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 DIAGNOSES EXPECTED PATIENT ASSESSMENT ACTION interventions: TEACHING interventions:

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

Impaired physical Patient will be able to Assess/monitor bed If patient is not I will encourage self-
mobility r/t decrease in independently ambulate mobility; supported and improving mobility, I efficacy and discourage
muscle strength AEB from bed to bathroom by unsupported sitting; will consult with a helplessness when
patient use of time of discharge. transition movements health care provider patient returns home
walker/wheelchair, (sit to stand); and about changing his because providing
inability to walk standing/walking exercise program to be unnecessary assistance
independently, needs activities. more effective for him. with activities may
assistance to turn in promote dependence
I will also assist patient
bed and loss of mobility.
with activities and
**Priority** exercises that he can Since patient has had
practice outside of history of CVA, I will
therapy in order to engage him in fall
prevention strategies
 improve strength, that he can use when he
balance, and mobility returns home.

Acute pain r/t physical Patient will report a pain Assess pain intensity If patient is in pain, I I will demonstrate the
injury agent (operative level of 0-1 out of a 0-10 level with a 0-10 will consult the nurse use of appropriate
procedure) AEB patient scale by time of discharge. numerical pain rating about administering a nonpharmacological
clutching incisional scale. PRN pain medication. approaches in addition
area, tenderness to pharmacological
I will also help patient
around incisional area, approaches to help
manage pain with
patient states it feels a control pain (heat/cold,
nonpharmacological
little sore distraction techniques,
agents such as
relaxed breathing)
distraction, imagery,
music therapy, I will also reinforce the
relaxation, and importance of taking
application of heat and pain medications to
cold. maintain patients
comfort-function goal.