JMU School of Nursing - NSG 352L

Directions for Preplanning Form ADVANCED

Fall 2017

Careplan
Directions: There are 5 steps to the nursing process: Assessment, diagnosis, planning,
implementation and evaluation. You will begin here the night before clinical by creating your
plan based upon the information gleaned during pre-planning. THEN, you will implement
during clinical.
About interventions: Consider what you will need to do to care for the patient. Include
activity, safety, mobility and teaching in this plan. Also consider any physical care requirements
needed such as bathing, dressing, feeding, repositioning, dressing changes, ambulation, oral
care, sensory aids and assistive devices. You need a minimum of 2 in each intervention box.

NURSING EXPECTED PATIENT ASSESSMENT ACTION TEACHING

DIAGNOSES OUTCOMES interventions: interventions: interventions:
(consider orders, (consider home
(note priority for Be sure they are S. (assess /
safety, allergies, regimens,
each below) M. A. R. T. (Specific, monitor for )
code status, fall procedures,
measureable,
(Be sure to use risk, etc.) discharge plan,
achievable/
related to and etc.)
attainable, relevant
as evidenced
and time-bound)
by)

Risk for Patient will increase Assess and Monitor O2 Instruct pt to

aspiration effective coughing monitor stats. increase fluid
related to and deep breathing respirations and intake if
Asthma and techniques once a breath sounds, secretions
COPD, AEB day to maximize noting any become thick.
heavy breathing, effort. abnormal Instruct pt to
moderately rates/sounds. take part in
deep breaths, breathing
and persistent exercises and
cough without when taking
sputum. inhaler, wait one
minute after the
first puff to take
the second puff,
because it will be
more effective.

1
 JMU School of Nursing - NSG 352L
Directions for Preplanning Form ADVANCED
Fall 2017

Risk for more Patient will select Monitor for Monitor that pt Instruct patient
than body better choices for weight loss and is receiving daily to stay away
requirements of meals, consisting of increase in nutritional from the sweets.
Nutrition r/t more veggies, a activity. requirements. Instruct pt to
heavy weight, protein and a carb, cook meals,
AEB finishing big when filling out including
meals, and carb meal plan sheets. Pt vegetables and a
consistent diet. will avoid desserts. protein.