Nursing Plan of Care
Client Initials: ___________
Date: _________________
Priority Problem: ___________________________________________
RT: _______________________________________________________
AEB: ______________________________________________________
Nursing Plan of Care
Priority Concept using
Roy’s Adaptation
Model
Roy’s Adaptation Model: (circle one)
Physiologic
Interdependence
Self-Concept
Role Function
Assessment
Goal Planning
Outcome for selected problem
Nursing Interventions
List nursing interventions
performed for problem
Rationale
Reason for interventions
Evaluation
Did performed interventions
achieve your goal
Goal Met?
Pertinent Data:
Patient Will:
Nurse Will:
Why:
What Happened:
Yes
No
Subjective:
Objective:
J, W
6/20/2022
acute pain
impaired skin integrity
inflammation
Medications:
Venelex, Lovenox,
Lasix, gabapentin, Bio-K+
Miconazole Nitrate,
Tramadol, acetaminophin
Celluilitis bilateral lower
extremities open wounds
Vitals:
T- 97.2 B/P-145/76
P-99 O2- 96%
R-17
Pain- 4-8 out of 10
States: "it hurts when I walk"
"It hurts when I move my
legs"
"I don't think I will ever get
better"
1. Pain level will be below
4 out of 10 by end of day.
1. Give prescribed pain
medication PRN to manage
pain level.
1. By giving pain medication
this will help to reduce the
PT pain so they can be
comfortable.
1. When patient complained
of pain we gave the
medication so that she was
able to get up an walk
around. Pt stated that pain
was better.
2. Walk down the hall by
afternoon for physical
therapy after lunch
2. Give pain medication 20 to
30 minutes prior to physical
therapy.
2. Providing the pain
medication prior to physical
therapy will help reduce the
inflammation and allow
the patient to walk easier and
with less pain.
2. Patient was able to walk
halfway down the hall
before needing to take a
break from the pain.
3. be able to have a dressing
change without reporting pain
level increase above a 4 for
the entire dressing change by
this afternoon.
3. Provide tramadol 20
minutes prior to dressing
change. Help the patient
relax and be calm.
3. When a person is in pain
they tend to tense up their
muscles. this causes the pain
to be worse. By relaxing the
muscles it helps the pain
become more manageable.
3. The patient was able
to stay relaxed and breathe
through the dressing change
and not show signs of pain
increase.
4. continue to eat all of her
meals and take all of her
prescribed medications, when
sitting she will have her legs
elevated to reduce
inflammation. Swelling will be
eliminated by end of stay.
4. give PT all medications
including pain/ anti-
inflammatory medications
and lasix.
4. By giving anti-inflammatory
medications this will help the
swelling decrease. By giving
lasix it will help the fluid
build up leave the body.
Keeping legs elevated will
keep the fluid from collecting
in the lower exremities.
4. While PT was in the chair
she kept her legs elevated,
when she was eating she
continued to have them
propped up off the ground.
Her pitting has decreased
from a 3+ last week to a
2+ this week.
