Nursing Care Plan Template

Initials:_VAge: 91 years old Date of Birth: 1/3/1926 Significant Medical Diagnoses:

Osteoporosis, Emphysema, Benign hypertension, Anaemia, Speech Articulation Disorder, Rectal
Prolapse, Hypokalemia, Chronic Obstructive Pulmonary disease, Intestinal obstruction, MRSA.

Safety Considerations:Braden scale  21

Morse fall scale  65 Blood Pressure 100/60
Pulse  61 bpm Respirations 15 breaths/min

Activity level and restrictions: No allergies, no restraints, no use of bedrails, high fall risk, sit to
stand assistance, use of walker for assistance.

Advanced Directive: Transfer to acute care hospital without CPR.Signed do not resuscitate
(DNR).

Activities of Daily Living:1 person care with minimal assistance.

Assessment of issue (NANDA Nursing Diagnosis):

Risk for impaired physical mobility as evidenced by activity intolerance, alteration in cognitive
functioning, decrease in muscle strength, insufficient environment support and disuse

Assessment Data Planning or Client Nursing Rationale for Evaluation or

 Outcomes Interventions or Interventions result of the
Plan intervention
Issue of Short term by the Encourage the Helps to increase
exploration: end of shift: patient to preform individual muscle Get up and go test
SMART upper body care movement and
Mobility themselves. strengthen muscle Objective data
Encourage the tone that is not her engagement in
patient to preform Complete 2-3 normally used. exercise and care
care for activities of daily during day.
Subjective data: themselves during living with the
HS or morning patient before Try helping her
Patient is part of care leaving room. walk to test her
the falling star gait/ posture
Program Allow resident without the walker
adequate time to
Patient demands do care or action Allows patient to Look at fall
assistance while in themselves. increase self history and
sit position to confidence in their prevention these
stand and get to Longer term: Encourage to own abilities, goals have
the bathroom Encourage patient attend daily while ensuring achieved.
to increase their exercise class, take safe practice is
transfer walks around unit, maintained and
ability/mobility, etc. patient is not at
Objective data: with limited risk.
assistance and Let patient get out
Unsteady gait some use of of bed herself,
walker. with limited
Difficulty siting to assistance and
standing close supervision.

References

Nursing diagnoses: Definitions and classification, 2015-2017. (2015). Choice Reviews Online,

52(07). doi:10.5860/choice.188207

Comments:

Great Care Plan Steph! Physiotherapy is also a great resource to help strengthen our clients;

Nursing interventions could include but not limited to the following: monitoring for pain as it

can be a hindrance on mobility, encourage repositioning every so many hours, engaging the use
of all extremities while assisting, monitoring vital signs before and after activity, ensuring

adequate nutrition etc