patient demonstrates understanding of self-care tasks.

January 20, 2050

Evaluation:

  • Goal 1: The patient was able to perform activities such as dressing with minimal assistance by January 20, 2050.

  • Goal 2: The patient was able to walk 50 feet with assistance, using a walker, by January 19, 2050.

  • Goal 3: The patient maintained adequate nutrition through assisted meal preparation and had no signs of skin breakdown by January 21, 2050.

Prepared by:

[YOUR NAME]
[YOUR EMAIL]

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