Planning

CARE PLANNING
Breathlessness/ Difficulty of Breathing

Unstable Asthma
Reduced mobility
Shortness of breathing
Chest Infection
Chest Pain
Pain (Headache)
Subdural Hematoma Risk for deterioration
Risk for falls
Pain
Pre-operative
Safe preparation to theatre
Pain
Post-operative Risk for infection
Risk for hemorrhage
Re-Evaluation Date
Shortness of Breath
Difficulty of Breathing
Pain (Chest Infection/ Pre-op/ Post-op/ SDH)
Hourly Reduced Mobility (Asthma/ SDH)
Risk for Deterioration (SDH)
Risk for Fall (SDH)
Risk for bleeding/ hemorrhage (Post-op)
4 hourly Risk for Infection (Post-op)
1
CARE PLAN
(UNSTABLE ASTHMA)
Patient Details
NAME: Ann Jones
AGE: 78 years old
DATE OF BIRTH: 01-01-1940
Complete each section. Please write clearly.

1. NURSING PROBLEM/ NEED/ Activity of Living:
Ann is experiencing breathlessness due to unstable asthma as evidenced by respiratory rate
of ___ breaths per minute
AIMS(S) OF CARE:
Ann will verbalize relief from breathlessness with respiratory rate of 12-20 breaths per minute
and will have a normal breathing pattern and depth
RE-EVALUATION DATE:
To be re-evaluated today, (Date Today), every hour and when her clinical condition changes
CARE BY NURSES(S) SELF-CARE

1. Ann verbalizes
1. Explain and discuss to Ann her aspects of care and gain
understanding of her care
consent for every intervention
plan
2. Monitor and record Ann’s observations especially the 2. Ann properly uses the
respiratory rate and oxygen saturation every ____ hour(s) call bell when needing
and escalate as per NEWS policy. assistance
3. Ann demonstrates deep
3. Assess Ann’s breathing pattern and monitor for signs of
breathing exercises and
respiratory distress such as cyanosis, labored breathing and
repositions self for
drowsiness
comfort
4. Teach Ann deep breathing exercises and repositioning 4. Ann actively participates
techniques for optimal lung expansion. on her care plan
5. Administer to Ann her prescribed oxygen and medications
and monitor for their effectiveness after 30 minutes
6. Refer Ann to respiratory specialist nurse as needed.
7. Instruct Ann the proper use of call bell and place it within
her reach.
8. Document all Ann’s care as planned.
Nurse Signature Date
2
CARE PLAN
(UNSTABLE ASTHMA)
Patient Details
NAME: Ann Jones
AGE: 78 years old

Ann is having reduced mobility due to breathlessness as a result of unstable asthma
AIMS(S) OF CARE:
Ann will mobilize with assistance, demonstrates use of assistive devices and performs
independently within the limits of her disease.
RE-EVALUATION DATE:

1. Ann verbalizes
1. Explain and discuss to Ann her aspects of care and gain
understanding of her
care plan
2. Monitor and record Ann’s observations especially the 2. Ann properly uses the
3. Ann performs her
3. Assist Ann with her activities of daily living while avoiding
activities of daily living
patient dependency.
with minimal assistance.
4. Teach Ann deep breathing exercises and repositioning 4. Ann actively participates
techniques for optimal lung expansion. on her care plan
5. Administer to Ann her prescribed oxygen and medications
6. Refer Ann to physiotherapist and occupational therapist as
needed.
7. Instruct Ann the proper use of call bell and place it within
her reach.
8. Document all Ann’s care as planned.
3
CARE PLAN
(CHEST INFECTION)
Patient Details
NAME: Daisy Green
AGE: 81 years old

Daisy is experiencing shortness of breathing due to chest infection as evidenced by
respiratory rate of ___ breaths per minute.
AIMS(S) OF CARE:
Daisy will verbalize relief from shortness of breathing with respiratory rate of 12-20 breaths
per minute and will have a normal breathing pattern and depth
RE-EVALUATION DATE:

