JMU School of Nursing

Fall 2017
Detailed Careplan

Directions: There are 5 steps to the nursing process: Assessment, diagnosis, planning, implementation and evaluation. You will
begin here the night before clinical by creating your plan based upon the information gleaned during pre-planning. THEN, you will
implement during clinical.
About interventions: Consider what you will need to do to care for the patient. Include activity, safety, mobility and teaching in this
plan. Also consider any physical care requirements needed such as bathing, dressing, feeding, repositioning, dressing changes,
ambulation, oral care, sensory aids and assistive devices. You need a minimum of 2 in each intervention box.

NURSING DIAGNOSES EXPECTED PATIENT ASSESSMENT ACTION interventions: TEACHING interventions:

OUTCOMES interventions: (consider orders, safety, (consider home
(note priority for each
allergies, code status, regimens, procedures,
below) Be sure they are S. M. A. R. T. (assess / monitor for )
fall risk, etc.) discharge plan, etc.)
(Specific, measureable,
(Be sure to use related
achievable/ attainable,
to and as evidenced
relevant and time-bound)
by)
Risk for falls r/t By (date) patient will Assess gait, balance, Use high-risk fall Encourage patient to
decrease in lower have the ability to and fatigue level with bracelet and fall risk wear glasses and use
extremity remain free of falls, ambulation room sign to alert staff walking aids
strength (first change environment for increased vigilance
priority) Evaluate patients Instruct patient and
to minimize incidence
Impaired walking medications to Orient patient to caregivers on how to
of falls, and explain
r/t limited determine if environment identify fall hazards
methods to prevent
physical mobility medications increase within the home
aeb need for injury. Maintain bed in low
fall risk
assistance with position Teach patient what to
ambulation and Assess for signs of do if he/she falls and
ADLs (second anemia cannot get up
priority)
 JMU School of Nursing
Fall 2017
Detailed Careplan
Assess mental health Ensure appropriate
and neurological lighting in the home
function
Encourage patient to
wear supportive, low-
heeled shoes with good
traction

References used written in APA format using your APA book (a required course textbook):
Ackley, Betty J., Gail B. Ladwig, and Mary Makic.

Nursing Diagnosis Handbook. 11th ed., 2017.