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James Madison University Department of Nursing

NSG 352L - Spring 2016

THE NURSING PROCESS (Your plan of care)


Student Name:
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. Lastly, you will
evaluate your plan in the last section of this document.
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.
NURSING
DIAGNOSES

EXPECTED PATIENT
OUTCOMES

ASSESSMENT
interventions:

(note priority for


each below)

Be sure they are S. M. (assess / monitor


A. R. T. (Specific,
for )
measureable,
(Be sure to use
achievable/ attainable,
related to and
relevant and timeas evidenced by)
bound)
Risk for injury
related to
confusion.

Client will
demonstrate
behaviors that
decrease the risk for
injury.

I will assess
patient for signs
of confusion, like
facial expressions
or vocal. I will also
monitor for
movements that
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ACTION
interventions:
(consider orders,
safety, allergies,
code status, fall
risk, etc.)

TEACHING
interventions:
(consider home
regimens,
procedures,
discharge plan,
etc.)

I will make sure


that room is tidy
and clear of
objects that could
potentially lead to
a fall.

I will teach pt how


to decrease the
potential of harm
with certain
movement, like
reaching in her
closet.

James Madison University Department of Nursing


NSG 352L - Spring 2016

THE NURSING PROCESS (Your plan of care)


could potentially
harm the pt.
Risk for chronic sorrow
related to loss of mental
function.

Client will express appropriate


feelings of guilt, fear, anger, or
sadness.

I will identify
problems of
eating and
sleeping; ensure
that basic human
needs are being
met.

I will allow the pt


time to express
their feelings in a
environment
without
judgement.

I will teach the


client effective
coping techniques,
like keeping busy
and taking one
day at a time.

Acute pain related


to physical injury
agent as
evidenced by sore
shoulder with
movement.

Client will use a self


report tool to identify
current pain intensity
level and establish a
comfort function goal.

I will assess for


facial expressions
that resemble
pain while pt is
moving.

I will ask the pt to


describe prior
experiences with
pain and
effectiveness of
pain
management.

I will teach non


pharmacological
interventions when
pain is relatively
well controlled with
pharmacologic
interventions.

Evaluation:
Even though it mentioned in the chart that the pt suffered from dementia, I was unable to see clear signs
of it while talking to her. She did seem confused at first when I woke her up and helped her into the
bathroom to use the toilet and brush her teeth. She couldnt seem to find the soap or paper towels to
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James Madison University Department of Nursing


NSG 352L - Spring 2016

THE NURSING PROCESS (Your plan of care)


wash her hands. Whether this is attributed to early morning wake up or confusion related to neurological
problems, I dont know. Due to her shoulder injury, she wasnt able to do a lot of reaching for things with
one of her harms. She used the other one to compensate. I still spoke with her about potential methods
she could use to prevent injury in the other shoulder and also that it is fine to ask for help if something
seems out of reach. She chose to ask for help when getting dressed, instead of pushing her shoulder
further.
Due to the patient being 92 years old and suffering from numerous illnesses and injuries, I had expected
the patient to be at a greater risk for chronic sorrow. We had some time before her therapy so we were
able to sit down and talk for a while. She didnt mention much about family but she does have a lot of
friends visit her often. While I was there, she had three people visit her. For her age, she was very put
together. She took time to brush her hair and put on Chapstick. While we were talking, she seemed
content with the fact that she is 92 years old. It was hard to get her to address feelings because she
seemed to only start talking when prompted. I was not able to discuss effective coping methods with her
because it never came up that she was struggling with any feelings.
She did have a lot of problems with her shoulder. It was painful for her and her ROM was very diminished.
She typically used her other arm to compensate. She was unable to put on shirt sleeves and had difficult
reaching the arm to the sink to wash it. She mainly just splashed soap and water on it while using the
other hand. Her chart had mentioned at she had hurt her shoulder while reaching I'm a closet but she told
me that the pt had hurt it while trying to strengthen her shoulder. I was hoping that I would be able to sit
in on a pt session so I would be able to work on those activities with her but the only pt session she had
simply involved her doing ADLs. She did mention that the pain medicine seemed to usually help her
manage it. She knew it wasnt going to be fully healed but she was hoping that her ROM would at least
improve so she could perform ADLs better.

References Used (list all used, but at least one) :


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James Madison University Department of Nursing


NSG 352L - Spring 2016

THE NURSING PROCESS (Your plan of care)


Ackley, B.J., & Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
(10th ed.). St. Louis MO: Mosby.
Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2014). Brunner & Suddarths textbook of medicalsurgical nursing (13th ed.). Philadelphia PA: Lippincott Williams & Wilkins.