1. Daisy verbalizes
1. Explain and discuss to Daisy her aspects of care and gain
care plan
2. Monitor and record Daisy’s observations especially the 2. Daisy properly uses the
3. Daisy demonstrates deep
3. Assess Daisy’s breathing pattern and monitor for signs of
breathing exercises and
respiratory distress such as cyanosis, labored breathing and
drowsiness
comfort
4. Daisy actively
4. Teach Daisy deep breathing exercises and repositioning
participates on her care
techniques for optimal lung expansion.
plan
5. Administer to Daisy her prescribed oxygen and medications
6. Refer Daisy to respiratory specialist nurse as needed.
7. Instruct Daisy the proper use of call bell and place it within
her reach.
8. Document all Daisy’s care as planned.
4
CARE PLAN
(CHEST INFECTION)
Patient Details
NAME: Daisy Green
AGE: 81 years old

Daisy is experiencing chest pain due to severe coughing with pain scale of __/10
AIMS(S) OF CARE:
Daisy will verbalize relief from chest pain with pain score of 0-3 out of 10
RE-EVALUATION DATE:
To be re-evaluated today, (Date Today), every hour, after 30 minutes of giving prescribed pain
medications and when her clinical condition changes
1. Daisy verbalizes
1. Explain and discuss to Daisy her aspects of care and gain
care plan
2. Daisy properly uses the
2. Monitor and record Daisy’s observations every ____ hour(s)
call bell when needing
and escalate as per NEWS policy.
assistance
3. Daisy demonstrates deep
3. Assess Daisy’s pain scale including location and breathing exercises and
characteristics using the Pain Assessment Tool. repositions self for
comfort
4. Daisy actively
4. Teach Daisy pain relief measures such as deep breathing
exercises and repositioning techniques for comfort.
plan
5. Administer to Daisy her prescribed pain medications and
monitor for their effectiveness after 30 minutes
6. Refer Daisy to pain management team as needed.
7. Instruct Daisy the proper use of call bell and place it within
her reach.
8. Document all Daisy’s care as planned.
5
CARE PLAN
(Subdural Hematoma)
Patient Details
NAME: Joe Smith
AGE: 75 years old

Joe is experiencing pain (headache) due to subdural hematoma with pain scale of __/10
AIMS(S) OF CARE:
Joe will verbalize relief from pain (headache) with pain scale of 0-3 out of 10
RE-EVALUATION DATE:
medications and when his clinical condition changes
1. Joe verbalizes
1. Explain and discuss to Joe his aspects of care and gain
understanding of his care
plan
2. Monitor and record Joe’s vital signs including neurological
observations
If GCS 15 - every 30 minutes for the first 2 hours, every
hour for the next 4 hours and every 2 hours thereafter until 2. Joe properly uses the call
stable and GCS maintains to 15/15 and escalate as per bell when needing
NEWS policy. Observe for signs of deterioration. assistance
If GCS 14 and below - every 30 minutes until stable and
GCS reaches to 15/15 and escalate as per NEWS policy.
Observe for signs of deterioration.
3. Joe demonstrates
relaxation techniques
3. Assess Joe’s pain scale including location and characteristics
such as deep breathing
using the Pain Assessment Tool.
exercises and repositions
self for comfort
4. Teach Joe relaxation techniques such as deep breathing 4. Joe actively participates
exercises and repositioning techniques for comfort. on his care plan
5. Administer to Joe his prescribed pain medications and
6. Refer Joe to the pain management team as needed.
7. Instruct Joe the proper use of call bell and place it within his
reach.
8. Document all Joe’s care as planned.
6
CARE PLAN
(Subdural Hematoma)
Patient Details
NAME: Joe Smith
AGE: 75 years old

Joe is at risk for falls due to history of falls/ left or right sided weakness and confusion
AIMS(S) OF CARE:
Joe will have no incidence of falls
RE-EVALUATION DATE:
To be re-evaluated today, (Date Today), every hour, and when his clinical condition changes

1. Joe verbalizes
understanding of his
care plan
observations
hour for the next 4 hours and every 2 hours thereafter until 2. Joe properly uses the
stable and GCS maintains to 15/15 and escalate as per call bell when needing
NEWS policy. Observe for signs of deterioration. assistance
Observe for signs of deterioration.
3. Joe verbalizes
3. Assess Joe’s falls risk and complete a Falls Risk Assessment understanding of being
Tool. reoriented to person,
time and place
4. Provide Joe a safe and clutter free environment and orient
4. Joe actively participates
him to person, time and place and leave a written reminder
on his care plan
on his bedside.
5. Administer to Joe his prescribed medications and monitor for
their effectiveness after 30 minutes
6. Refer Joe to the falls risk team as needed.
reach.
7
CARE PLAN
(Subdural Hematoma)
Patient Details
NAME: Joe Smith
AGE: 75 years old
Joe is at risk for deterioration due to impaired level of consciousness as evidenced by GCS
of __/15 secondary to subdural hematoma
AIMS(S) OF CARE:
Joe will have reduced risk of deterioration with GCS of >13/15
RE-EVALUATION DATE:
To be re-evaluated today, (Date Today), every hour, and when his clinical condition changes

