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JMU School of Nursing

Spring 2017
Detailed 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. M. (assess / monitor
safety, allergies, regimens,
each below) A. R. T. (Specific, for )
code status, fall procedures,
measureable,
(Be sure to use risk, etc.) discharge plan,
achievable/ attainable,
related to and etc.)
relevant and time-
as evidenced by)
bound)
Risk for skin Patient will learn how Nurse will asses Nurse will Nurse will teach
breakdown related to be able to assess for pitting edema frequently ask patient how to
to reported breakdown of skin and in bilateral lower patient if they are assess skin
neuropathy redness in places extremities in pain and assess breakdown in
(weakness and
where there is (Ackley, 2014). the level of pain lower extremities
numbness in
numbness or loss of on a pain scale. where there is a
extremities Nurse will monitor
normally hands and sensation and know loss of sensation.
for skin Nurse will assist
toes) as evidence when to contact a
breakdown around patient with Nurse will teach
by pain and doctor or alert a nurse
brace incase the ambulation and patient what skin
restricted range of by the time of
patient cannot be a contact breakdown looks
motion in lower discharge and return
register the pain guard when like and how often
to assisted living.
JMU School of Nursing
Spring 2017
Detailed Careplan
extremities. on their own due ambulating with to asses it with the
to numbness or rolling walker. use of pictures.
loss of feeling.

Impaired range of Patient will be able to Nurse will assess Nurse will round Nurse will teach
motion related to confidently perform for improvements at least hourly patient to wait for
left femur fracture daily care (feeding, in daily activities and answer call assistance and
surgery as evidence brushing, toileting, and let patient bell promptly so remind her that
by hinge knee brace
etc.) before returning perform as much patient does not she needs
worn on left leg.
to assisted living. as she can on her decide to perform someone to watch
own. an activity without her while
assistance. ambulating to the
bathroom, and to
Nurse will monitor not go on her own.
(Currently this patient
for times the Nurse will make
is performing almost
patient may lean sure that patient
all care to ones self
too far or push has call bell in Nurse will show
with little assistance
their limits and reach at all times patient how to
once left leg is 100%
explain to them and will pin to properly use
weight bearing
why what she did gown as a assistive devices
activity of daily life will
made herself at a reminder to call to carry out daily
be easier to perform)
high risk for a fall. for assistance activities.
before trying to
move.

Risk for injury Patient will continue to Nurse will monitor Nurse will Nurse will teach
related to fall risk increase percentage patient for light- encourage patient patient to elevate
as evidence by 50% weight bearing in LLE headedness when to participate in LLE while sleeping
weight-bearing LLE each month with moving from a to help blood flow
JMU School of Nursing
Spring 2017
Detailed Careplan
one assist required therapy. laying down to all therapies. back to heart and
for ambulation and sitting up position. reduce
contact guard. pain/tenderness
Nurse will assess
Nurse will due to edema and
if patient is in pain
motivate swelling.
when ambulating
individual to do
or if the pressure Nurse will
their best during
from the hinge encourage patient
therapy and
brace is bothering to carry out daily
continue to try
her. activities
new things that
individually as part
the therapist
of therapy, such as
suggest.
pressing buttons or
turning on the
faucet.

References used written in APA format using your APA book (a required course textbook):
Ackley, B., Ladwig, G. (2014). Nursing Diagnosis Handbook: An evidence-based guide to
planning care (11th ed.). St. Louis, MO: Mosby.