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 fall r/t Pt will be able to Assess for Carefully assist Teach patient
impaired balance, identify 3 factors that drowsiness the patient in and ideas to keep
gait, and lethargy lead to fall by the end caused by out of bed, as well home safe from
of the 7-3 shift on Parkinson meds as wheelchair falls
2/22/17
Place and Teach patient deep
maintain bed in breathing methods
Monitor patients
low, locked to increase SpO2
SpO2 levels for
position with
hypoxemia
upper side rails
raised
Impaired verbal Pt will be able to Monitor for Encourage patient Teach patient non-
 JMU School of Nursing
Spring 2017
Detailed Careplan
communication r/t answer 4 questions increased loss of to speak loudly verbal cues when
Parkinsons loud and clear by the facial muscle until they can be they can not
disease and end of the 7-3 shift on movements heard speak, such as
impaired facial 2/22/17 forms of sign
Assess patients Ask patient to
muscles AEB language
slurring of words perform multiple
decreased speech
facial exercises to Teach patient
volume,
keep muscles calming
decreased speech
from stiffening techniques when
clarity, and
even more they get stressed
slowness of
from being unable
responses
to communicate

References used written in APA format using your APA book (a required course textbook):

Ackley, B.J., Ladwig, G.B., & Makic, M. (2017). Nursingdiagnosishandbook:Anevidencebasedguidetoplanningcare(11th

ed.). St. Louis, MO: Mosby-Elsevier.