NURSING CARE PLAN
Sample Form
STUDENT_________________________________
DATE__________________________
PATIENT'S INITIALS_________AGE_________SEX_________
PRIMARY (ADMITTING) MEDICAL DIAGNOSIS______________________________________________________
SECONDARY MEDICAL DIAGNOSIS________________________________________________________________
CONCEPT_Mobility_______________________________________________________
Nursing Diagnosis
Use NANDA terminology only
Impaired physical mobility
Select Type:
Actual
Potential
Related to:
Weakness
Pain
Anxiety
Evidenced by:
Gait changes
Limited ability to perform gross motor skills
Reluctance to initiate movement
Expected Outcome (Goals)
Need to be:
•
specific
•
measurable
•
achievable
•
realistic
•
relevant to diagnosis
•
have a specific time frame
Expected Outcome
Measurement/Time Frame
Short Term Expected Outcome: These are incremental
statements intended to measure intermediate progress toward
goals.
Short Term Expected Outcome is targeted to be reached by end of shift or within a couple
of days.
Patient will verbalize less fear of falling and
pain with physical activity.
Pain scale less than 4 as stated by patient upon ambulation.
Long Term Expected Outcome:
Post discharge target dates should only be considered if the patient
will be followed post discharge.
The long term expected outcomes are those that are targeted for achievement by
discharge.
Patient will meet mutually defined goals of
increased ambulation.
The patient will ambulate to the nursing station and back by
discharge.
Interventions
Interventions need to be specific and measurable. Specify who, when, how (method).
Interventions
Rationales
Assessment:
What will be assessed, by what method, how often?
Give specific text references for each intervention (name of text and page number).
Before activity, observing the patient for and, if
possible, treating pain
Pain limits mobility. (Ackley, 2017)