Download Indiana University School of Nursing Baccalaureate of Science in

Indiana University School of Nursing Baccalaureate of Science in Nursing Program
Nursing Care Plan - Example
Care Plan
Care Planning, Implementation, and Evaluation
From the Comprehensive Nursing Diagnosis list, select one Nursing Diagnosis: Actual or
problem statement, related to etiological factors or Risk for problem, related to presence of risk
factors (list)
NURSING DIAGNOSIS
1. Acute pain related to surgical procedure AEB by pain level 8-10/10, grimacing and guarding.
2. Impaired physical mobility related to surgical procedure on left knee AED pain in ambulation
and swelling.
3. Risk of infection related to inflammation of wound surgery
State a measurable patient outcome that is achievable within a clinical time frame:
1. Patient will report a decreased in pain (0-1/10 and shows no grimacing or guarding at the
end of hospitalization.
2. Patient will demonstrate use of adaptive equipment (walker) to increase mobility at the end
of hospitalization.
3. Patient will state the symptoms of which to be aware at the end of hospitalization
NURSING
RATIONALE :
IMPLEMENTATION:
Describe effectiveness
INTERVENTIONS State rationale for individual intervention
Select appropriate
Include source Ex (Ackley and
of interventions done in
assessment, therapeutic Ladwig,2008)
clinical
and patient education
interventions to
achieve patient
outcome:
Assess client’s pain
and vital signs every 4
hour.
Administer scheduled
pain management
medications and PRN
medications as needed
to reduce pain.
“Pain assessment is as important as
physiological vital signs and pain is
considered as the fifth vital sign. Routine
monitoring of the effects of the pain
management regime results in improved pain
management and decreased risk of adverse
effects” (Ackley & Ladwig, 2008, p. 611)
Consult with the
physical therapist to
begin an exercise
program post surgery
“Exercise has been shown to be beneficial in
arthirits” (Ackley & Ladwig, 2008, p. 551)
Assess client’s pain
before physical
exercise.
“Pain limits mobility and is often
exacerbated by movement” (Ackley &
Ladwig, 2008, p. 550).
Obtain any assistive
devices needed for the
activity..
Educate patient about sign
and symptoms of infection,
such as: fever (101 F),
redness, warmth, and
discharge on surgical
wound and the need to call
her health care provider
“Assistive devices can help increase
mobility” (Ackley & Ladwig, 2008, p. 550).
“Fever is often the first sign of an infection
(Ackley & Ladwig, 2008, p. 492).
“Clinical manifestations of infection include
redness, swelling, pain, fever, and increased
white blood cell count” (Ackley & Ladwig,
2008, p. 379).
Assess client’s pain and
vital signs every 4
hours: intensity,
location, & duration and
signs & symptoms.
Inform the patient that
she can resume her pain
medication at home,
especially before and
after activity.
Consult with the
physical therapist to
begin an exercise
program that includes
aerobic exercise,
resistance exercise and
gentle stretching.
Assess pain level and
administer pain medications
as prescribed before and after
activity.
Obtain any assistive
devices needed for the
activity, such as gait belt
and walker before
activity and consult with
the physical therapist
about assistive device
teaching.
Discharge teaching will
include the the signs and
symptoms of infection, which
including: fever (101 F),
redness, warmth, and
discharge on surgical wound
and the need to call her health
care provider.
EVALUATION OF PATIENT OUTCOME:
(outcome met, not met, partially met) Problem resolution?
Outcome Met: Goals was met
- Patient reported decreased pain level (3/10) and verbalized understanding to resume her pain
medication at home.
-Patient verbalized understanding about the sign and symptoms of infection and the need to
contact her health care provider if infection occurs
- Patient verbalized understanding about the benefits of exercise post knee surgery.
-Patient was able to do return demonstration of exercise and how to use the walker.
Reference: Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook (8 th ed). St.Louis: C.V. Mosby.