Care plan Activity

NURSING CARE PLAN- Utilize your assessment data and the NURSING PROCESS to create an
individualized Care Plan for your patient, be specific to their needs.

Nursing Diagnoses Expected Outcomes (S.M.A.R.T.) Nursing Interventions

Use your Assessment Specific, measurable, attainable, realistic,
data to I.D. clinical & time-oriented (I.D. a future time or date 9 interventions for each nursing
problems for reassessment/evaluation) diagnosis

 3 things to
monitor/reassess
 3 things to do/actions for
patient
 3 things to teach the
client

#1 Ineffective airway The patient will… The nurse will…

clearance Short-term goal: 1. Note the presence of dyspnea.
Ease her breathing process by maintaining 2. Evaluate the degree of dyspnea.
- The patient has a the recommended position (1-2 weeks). 3. Assess the respiratory rate.
history of 4. Monitor the respiratory rate.
smoking. Long-term goal: 5. Help the patient to maintain a
- She is oxygen- Learn and perform regular deep breathing comfortable breathing position to
dependent. exercises to alleviate their condition (4-6 enable breathing.
- Has C.O.P.D. weeks). 6. Elevate the bed’s headrest to
facilitate easier breathing.
7. Help with abdominal breathing
exercises.
8. Assist with pursed-lip breathing
exercises.
9. Encourage the patient to
practice the suggested breathing
exercises.
#2 Risk for injury or The patient will… The nurse will…
trauma Short-term goal: 1. Identify visual perceptual deficit
- Had two falls over Stay indoors and notify the nurse of her to reduce the risk for falls.
the last one month movements (1 week). 2. Identify risks and potential
without injury. hazards to reduce the risk for
- The patient Long-term goal: injuries.
showed signs of Develop a routine to ensure they remain 3. Forbid access to stairs and other
occasional safe and show any behavioral changes (3-5 places that may increase the risk of
 forgetfulness. weeks). fall.
4. Lock outside doors as needed to
protect the patient from injuries.
5. Provide constant supervision.
6. Monitor the patient’s behavior
regularly to note any behavioral
changes.
7. Observe the patient note any
instances of increased confusion.
8. Implement stringent measures
where necessary to safeguard the
patient.
9. Advise the patient about safety
and what to avoid to enhance their
safety.
#3 Confusion The patient will… The nurse will…
- Sitting by the front Short-term goal: 1. Approach Alice calmly and
door 3-4 days a Stop sitting by the door and claiming that slowly.
week, stating that the son is coming to pick her up (2 weeks) 2. Maintain a quiet and pleasant
the son is coming environment in the facility.
to pick her yet the Long-term goal: 3. Address Alice by her name in
son only comes for Stop forgetting occasionally and relate well conversations.
scheduled visits. with the routine visits her son makes (4-6 4. Face the client in all exchanges.
- Occasional weeks). 5. Speak slowly to the client.
forgetfulness. 6. Apply the lower voice register
when talking to the patient.
7. Engage in regular
communication with Alice to
address her concerns.
8. Express interest and arouse
attention when talking to the
client.
9. Avoid hurrying the client to
alleviate the confusion.