1. Joe verbalizes
understanding of his
care plan
observations
2. Joe properly uses the
hour for the next 4 hours and every 2 hours thereafter until
stable and GCS maintains to 15/15 and escalate as per
assistance
NEWS policy.
3. Joe verbalizes
3. Assess Joe for signs of deterioration such as restlessness, understanding of being
irritability and lethargy and escalate as needed. reoriented to person,
time and place
4. Provide Joe a safe and clutter free environment and orient
4. Joe actively participates
him to person, time and place and leave a written reminder
on his care plan
on his bedside.
5. Administer to Joe his prescribed medications and monitor for
their effectiveness after 30 minutes
6. Refer Joe to the medical team for further management as
needed.
reach.
8
CARE PLAN
(Pre-OP)
Patient Details
NAME: Josefina Fernandez
AGE: 68 years old

Josefina is experiencing pain due to abdominal hernia with pain scale of __/10
AIMS(S) OF CARE:
Josefina will verbalize relief from chest pain with pain score of 0-3 out of 10
RE-EVALUATION DATE:
1. Josefina verbalizes
1. Explain and discuss to Josefina her aspects of care and gain
care plan
2. Josefina properly uses
2. Monitor and record Josefina’s observations every ____
the call bell when
hour(s) and escalate as per NEWS policy.
needing assistance
3. Josefina demonstrates
deep breathing
3. Assess Josefina’s pain scale including location and
exercises and
characteristics using the Pain Assessment Tool.
comfort
4. Josefina actively
4. Teach Josefina pain relief measures such as deep breathing
plan
5. Administer to Josefina her prescribed pain medications and
6. Refer Josefina to pain management team as needed.
7. Instruct Josefina the proper use of call bell and place it
within her reach.
8. Document all Josefina’s care as planned.
9
CARE PLAN
(Pre-OP)
Patient Details
AGE: 68 years old

Josefina is for abdominal hernia repair and requires safe preparation to theatre
AIMS(S) OF CARE:
Josefina will verbalize that she feels safely prepared for theatre
RE-EVALUATION DATE:

plan
2. Josefina properly uses the
2. Monitor and record Josefina’s observations every ____
hour(s) and escalate as per NEWS policy.
assistance
3. Ensure that Josefina has signed the consent as completed by understanding of the
the surgeon and her pre-operative checklist is completed importance of anti-
prior to theatre. embolic stockings post-
surgery
plan
5. Administer to Josefina her prescribed pre-operative
medications and monitor for their effectiveness after 30
minutes
6. Measure Josefina’s size for anti-embolic stockings and
explain its importance post-surgery.
7. Refer Josefina to surgical team as needed.
within her reach.
10
CARE PLAN
(Post-OP)
Patient Details
AGE: 68 years old

Josefina is experiencing pain due to incision site following abdominal hernia repair with pain
scale of __/10
AIMS(S) OF CARE:
Josefina will verbalize relief from chest pain with pain score of 0-3 out of 10
RE-EVALUATION DATE:
plan
2. Monitor and record Josefina’s observations every 15 minutes
for the first hour, every 30 minutes for the next hour and
every hour for the next 4 hours and escalate as per NEWS
assistance
policy.
3. Josefina demonstrates
3. Assess Josefina’s pain scale including location and deep breathing exercises
characteristics using the Pain Assessment Tool. and repositions self for
comfort
plan
5. Administer to Josefina her prescribed pain medications and
6. Refer Josefina to pain management team as needed.
within her reach.
11
CARE PLAN
(Post-OP)
Patient Details
AGE: 68 years old

