NURSING CARE PLAN FORM
ASSESSMENT*
ANALYSIS*
(DATA BASE sorted &
(NURSING
DIAGNOSIS/ES)
grouped for EACH
nursing diagnosis)
Objective
Temp: 98.4 F
Heart Rate: 98
Respirations: 16
BP: 99/67
SpO2: 96%
Hgb: 6.9 g/dL
Subjective
Complaints of fatigue
with physical therapy.
Does not tolerate
changes in position
without dizziness.
Impaired Physical
Mobility related to
fatigue and
dizziness due to a
reduced
hemoglobin level
and hematocrit.
PLAN
IMPLEMENTATION RATIONALE FOR
EACH NURSING
(CLIENT GOAL/ (NURSING ACTIONS,
ACTION
OUTCOME for
including teaching)
EACH nursing
diagnosis)
Client will be
able to complete
physical therapy
sessions without
injury.
1) Administer
packed red
blood cells as
ordered by the
physician.
2)
EVALUATION OF
CLIENT GOALS