Nursing Care Plan
Assessment equals Data Collection + Analysis
| Nursing Diagnosis – Actual/Potential
| Nursing Goal(SMART)
| Nursing Interventions/ActionsInclude Rationale/Reference
| Female Age : 85Code status: Full Code initially but changed to DNR on 14/Jan-2012Primary diagnosis: PancytopeniaReason for Hospital Admission: Fall at home. Allergy: PenicillinMedical History: Pacemaker, Hypertension, Fall at home, Bradycardia, Hyperlipidemia.Neurological: Alert, Oriented x 4.Diet as ToleratedActivity as tolerated.Does not want to do physiotherapy.Would prefer to remain in bed.Will only move her arms and legs and adjust as needed.
| Activity Intolerance related to weakness, bed rest and immobility as evidenced by client verbalizing lack of interest/desire in activity.Risk for falls related to generalised weakness and impaired mobility as evidenced by client having a history of fall in the past.Hopelessness related to failing or deteriorating physical condition as evidenced by client stating “Why god is not calling me to him”.
| 1. Client will participate in daily activity with vital signs within limit in a week’s time.2. Client will perform ADLs with some assistance, e.g., toilets with help ambulating to bathroom, by discharge.1. Client will not experience a fall by identifying risks that increase susceptibility to falls by the end of the day. 2. Client and caregiver will apply tactics and ways to increase safety and provide a safe home environment.1. Client will initiate behaviours that may reduce feeling of hopelessness by the end of week. 2. Client will be hopeful verbalizing optimistic plans after she is discharged and reaches home.
| 1. Record client’s vitals before and after any activity.
Rationale: Variation can be caused by temporary insufficiency of blood supply (Ackley & Ladwig, 2008, p 119). 2. Administer pain medications prior to activity.
Rationale: Pain restricts client from performing maximum activity and may worsen the...
References: (Day,R.A., Paul, P.,Willaims, B., Smeltzer, S.C., Bare, B.(2010). Textbook of Canadian Medical-Surgical Nursing (pp. 982-983). Williams & Wilkins.
White, L. (2005). Foundations of nursing. Australia United States Clifton Park, NY: Delmar Learning.
Carpenito-Moyet, L. J. (2008). Nursing care plans & documentation, nursing diagnoses and collaborative problems. (5 ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.
Kozier, B., Erb, G., Berman, A., Synder, S., Bouchal, S. R., & Hirst, S. (2010). Fundamentals of canadian nursing, concepts, process and practice. (2 ed.). Toronto: Pearson Canada.
Gulanick, M., & Myers, J. L. (2010). Nursing care plans, diagnoses, interventions, and outcomes. (7 ed.). PA: Mosby.
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