Nursing Care Plan Template for Clinical Applications

Student Name: ID#: Date: Week: Client Initials: Clinical Professor:

Assessment equals Data Nursing Problem Goals Nursing Outcome/Evaluation

Collection + Analysis
Subjective
• Patient states” I feel
heavy and tight on both
my legs especially my
ankles and it is also
painful when you touch
it. I think it has to do
with my swollen legs.”
• Patient is experiencing
pain on both ankles and
dorsal region of the foot,
he rated 6 on a pain scale
of 0-10.
Objective
• Age: 87
• Male
• Undergoing treatment
for compression fracture
of Lumbar 3 vertebra,
high cholesterol and
Statements/Concerns – Use RUMBA or Interventions/Actions with Data Analysis
Actual/Potential SMART Rationale
Priority
• Acute pain related to • By the end of the • Proper repositioning, • Elevation increases venous
bilateral pitting edema shift patient will such as elevating the return to the heart and, in
+1 of the dorsal foot, have reduced legs with mild edema, turn, decreases edema.
lower extremity pain in the lower focused on removing or Edematous skin is more
weakness as evidenced extremities rated decreasing swelling. To susceptible to injury. Thus,
by patient stating” I 3 on a scale of relieve pain in both repositioning the patient
feel heavy and tight on 0 – 10. ankles and the dorsal will help to improve
both my legs region of the foot, the comfort, functional ability,
especially my ankles • The patient will patient will be and safety. (Potter, Perry,
and it is also painful have limited repositioned and a Stockert &Hall, 2019,
when you touch it. I ambulation on supportive pillow will be p.424)
think it has to do with the lower placed under the ankle
my swollen legs.”, and extremities by the area of both feet for
rating pain 6 on a pain end of the shift. comfort.
scale of 0-10.
• Acetaminophen • This will enhance patient’s
(TYLENOL) two tabs, pain management, enhance
650 mg PRN, will be patient perception of pain,
administered to the and lessen patient anxiety
patient as ordered to related to being immobile

References:
Elsevier. (n.d.). Lewis's medical-surgical nursing in Canada. Lewis's Medical-Surgical Nursing in Canada - 5th Edition. Retrieved July 9,
2022, from https://www.elsevier.com/books/lewiss-medical-surgical-nursing-in-canada/osaben/978-0-323-79156-4

Potter, P. A., Perry, A.G., Stockert, P.A., & Hall, A.M. (Eds.). (2019). Canadian fundamentals of nursing (6th Cdn. ed.) (B. J. Astle & W.
Duggleby, Cdn. Adapt.). Toronto, ON: Elsevier Canada.

S121-George Brown College - Practical Nursing Program 2018/2019

 Assessment equals Data
Collection + Analysis
hypertension.
• Patient has history of
myocardial infraction,
hyponatremia, lower
extremities weakness
and constant falls.
• Fluid intake 868 ml
(Daily fluid restrict of
1200ml).
• Output 1100 ml
• Diet - consumes 75% of
meal on average.
• VS Temp 37.2c, HR 81,
RR 18, BP 143/60, SpO
93%, Pulse 61 (0720 h).
• Alert and oriented to
person, place, time and
situation (0740 h).
Nursing Problem Goals Nursing Outcome/Evaluation
Statements/Concerns – Use RUMBA or Interventions/Actions with Data Analysis
Actual/Potential SMART Rationale
treat pain. from pain. (Potter, Perry,
Stockert &Hall, 2019, p.
Secondary 426).
• Risk of skin integrity • The patient will • Assist the patient with • The patient will be able to
related to immobility be free from skin minimal lower ankle perform range of motion
as evidenced by breakdown. muscle exercises as activities within the limits
redness, itching, tolerated to prevent of his toleration (Pottery,
swelling and distended • Patient localized swelling, Perry, Stockert & Hall,
epithelial tissue on the demonstrates redness, skin 2019, p.424).
dorsal foot. measure to breakdown, and muscle
increase mobility weakness exacerbated
by prolonged immobility
(Lewis's Medical-
Surgical Nursing in
Canada - 5th
Edition,2019, p.774).

