JMU School of Nursing

Spring 2017
Detailed Careplan

NURSING EXPECTED PATIENT ASSESSMENT ACTION TEACHING

DIAGNOSES OUTCOMES interventions: interventions: interventions:
(consider orders, (consider home
(note priority for Be sure they are S. M. (assess / monitor
safety, allergies, regimens,
each below) A. R. T. (Specific, for )
code status, fall procedures,
measureable,
(Be sure to use risk, etc.) discharge plan,
achievable/ attainable,
related to and etc.)
relevant and time-
as evidenced by)
bound)
Instability r/t high The patient will walk 1. Assess mobility 1. To use non-slip 1. Teach the
fall risk AEB inability independently with of body. socks for patient patient about the
to walk steadily. the assistance of a to help promote importance of
2. Monitor
(Ackley, 2014) walker not relying on stability. wearing non-slip
assessments of
assistance from a shoes or socks at
strength and grip. 2. Use a walker to
person. home.
help promote
(Ackley, 2014)
(Ackley, 2014) balance. 2. Give the
patients
(Ackley, 2014)
suggestions on
how to be safe
when walking on
uneasy ground.
(Ackley, 2014)
Weakness r/t Increased range of 1. Monitor 1. Encouragement 1. Teach the
instability of right motion in right arm by patients ADLs. during therapy. patient the
arm AEB inability to actively participating importance of
use full ROM in right 2. Monitor therapy 2. Continually
in therapy. keeping his arm in
arm while activity. remind patient to
the sling when he
performing ADLs. try and keep the
 JMU School of Nursing
Spring 2017
Detailed Careplan
(Ackley, 2014) (Ackley, 2014) (Ackley, 2014) arm in the sling is not using it.
when he is not
2. Give patient
trying to promote
suggestions on
movement.
strengthening
(Ackley, 2014) activities outside
of therapy.
(Ackley, 2014)

References used written in APA format using your APA book (a required course textbook):
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: an evidence-based guide to planning care. Maryland Heights,
MO: Elsevier.