Client Plan of Care with Nursing Interventions

Client Plan of Care with Nursing Interventions and Goal(s) Instructions: Review the data collected and identify alterations that interfere with the clients healing process or the ability to function at his/her highest level. Prioritize the problems indicating the most important first. Document what you as the nurse will do in caring for the patient to help with his/her problem/need. Focus of the Care plan is for actual problems ( NO RISK FOR except in rare instances). Highest Priority Nursing Diagnosis #1: __Risk for injury________________R/T____substance intoxication or withdrawl____________________________as evidenced by infant testing postive for opiates_at birth__ Nursing Intervention #1: Assess________________________________________________________________________________(Frequency)______________ Delegatable: Y / N To Whom: (Circle) CNA LVN RN Nursing Intervention #2: Monitor ______________________________________________________________________________(Frequency)______________ Delegatable: Y / N To Whom: (Circle) CNA LVN RN Nursing Intervention #3: Implement/Administer __________________________________________________________________(Frequency) ______________Delegatable: Y / N To Whom: (Circle) CNA LVN RN Nursing Intervention #4: Teach ________________________________________________________________________________(Frequency) ______________Delegatable: Y / N To Whom: (Circle) CNA LVN RN Goals: Short-term: By the end of the shift the patient will __________________________________________________________________________________________________________ Long-term: By discharge the patient will __________________________________________________________________________________________________________________ Evaluation: Patient Short-term goal (Met/Not Met). Patient Long-term goal (Met/Not Met). _____________________________________________________________________________ Medium Priority Nursing Diagnosis #1: ____Imbalanced nutrition____________________R/T________________________________as evidenced by___________________________________________ Nursing Intervention #1: Assess ________________________________________________________________________________(Frequency) ______________Delegatable: Y / N To Whom: (Circle) CNA LVN RN Nursing Intervention #2: Monitor ______________________________________________________________________________(Frequency) ______________Delegatable: Y / N To Whom: (Circle) CNA LVN RN Nursing Intervention #3: Implement/Administer __________________________________________________________________(Frequency) ______________Delegatable: Y / N To Whom: (Circle) CNA LVN RN Nursing Intervention #4: Teach_________________________________________________________________________________(Frequency) ______________Delegatable: Y / N To Whom: (Circle) CNA LVN RN Goals: Short-term: By the end of the shift the patient will __________________________________________________________________________________________________________ Long-term: By discharge the patient will___________________________________________________________________________________________________________________ Evaluation: Patient Short-term goal (Met/Not Met). Patient Long-term goal (Met/Not Met).______________________________________________________________________________ Lowest Priority Nursing Diagnosis #1: ____________________________________________R/T________________________________as evidenced by___________________________________________ Nursing Intervention #1: Assess________________________________________________________________________________(Frequency) ______________Delegatable: Y / N To Whom: (Circle) CNA LVN RN Nursing Intervention #2: Monitor_______________________________________________________________________________(Frequency) ______________Delegatable: Y / N To Whom: (Circle) CNA LVN RN Nursing Intervention #3: Implement/Adminster___________________________________________________________________(Frequency) ______________Delegatable: Y / N To Whom: (Circle) CNA LVN RN Nursing Intervention #4: Teach_________________________________________________________________________________(Frequency) ______________Delegatable: Y / N To Whom: (Circle) CNA LVN RN Goals: Short-term: By the end of the shift the patient will __________________________________________________________________________________________________________ Long-term: By discharge the patient will __________________________________________________________________________________________________________________ Evaluation: Patient Short-term goal (Met/Not Met). Patient Long-term goal (Met/Not Met) SCIENCE HEALTH SCIENCE NURSING MATERNAL C 254

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