NURSING CARE PLAN
NAME OF THE PATIENT:
DIAGNOSIS:
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: “She was Activity Intolerance, the Short term: Independent: Independent: Fully Met.
unable to stand on her own patient may be susceptible
feet.” As stated by the to experiencing insufficient Achieve 100beat-min. Assist with activities To maintain or After 8 hours of nursing
patient’s son. physiological or Identify factors, such and provide/monitor improve the patient’s intervention, the client was
psychological energy to as client resistive to client’s use of functioning and able to regain or maintain
Objective: endure or complete efforts, painful assistive devices independence, maximum mobility. As
required or desired conditions, and need (e.g., crutches, thereby promoting asserted, pain is
Shortened right limb, activities, which may for mobility walker, or wheelchair) their well-being. reduced/controlled to a
rotated internally compromise health. assistance that could to protect client from Patients must find tolerable level. Methods of
Lesions on right block/ affect the injury. comfort that when pain relief and relaxation
upper limb & face desired level of Provide positive they visit a hospital, are discussed and
Discoloration with activity. atmosphere while they are receiving the demonstrated.
slashing four Note client reports of acknowledging the best possible care
centimeters down, weakness, fatigue, difficulty of the without risking their
right the lower arm. pain, difficulty situation for the client. health or, worse yet,
Tachycardia accomplishing tasks, Promote comfort losing their lives.
and/or insomnia. measures and To lessen pain's
provide for relief of impact on patient
Long term: pain to enhance function and quality of
ability to participate in life.
Ascertain the client’s activities.
ability to stand and Dependent:
move about and the Dependent:
degree of assistance To help diagnose
necessary or use of Note client reports of the patient more
equipment to deter- weakness, fatigue, efficiently.
mine current status pain, difficulty
and needs associated accomplishing tasks, Collaborative
with participation in and/or insomnia.
needed/desired Fentanyl's rapid
activities. Collaborative: onset of action can
Encourage match the rapid
expression of feelings The ambulance crew onset of action for
contributing to or administered most types of acute
resulting from the Fentanyl 100 mcg pain.
NURSING CARE PLAN
NAME OF THE PATIENT:
DIAGNOSIS:
condition. intranasally. Rehabilitation is
Plan for progressive Provide referral to care that can help
increase of activity other disciplines, you regain,
level/participation in such as exercise maintain, or
exercise training, as physiologist, improve abilities
tolerated by client. psychological needed for daily
counseling/therapy, living. These
occupational/physical abilities could be
therapists, and physical, mental, or
recreation/leisure cognitive.
specialists