Josefina is at risk of infection due to incision site following abdominal hernia repair
AIMS(S) OF CARE:
Josefina will have normal vital signs with clean, dry and intact operative site with no signs of
infection.
RE-EVALUATION DATE:
To be re-evaluated today, (Date Today), every four hours and when her clinical condition
changes
care plan
2. Josefina properly uses
the call bell when
needing assistance
policy.
3. Assess Josefina’s operative site for signs of infection such as understanding of the
pain, redness, swelling, pus formation and foul odor. importance of reporting
signs of infection
4. Change Josefina’s dressing as prescribed and as needed
observing aseptic non touch technique at all times.
plan
5. Administer to Josefina her prescribed antibacterial
medications and monitor for their effectiveness after 30
minutes
6. Refer Josefina to infection control nurse and tissue viability
nurse as needed.
within her reach.
12
CARE PLAN
(Post-OP)
Patient Details
AGE: 68 years old

Josefina is at risk of hemorrhage at incision site following abdominal hernia repair
AIMS(S) OF CARE:
Josefina will have normal vital signs with clean, dry and intact operative site with no signs of
bleeding.
RE-EVALUATION DATE:

plan
assistance
policy.
3. Assess Josefina’s operative site for any signs of bleeding and understanding of the
apply pressure dressing as prescribed and as needed. importance of reporting
early signs of bleeding
4. Teach Josefina when to report signs of bleeding such as
increased pain, reduced urine output and tachypnea.
plan
5. Administer to Josefina her prescribed medications and
6. Refer Josefina to surgical team as needed.
within her reach.
13
EVALUATION
Transfer of Care Letter
Identified Potential Area for Patient Education
F – Follow up care (referrals to OT/PT, Pain team, etc.)
L – Lifestyle (Smoking, Alcohol)
A – Activity (Deep Breathing Exercises/ Repositioning techniques)
M – Medications (Side Effects/ Desired Effects)
E – Equipment used (Assistive Devices, Inhaler, Peak Flow)
D – Diet (Healthy Diet)
C – Compliance to treatment
Actual / Potential Problems to Delay Discharge
D – Delay in Package of Care/ Deterioration
E – Embolism (Risk for DVT)
A – Access to Home
F – Falls (Risk for fall)
P – Pressure Ulcer (Risk for Pressure Ulcer)
I – Infection (Risk for Infection, Risk for Hospital Acquired Infection)
N – Non-compliance to treatment
14

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CARE PLANNING

Breathlessness/ Difficulty of Breathing

Complete each section. Please write clearly.

CARE BY NURSES(S) SELF-CARE

Complete each section. Please write clearly.

2. NURSING PROBLEM/ NEED/ Activity of Living:

CARE BY NURSES(S) SELF-CARE

Complete each section. Please write clearly.

CARE BY NURSES(S) SELF-CARE

Complete each section. Please write clearly.

2. NURSING PROBLEM/ NEED/ Activity of Living:

1. NURSING PROBLEM/ NEED/ Activity of Living:

2. NURSING PROBLEM/ NEED/ Activity of Living:

CARE BY NURSES(S) SELF-CARE

CARE BY NURSES(S) SELF-CARE

Complete each section. Please write clearly.

1. NURSING PROBLEM/ NEED/ Activity of Living:

Complete each section. Please write clearly.

2. NURSING PROBLEM/ NEED/ Activity of Living:

CARE BY NURSES(S) SELF-CARE

Complete each section. Please write clearly.

Complete each section. Please write clearly.

2. NURSING PROBLEM/ NEED/ Activity of Living:

Complete each section. Please write clearly.

3. NURSING PROBLEM/ NEED/ Activity of Living:

CARE BY NURSES(S) SELF-CARE

Transfer of Care Letter

Identified Potential Area for Patient Education

F – Follow up care (referrals to OT/PT, Pain team, etc.)

L – Lifestyle (Smoking, Alcohol)

A – Activity (Deep Breathing Exercises/ Repositioning techniques)

M – Medications (Side Effects/ Desired Effects)

E – Equipment used (Assistive Devices, Inhaler, Peak Flow)

D – Diet (Healthy Diet)

Actual / Potential Problems to Delay Discharge

D – Delay in Package of Care/ Deterioration

E – Embolism (Risk for DVT)

F – Falls (Risk for fall)

P – Pressure Ulcer (Risk for Pressure Ulcer)

I – Infection (Risk for Infection, Risk for Hospital Acquired Infection)

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