James Madison University Department of Nursing

NSG 352L - Spring 2016

THE NURSING PROCESS (Your plan of care)

NURSING
DIAGNOSES

EXPECTED PATIENT
OUTCOMES

ASSESSMENT
interventions:

(note priority for

each below)

Be sure they are S. M. (assess / monitor

A. R. T. (Specific,
for )
measureable,
(Be sure to use
achievable/ attainable,
related to and
relevant and timeas evidenced by)
bound)
Impaired mood
regulation r/t
anxiety as
evidenced by
irritability

Patient will have

posture, gestures and
activity levels that
reflect decreased
distress for the entire
day.

Assess patients
level of anxiety
and physical
reactions to
anxiety. Assess
patients mood.
Assess patients
comfort and close
door and windows
when dressing
patient or taking
vitals because
patient gets
paranoid that
people may be
able to see her.

ACTION
interventions:
(consider orders,
safety, allergies,
code status, fall
risk, etc.)

TEACHING
interventions:
(consider home
regimens,
procedures,
discharge plan,
etc.)

Provide patient
with activities to
enhance mood
such as painting
nails, balloon
volleyball and
watch TV. Request
and receive
patients
permission before
moving
unoccupied
wheelchair in
room or out to
hallway because
patient gets
aggravated easily
if you dont ask

Teach patient to
express feelings of
anxiety or
paranoia. Teach
relationship
between a healthy
physical and
emotional lifestyle
and realistic
mental attitude.

James Madison University Department of Nursing

NSG 352L - Spring 2016

THE NURSING PROCESS (Your plan of care)

before.
Risk for impaired skin
integrity r/t extremes of
age as evidence by
limited mobility.

Patient will report altered

sensation or pain at risk areas
as soon as noted for the entire
day.

Asses patient skin

condition every 4
hours for color
changes, texture
changes, redness,
localized heat or
edema. Asses
patients
continence status
and change brief
every 4 hours to
minimize skin
integrity.

Move patient
every 4 hours in
wheel chair and
during nap to
decrease risk of
skin impairment.
Place wedge or
pillow in wheel
chair to provide
comfort for
patient and
decrease risk of
skin integrity. Put
patients barrier
cream on
buttocks after
using the
bathroom to
prevent rash from
brief.

Teach the patient

skin assessment
and ways to
monitor for
impending skin
breakdown. Teach
patient to use
pillows, foam
wedges, chair
cushions and
pressure
redistribution
devices to prevent
pressure injury.

James Madison University Department of Nursing

NSG 352L - Spring 2016

THE NURSING PROCESS (Your plan of care)

Evaluation:
Patient remained free of any risk of skin integrity. Patient reported no signs of pain or areas at risk for pain
throughout the entire day. Patient showed satisfaction with pillow to decrease chance of skin integrity.
Patients skin remained clean and free of lesions or skin breakdown.

References Used (list all used, but at least one) :

Nursing Diagnostic Handbook:
Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook: An evidence-based guide
to planning care (11th ed.). St Louis, MO: Elsevier.