Patient Initials

Room #

Code Status

Allergies

Diagnosis

Relevant Medical/Surgical History

Drug

Dose/Range

Route

Time

Reason for RX

Top 4 Side Effects

Student Name

Date

Patient (initials only)

Patient Medical Diagnosis

Nursing Diagnosis (use PES format)

(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)

(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.)

(List at least three nursing or collaborative interventions with rationale for each goal & outcome.)

(Provide reason why intervention is indicated / therapeutic; provide references.)

Outcome Evaluation & Re-planning

(Was goal met? How would you revise the plan of care according the patient’s response to current plan?)

1.

2.

3.

Statement #1

Statement #2

2.

3.

1.

2.

3.

Outcome #1

Outcome #2

(List at least two nursing or collaborative interventions with rationale for each goal & outcome.)

(Provide reason why intervention is indicated/therapeutic; provide references.)

Outcome Evaluation & Replanning

(Was goal(s) met? How would you revise the plan of care according the patient’s response to current plan of care?)

1. +2 weakness on left

upper and lower

extremity

2. Inability to walk without

assistance (patient

shuffles when walks and

gets confused as to

which leg needs to

move to propel forward)

Statement #1: Patient will perform ROM exercises each hour during the shift.

Statement #2: Patient will ambulate from bed to door twice by the end of shift.

1. Educate pt about importance of ROM exercises.  Rationale:  If pt understands the importance of ROM exercises (to maintain and hopefully increase strength), the pt is more likely to participate in exercises (Potter & Perry, p. 4).

2. Assist pt w/ ROM exercises while teaching him how to perform ROM exercises. 

3. Consult with physical therapist for strength training and development of a mobility plan

1. Determine amount of assistance needed to get patient out of bed and ambulate. 

2. Clear walkway of hazards.  Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3).

1. If patient understands the important of ROM exercises (to maintain and hopefully increase strength), the patient is more likely to participate in exercises (Potter & Perry, p. 4).

2. Pt needs to be instructed on how to perform ROM exercises, and performing the exercises while instructing the patient will solidify his understanding so he can perform exercises on his own (Potter & Perry, p. 5).

3. Techniques such as gait training, strength training, and exercise to improve balance and coordination can be very helpful for rehabilitation patients (Tempin, Tempkin, & Goodman, 1997)

1. Weakness and lack of coordination can cause the pt to be off balance which would put him at risk for a fall.  Determining level if assistance needed before trying to assist out of bed and ambulate will prevent a fall for the patient (Potter & Perry, p. 2).

2. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3).

Outcome #1: Pt partially met goals.  He was open to and understanding of the need to perform ROM exercises, but he still needs guidance in how to perform.  Will continue to with current plan.

Outcome #2: Patient exceeded goal:  he walked 4 times. Wil modify plan to increase distance (to nurses’ station).