BSN
NURSING PROCESS CARE PLAN
NURSING DIAGNOSIS: Acute Pain R/T (Related to) post-surgical procedure AEB (as evidenced by) Left Ankle Hardware Implant.
PRIORITY #
ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION
Subjective and Objective Data
1 Client Goal
(Goal must be timed and measurable) SMART
Interventions
(3 Nursing Interventions with Rationale and Reference for each)
Actual Completion of Nursing Interventions
Goal Evaluation
(met, not met, partially met and explanation)
Subjective
Objective
* Cite all interventions/rationales per APA format
NURSING DIAGNOSIS: Limited Mobility R/T inability to walk AEB L Ankle Pain
PRIORITY #
ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION
Subjective and Objective Data
1 Client Goal
(Goal must be timed and measurable) SMART
Interventions
(3 Nursing Interventions with Rationale and Reference for each)
Actual Completion of Nursing Interventions
Goal Evaluation
(met, not met, partially met and explanation)
Subjective
Objective
* Cite all interventions/rationales per APA format
References
02/02/2021