James Madison University Department of Nursing

NSG 352L - Spring 2016

THE NURSING PROCESS (Your plan of care)

Student Name:

Claire Kirchmier

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)
Impaired physical
mobility r/t
musculoskeletal
impairment,
surgery, and
replacement as
evidenced by use

By the end of the shift,

the patient will be
able to walk to the
bathroom with the
walker and minimal
assistance.

Monitor the
patient due to
high fall risk,
monitor the
medications taken
in case they
compromise the
1

ACTION
interventions:
(consider orders,
safety, allergies,
code status, fall
risk, etc.)

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

Always be near
the patient and
helping the
patient get up and
walk due to high
fall risk, know
when the last

Use of the walker

whenever she feels
unstable upon
standing or
walking. Educating
her friend that has
stayed with her in

James Madison University Department of Nursing

NSG 352L - Spring 2016

THE NURSING PROCESS (Your plan of care)

of walker,
assistance from
RN, PT, or OT, and
difficulty walking
on or moving right
knee.

ability to walk
(narcotics), assess
pain level before
and after getting
up to use the
bathroom, assess
ability to move
while using the
walker.

dose of narcotics
was given
because the
patient could be
sedated and not
able to stand on
her own properly,
always use the
gait belt when
moving the
patient to prevent
the patient from
falling.

the hospital about

use of the walker
and how to assist
the patient when
needed to. Patient
education on how
to use the walker,
when to use the
walker, and when
to ask for
assistance from
whomever is with
her. Patient
education about
the importance of
increasing mobility
to heal the knee.

James Madison University Department of Nursing

NSG 352L - Spring 2016

THE NURSING PROCESS (Your plan of care)

Evaluation:
In this section, evaluate how your plan worked. Consider what interventions worked and also discuss any
that you needed to perform that were not in your plan of care.
The SMART goal that was created was implemented during the shift. In the early morning, the patient was
unable to move on her own because she was so severely stiff from the surgery and sleep the night before
this shift. One of the physical therapists showed up to help her up and out of bed to use the restroom. The
patient also had severe trouble squatting to sit herself on the toilet. After the initial movement in the
morning, the patient seemed more at ease. However, when it was time to get up and use to commode in
the afternoon, the patient did not want to use the walker. After the RN came in to assist with the patient,
she was able to get up and walk with the walker and only one person assisting her. Even though the
patient was reluctant to use the walker, she made it to the restroom and onto the commode with less
assistance than in the morning. Using the pain medication partially eased the patient in walking because
it relieved most of the pain in the morning, but in the afternoon, the patient complained of severe pain in
both legs that made her reluctant in walking with the walker. This nursing plan was partially met because
the patient was able to use the walker to walk to the restroom, but she needed more than minimal
assistance and was reluctant to get up and walk around. Since the patient was reluctant and complaining
of pain, the RN came in to give her more pain medications, but the patient still had reluctance towards
using the walker. Due to the patients reluctance to use her walker, there were not many other
interventions that could be applied to encourage use of the walker upon ambulation.

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

Ackley, B. J., Ladwig, G. B., Makic, MB. F. (2014). Guide to nursing diagnosis. In (11 th ed.) , Nursing
diagnosis handbook: An evidence-based guide to planning care (p 116). St. Louis, Missouri: Elsevier, Inc.