Sample nursing care plan.-------------------------------------------------
Name: Mrs. Rita Williard Age: 68 Date of Admission: 11/10 -------------------------------------------------
Diagnosis on Admission: CVA with lift-sided weakness.-------------------------------------------------
Nursing Diagnosis: Impaired Physical Mobility, High Risk for Injury, Situational Low Self-Esteem.-------------------------------------------------
Long term goals: Independent mobility using walker or quad cane, record of personal safety, positive self-regard |
Date | Problem | Goal | Target   date | Nursing orders |
11/10 | 1. Impaired physical mobility related to lift-sided weakness as manifested by decreased muscle strength in left leg and arm, slowed gait, dragging foot | The patient will stand and rotate from bed to wheelchair | 11/24 |     1. Passive ROM( rang of motion) t.i.d to left arm and leg   2. Physical therapy twice daily for practice at parallel bars   3. Apply left leg support and hang to left arm when up   4. Assist to balance on right leg at bedside before and after physical therapy daily K.L , RN |
11/10 | 2. Risk for Injury related to motor deficit | The patient will transfer from bed to wheelchair without injury | 12/1 |     1. Keep side rails up and trapeze over bed.   2. Use shoe on right foot ( leg brace on left)before transfer   3. Dangle for 5 minutes before attempting to stand   4. Lock wheels on wheelchair before transfer   5. Obtain help of second assistant.   6. Block left foot to avoid slipping during rotation   7. Place signal light on right side within reach at all timesM.M,   RN |
12/2 | 3. Situational Low Self-Esteem related to dependence on others as manifested by statement   " I need as much help as a baby, I feel so useless, How to embarrassing to be so dependent" | The patient will identify one or more   examples of improved mobility and self-care | 12/18 |     1....

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