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Care Plan 2

Brooke Gagnon

NUR420

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
Kardex.
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
edema
 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
present
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
References:

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