Napa Valley College
Associate Degree Program in Nursing
Nursing Care Plan
Student’s Name: ________________________________________Date: _______________________ Client’s initials: ____________
Prioritize your nursing diagnoses based on Maslow’s Hierarchy of Needs and give your rationale.
1. _____________________________________________________________________________________________________________________
2. _____________________________________________________________________________________________________________________
3. _____________________________________________________________________________________________________________________
Nursing Diagnosis
Relate to: (causes)
Evidenced by: (S & S)
Constipation r/t
immobility; secondary
to Parkinson’s disease
AEB infrequent,
uncomfortable passage
of hard dry stool.
Expected Outcomes
(Goals)
Implementation
(Singular, measurable and
realistic, dated)
(Nursing interventions, actions,
teaching, medical
treatments)
Staff will assist client
with passive ROM
exercises, by the end of
the shift.
Assess usual pattern of
defecation and establish the
extent of the constipation
problem.
Patient will attempt to
use assistive devices
for self care at least 2x
this shift
Passive ROM exercises
2x/day. Including, knee to
chest movements, and
waist twists, as tolerated by
patient.
Evaluation
(Actual Outcomes)
(Did nursing interventions
lead to expected outcomes?)
Rationale
(Evidence based resources include source and page
numbers)
A detailed and accurate
assessment of the client
enables the nurse to plan
interventions, monitor
outcomes, and evaluate
care, ensuring no
unnecessary treatment is
rendered (Noiesen et al,
2013).
Physical activity can help
stimulate peristaltic waves in
the colon and encourage the
transit of feces to the rectum
(Rogers, 2013)
Napa Valley College
Associate Degree Program in Nursing
Nursing Care Plan
Nursing Diagnosis
Relate to: (causes)
Evidenced by: (S & S)
Self-Care Deficit related
to musculoskeletal
impairment and physical
limitations secondary to
contractures AEB
decreased ability to
bathe, get dressed, and
inability to ambulate
without assistance.
Expected Outcomes
(Goals)
(Singular, measurable and
realistic, dated)
Implementation
(Nursing interventions,
actions, teaching, medical
treatments)
Patient will attempt to
assist in his ADL’s 1x
this shift, using adaptive
techniques.
Patient will assist by
using using the hand
over hand technique with
staff to assist with
brushing teeth.
The patient will perform
three active ROM
exercises in prevention
of contracture
progression. Patient will
do this 2x this shift.
Three active ROM
exercises will be
performed as tolerated
by patient. Patient will
work arms, legs and
hands by performing flex
ion, and extension at
least 2x on each body
part. This will be done
as tolerated by patient,
Evaluation (Actual
Outcomes)
(Did nursing interventions lead
to expected outcomes?)
Rationale
(Evidence based resourcesinclude source and page
numbers)
Facilitate self-efficacy by
ensuring the adequacy of
self-care adaptations.
Confidence is an
important element in
successful self-care
activities. Grafton and
Bassett (2017)
Physical rehabilitation
interventions were found
to be safe, reduced
disability, and resulted in
few adverse events
(Crocker et al, 2013).