Edith Jacobsen Nursing Care Plan

Name

Course

Instructor

Institution

Date
 Care Plan Form

Indicate the Mode

Student Name: Patient Initials/ Code Status E.J / Full Code __Physiologic Mode
__Self Concept Mode
Instructor: Date __Role Function Mode
__Interdependence
Priority Nursing Diagnosis
(I) Behaviors (II) Stimuli (III)Nursing Diagnoses (V) Nursing Interventions (VI) Evaluation of
Non-Observable Observable NANDA (Problem- and Rationales (Impact) Patient
(Subjective) (Objective) Focal, Contextual, Residual Based Nursing (3-Best Evidence-Based Goals/Outcomes
Diagnosis) Rationales with references)
The patient described Skin assessment: intact, color Focal Stimuli: Impaired physical mobility Rationale for short-term goals:  Patient demonstrates
the pain level of 2 and and sensation around hip are  Immobility related to a recent surgical  Encourage early improved balance and
under controlled normal  Fear of further falls intervention as evidenced by ambulation (Fairhall et al., mobility as evidenced
and injury 2022) by successfully
The patient’s daughter Morse fall scale assessment: decreased muscle strength completing physical
reported that she has 45 Lack of movement,
 Loss of independence
 Motivate the patient to therapy exercises and
been having dizzy cannot perform ADLs (IV) Patient Care actively participate in walking short
Contextual Stimuli:
spells physiotherapy sessions distances without
Knowledge deficit about  Advanced age (84 Goals/Outcomes (Fairhall et al., 2022) assistance.
The patient has a 10- safety, fall risk, osteoporosis years old) Short and Long Term  Patient reports
year history of Decrease strength in muscle,  Pre-existing (Including timeframes) Rationale for long-term goal: increased knowledge
osteoporosis pain, weakness and fractures conditions Short-term goals:  Through a and confidence in fall
(osteoporosis)  Increase the range of multidisciplinary prevention strategies,
motion of the affected approach, occupational as demonstrated by
Residual Stimuli: limb in one week therapists can assist in the implementation of
 Rehabilitation and through physical therapy helping patients restore safety measures at
physical therapy  Improve patient's functional capacity home and in the
 Emotional distress balance and mobility (Fairhall et al., 2022) community.
and anxiety through physical therapy  Patient's risk of falls
 Need for ongoing within one week. and fractures is
support and assistance Long-term goal: reduced by 50%, as
 Restore normal function evidenced by the
to 50% prior to injury absence of any falls
within six months or fractures within the
through lifestyle six-month timeframe.
modifications and
environmental safety
measures.

3
Subject to change as needed. Revised 2/1/2024.
 Care Plan Form

Indicate the Mode

Student Name: Patient Initials/ Code Status E.J / Full Code __Physiologic Mode
__Self Concept Mode
Instructor: Date __Role Function Mode
__Interdependence
#2 Nursing Diagnosis
(I) Behaviors (II) Stimuli (III)Nursing Diagnoses (V) Nursing Interventions (VI) Evaluation of
Non-Observable Observable Focal, Contextual, Residual NANDA (Problem- and Rationales (Impact) Patient
(Subjective) (Objective) Based Nursing (3 Best Evidence-Based Goals/Outcomes
Diagnosis) Rationales with
references)
The patient described Skin assessment: intact, color Focal Stimuli: Acute Pain related to Rationale for short-term goals:  The patient reported a
the pain level of 2 and and sensation around hip are  Immobility  Hourly assessment of vital pain level of 2
physical injury due to
a signs and verbal pain scores
under controlled normal  Fear of further falls and indicating a
bone fracture as evidenced (Farzaneh Didvar et al.,
significant reduction
injury 2024)
The patient’s daughter Morse fall scale assessment: by verbal reports from the in pain intensity
 Loss of independence
reported that she has 45 Lack of movement, patient  Administration of compared to
been having dizzy cannot perform ADLs admission.
spells
Contextual Stimuli: (IV) Patient Care analgesics while monitoring
effectiveness and side  The patient
Knowledge deficit about  Advanced age (84 years Goals/Outcomes effects (Farzaneh Didvar et demonstrated the
old)
The patient has a 10- safety, fall risk, osteoporosis Short and Long Term al., 2024) ability to use guided
year history of Decrease strength in muscle,  Pre-existing conditions .
(Including timeframes) Rationale for long-term goal: imagery and
osteoporosis pain, weakness and fractures (osteoporosis) Short-term goals: relaxation techniques
 Collaborate with a
1. The patient will report a multidisciplinary healthcare
effectively to manage
Residual Stimuli: pain level of no more than pain, as evidenced by
team to develop a pain
 Rehabilitation and 4 out of 10 one hour management plan tailored to verbal reports and
physical therapy postoperatively. the patient's needs and observations of
2. 24 hours postoperatively,
 Emotional distress and the patient will demonstrate
preferences (Farzaneh decreased distress.
anxiety Didvar et al., 2024)  The patient was able
the ability to use pain
 Need for ongoing management strategies to participate in
support and assistance effectively, activities of daily
Long-term goal: living with less pain
1. By discharge, the patient and increased
will demonstrate improved mobility, suggesting
pain management, and a improved pain
pain intensity of less than 3
management and
out of 10.
functional status.