Medications and/ or lab

results (if applicable)
• predniSONE tab 10mg
Daily
• calcium carbonate tab
1,250mg

References:
Elsevier. (n.d.). Lewis's medical-surgical nursing in Canada. Lewis's Medical-Surgical Nursing in Canada - 5th Edition. Retrieved July 9,
2022, from https://www.elsevier.com/books/lewiss-medical-surgical-nursing-in-canada/osaben/978-0-323-79156-4

Potter, P. A., Perry, A.G., Stockert, P.A., & Hall, A.M. (Eds.). (2019). Canadian fundamentals of nursing (6th Cdn. ed.) (B. J. Astle & W.
Duggleby, Cdn. Adapt.). Toronto, ON: Elsevier Canada.

S121-George Brown College - Practical Nursing Program 2018/2019

 Assessment equals Data Nursing Problem Goals Nursing Outcome/Evaluation
Collection + Analysis Statements/Concerns – Use RUMBA or Interventions/Actions with Data Analysis
Actual/Potential SMART Rationale
• acetaminophen
(TYLENOL) tab 650mg
QID
• acetylsalicylic acid
(ASA) tab 80mg Daily
• brinzolamide (AZOPT)
1%bophthalmic
suspension 1 drop BID
• brimonidine
(ALPHAGAN) 0.2%
ophthalmic suspension
solution 1 drop BID
• furosemide (LASIX) tab
20mg Daily
• Multivitamins tab 1
Daily
• saccharomyces boulardii
(FLORASTOR)
CAPSULE 500MG bid
• silodosin (RAPAFLO)
capsule 4mg TID
• amLODIPine
(NORVASC) tab 5mg
BID
• potassium chloride oral

References:
Elsevier. (n.d.). Lewis's medical-surgical nursing in Canada. Lewis's Medical-Surgical Nursing in Canada - 5th Edition. Retrieved July 9,
2022, from https://www.elsevier.com/books/lewiss-medical-surgical-nursing-in-canada/osaben/978-0-323-79156-4

Potter, P. A., Perry, A.G., Stockert, P.A., & Hall, A.M. (Eds.). (2019). Canadian fundamentals of nursing (6th Cdn. ed.) (B. J. Astle & W.
Duggleby, Cdn. Adapt.). Toronto, ON: Elsevier Canada.

S121-George Brown College - Practical Nursing Program 2018/2019

 Assessment equals Data Nursing Problem Goals Nursing Outcome/Evaluation
Collection + Analysis Statements/Concerns – Use RUMBA or Interventions/Actions with Data Analysis
Actual/Potential SMART Rationale
solution 40mmol BID
• sodium chloride 4g TID
• hypromellose (ISOPTO
TEARS) 0.5%
ophthalmic solution 1
drop TID
• Vitamin D3(VITAMIN
D-3) tab 2000units Daily
• hydrALAZINE
(APRESOLINE) tab
50mg
• levothyroxine
(SYNTHROID) tab 0.2
Daily
• loperamide (IMODIUM)
tab 1mg Daily

References:
Elsevier. (n.d.). Lewis's medical-surgical nursing in Canada. Lewis's Medical-Surgical Nursing in Canada - 5th Edition. Retrieved July 9,
2022, from https://www.elsevier.com/books/lewiss-medical-surgical-nursing-in-canada/osaben/978-0-323-79156-4

Potter, P. A., Perry, A.G., Stockert, P.A., & Hall, A.M. (Eds.). (2019). Canadian fundamentals of nursing (6th Cdn. ed.) (B. J. Astle & W.
Duggleby, Cdn. Adapt.). Toronto, ON: Elsevier Canada.

S121-George Brown College - Practical Nursing Program 2018/2019