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Patient care plan

NURSING EXPECTED ASSESSMENT ACTION TEACHING


DIAGNOSES PATIENT interventions: interventions: interventions:
OUTCOMES (consider (consider home
(note priority for each (assess / monitor
orders, safety, regimens, procedures,
below) Be sure they are for )
allergies, code discharge plan, etc.)
S. M. A. R. T.
(Be sure to use status, fall
(Specific,
related to and as risk, etc.)
measureable,
evidenced by)
achievable/
attainable,
relevant and time-
bound)
Self care deficit Patient will stay Regularly assess Pt. will Teach pt. about
related to admitted and heal ability to manage continue OT avoiding dangerous
musculoskeletal for the next 3-4 any complications and PT activities that put pt.
impairment (and weeks or until due to fracture or frequently to at risk for
husbands inability to able to care for rheumatoid regain musculoskeletal
support her). herself arthritis. Monitor mobility. Pt. impairment. (Pt. was
independently. for level of fall will use admitted for falling
risk based on pt. incentive off stepping ladder)
ability to spirometer
ambulate throughout
independently. the day.
Acute pain related to Patient will no Assess pt.s level Continue to Teach pt. about OTC
injury/surgical longer need of pain on 1-10 provide medications to
procedure/movement. Oxyconton or scale several patient with manage slight pain
Roxicone by the times throughout PRN after discharge.
end of the next 3 the day. Monitor Oxyconton Educate pt. on the
weeks of her stay. for pain while and Roxicone. importance of
Any pain will be ambulating/doing Do not exercising to regain
managed by OTC independent daily overwork pt. strength, but not to
drugs. activities. during PT/OT overwork excessively
to avoid taking care of
delaying husband.
healing.

Reference List:
Acklet, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook: an evidence-based
guide to planning care. St. Louis, MO: Elsevier.
Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing:
assessment and management of clinical problems. St. Louis (Miss.): Elsevier.