3
 Care Plan Form

Indicate the Mode

Student Name: Patient Initials/ Code Status E.J / Full Code __Physiologic Mode
__Self Concept Mode
Instructor: Date __Role Function Mode
__Interdependence
#3 Nursing Diagnosis
(I) Behaviors (II) Stimuli (III)Nursing Diagnoses (V) Nursing Interventions (VI) Evaluation of
Non-Observable Observable NANDA (Problem- and Rationales (Impact) Patient
(Subjective) (Objective) Focal, Contextual, Residual Based Nursing (3 Best Evidence-Based Goals/Outcomes
Diagnosis) Rationales with references)
The patient described Skin assessment: intact, color Focal Stimuli: Loss of balance related to Rationale for short-term goals:  Patient will report feeling
the pain level of 2 and and sensation around hip are  Immobility  The patient must be more balanced and stable
history of dizzy spells. during ambulation.
under controlled normal  Fear of further falls Manifested by vertigo encouraged to ambulate
gradually until they  Patient will demonstrate
and injury improved ability to perform
The patient’s daughter Morse fall scale assessment: achieve equilibrium
reported that she has 45 Lack of movement,
 Loss of independence activities of daily living
 The patient must be without loss of balance.
been having dizzy cannot perform ADLs encouraged to use walkers  Patient will verbalize
Contextual Stimuli:
spells or wheelchair to support
Knowledge deficit about  Advanced age (84 (IV) Patient Care understanding of strategies
their balance to prevent falls and manage
The patient has a 10- safety, fall risk, osteoporosis years old) Goals/Outcomes . vertigo episodes.
year history of Decrease strength in muscle,  Pre-existing Short and Long Term Rationale for long-term goal:
osteoporosis pain, weakness and fractures conditions (Including timeframes)  Through a
(osteoporosis) Short-term goals: multidisciplinary
1. Within I hour after approach, the patient can
Residual Stimuli: admission, the patient’s be educated on strategies
 Rehabilitation and extensive history of of preventing injury during
physical therapy dizziness and vertigo.
dizzy spells and vertigo
2. 1 week postoperatively,
 Emotional distress assess the patients ability to attacks
and anxiety ambulate safely
 Need for ongoing Long-term goal:
support and assistance 1. By discharge, the patient
must undergo diagnostic
audiometric tests to assess
middle ear pathologies

3
 References

Fairhall, N. J., Dyer, S. M., Mak, J. C., Diong, J., Kwok, W. S., & Sherrington, C. (2022). Interventions

for improving mobility after hip fracture surgery in adults. Cochrane Database of Systematic

Reviews, 2022(9). https://doi.org/10.1002/14651858.cd001704.pub5

Farzaneh Didvar, Ghaffari, F., & Abbas Shamsalinia. (2024). Evaluating and Ranking the Factors

Affecting the Acute Pain Management in Older Adults with Dementia after Hip Fracture Surgery:

Second-Order Confirmatory Factor Analysis. PubMed, 28(6), 751–757.

https://doi.org/10.4103/ijnmr.ijnmr_386_21