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 2 2 What will you
as evidenced
and time-bound) do 1
by)

Constipation Resident will be 1. I will assist 1. Resident is at 1. I will teach my

related to ambulated at least patient with risk for fall. I will resident the
insufficient 40-60 feet with gait ambulation as use a gait belt to importance of
dietary habits, belt using front noted in protect her skin increasing fiber
insufficient fiber wheel walker with restorative in case of fall. I intake when
intake, wheelchair order using gait will prevent fall constipated in
confusion, following in 10 belt and front by constantly residents room.
average daily minutes. Resident wheel walker by checking up on I will tell her this
physical activity will be encouraged standing beside resident for should be done
is less than to walk from room patient and fatigue. gradually. 18-25
recommended to down their supporting g of fiber is
2. I will offer
for gender and hallway. Goal is ambulation of recommended.
resident fluids
age as working toward 40 to 60 feet. Fiber foods
from hydration
evidenced by relieving include prune
2. I will monitor stating during
nutritional constipation. juice, leafy green
and report any time in common
deficiency, Ambulation will help vegetables,
bowel area and
difficulty in with peristalsis. whole meal
movements between meals.
walking, bread and pasta.
resident has to Resident should
volvulus, and During meals,
keep an exact have at least 1.5
She should trying
record when liters per day or
history of resident is more to eating more fiber
constipation. toileted every 2 promote the foods than
hours. formation of a normal due to
softer fecal her constipation.
mass.

At risk for Resident will 1. Blood 1. I will I will teach my

decreased cardiac maintain an pressure, pulse encourage resident the
output related to
adequate cardiac and condition resident to eat a importance of
diagnosis of atrial
fibrillation, output by keeping checked before sodium- physical activity.
primary her blood pressure, administering restricted, low Exercising helps
hypertension, and pulse rate, and cardiac fat meal. control blood
hyperlipidemia. rhythm within her medication to pressure and
2. I will cluster
specific norms treat residents weight; these are
nursing care and
throughout the hypertension. controlled risk
activities to
morning shift. factors for
2. Monitor daily allow restful ,
Residents defined cardiovascular
weight. Weight un-interrupted
parameters for disease. She can
is a good times for naps,
blood pressure is increase her
indicator of fluid decreasing
130/70 mm Hg and physical activity
balance. demands on
pulse is 71 beats per as tolerated by
Increase weight cardiac function.
minute. walking with a
indicates
gait belt using a
decreased
front wheel
cardiac function
walker with a
with retention
one person
of fluids.
assist,
Residents
participating in
weight is 115.60
seated exercised,
pounds
and ambulating
currently.
to br.

Reference List:
Ackley, B.J., & Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning
care (11th ed.). St. Louis MO: Mosby.