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Care Plan 2

Brooke Gagnon


Maria Isorena

March 26, 2019

Individualized Plan of Care- Nursing Process

Nursing Plan of Care

Assessment Clinical Problem Client Nursing Intervention With rationale Client
(subjective/objective) goals/desired Response
Prioritize clinical problem outcomes

Objective: Impaired walking due Pt does not Follow weight-bearing restrictions Pt does
to R tibia fracture fall during (Jensen, 2011) not fall.
Vital signs: surgery (nailing tibia, her stay in
irrigation, the Rationale: Provide time for patient to
t- 36.1 p- 80 r- 18
debridement) and Scarborough heal before trying to get them up
bp- 111/56 O2- 94 ra @0730 immobilized L leg Health
evidenced by R leg in Network
t- 36.3 p- 72 r- 18 a cast, L leg in a General Site
bp- 104/54 O2- 95ra @1345 Zimmer splint, and unit CP3.
NWB order in the Pt
R leg cast, dry+intact, toes-just Teach the Pt to call for help before trying
above knee, toes warm, pink, no to get up
 Education should be done in a
L leg Zimmer splint, heel-just variety of formats in the patient’s
above knee, foot warm, pink, no language of choice (RNAO, 2017)
edema, dorsalis pedis pulse
Rationale: If patient calls for help they
will not attempt to get up alone and will
Use of Hoyer lift to move Pt from not fall
bed to chair with PT
Subjective: Communicate falls risk with the
Pain: interdisciplinary team
10/10, upper R back, stabbing Rationale: “Lack of communication at
@0730 care transitions could increase a
0/10 @1345 person’s risk for falls and fall injury”
(RNAO, 2017)
Pt stated no numbness or tingling

Jensen, S. (2011). Nursing health assessment: A best practice approach. Philadelphia: Wolters Kluwer.

Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Barry, M., Lok, J., Tyerman, J., & Goldsworthy, S. (2019). Medical-surgical nursing
in Canada: Assessment and management of clinical problems (4th ed.). Toronto: Mosby Elsevier
ISBN 9781771720489

Registered Nurses’ Association of Ontario. (2017). Preventing Falls and Reducing Injury from Falls (4th ed.). Toronto, ON: Author