Second Degree BS Program in Nursing
Nursing Care Plan Format
Student NameDate PRIORITY # ________
|Nursing Diagnosis |Nursing Interventions |Scientific Rationale |Evaluation | | | | | | | |Assess BP, pulse, temperature, and respirations q4h, noting and |1.Frequent assessment of these help provide data of development of a | | |Impaired physical mobility r/t |reporting variations from the patient’s norm. Also pain, LOC, |possible complication. | | |surgical procedure m/b limited |neurovascular status, breath sounds, bowel sounds and fluid balance. | |Outcome met; patient walked from her | |ROM, decreased muscle |Assess/inspect pt. skin to observe for reddened areas and keep linens | |bed to the hall and back with proper | |strength/control, pain, and |dry and wrinkle free. | |use of her walker and a steady upright| |unsteady gait. |Assess patient’s surgical incision to observe for redness, swelling and |2. Prevents skin irritation or breakdown |gait. | | |purulent drainage....