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 ASSESSMENT ACTION TEACHING
DIAGNOSES PATIENT interventions: interventions: interventions:
OUTCOMES (consider (consider home
(note priority (assess /
orders, safety, regimens,
for each Be sure they are S. monitor for )
allergies, code procedures,
below) M. A. R. T.
status, fall risk, discharge plan,
(Specific,
(Be sure to use etc.) etc.)
measureable,
related to
achievable/
and as
attainable,
evidenced by)
relevant and time-
bound)
Impaired gas Patients O2 stats Monitor O2 Place oxygen Teach the
exchanged will stay above stats every 2 on patient client to get
related to 92% for 24 hours hours to before they go yearly flu
pneumonia as in a week. ensure that to sleep to vaccinations
evidence by patients stats ensure they
Teach the
low O2 stats dont drop keep their
patient and the
Patients lungs will below 92% levels up
family the
sound clear in 3 during the
Auscultate importance of
weeks. night.
breath sounds not smoking
every 2 hours Ensure patient
is moving and
uses incentive
spirometer to
prevent
pneumonia in
the future
Overweight Patient will begin Take weekly Preparing a Teach the
related to to go on short weights to balanced diet patient how to
average walks each day measure the that is make healthy,
physical patients achievable and yet possible
Patient will follow
actively less progress reasonable for food choices
their diet regimen
than the patient
and slowly begin Check patients Include the
recommended while they are
to lose weight vitamin levels patients family
as evidence by at VMRC
to ensure she in plans to
BMI > 25 kg/
is getting Create an promote
m^2
enough of exercise plan healthy living
each vitamin that the
and mineral patient can
perform while
recovering
from
pneumonia