Free Simple Nursing Action Plan Template
Simple Nursing Action Plan
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
Case 1: Pain Management
|
Date |
Nursing Diagnosis |
Goal/ Expected Outcome |
Nursing Intervention |
Evaluation/ Outcome |
|---|---|---|---|---|
|
May 5, 2050 |
Acute Pain related to surgical procedure |
Patient will report pain level less than 3 on a 0-10 scale |
Administer prescribed pain medication as per orders |
Pain level reduced to 2/10 |
|
May 6, 2050 |
Acute Pain related to surgical procedure |
Patient will demonstrate improved comfort |
Monitor vital signs and assess pain regularly every 4 hours |
Patient reports pain relief after medication |
|
May 7, 2050 |
Acute Pain related to surgical procedure |
Patient will demonstrate ability to use non-pharmacological pain relief methods |
Educate patient on relaxation techniques like deep breathing |
Patient demonstrates deep breathing technique during pain |
|
May 8, 2050 |
Acute Pain related to surgical procedure |
Patient will report satisfaction with pain management |
Reassess pain levels every 6 hours and adjust pain management plan as necessary |
Patient states pain well managed with current regimen |
Case 2: Post-Surgery Recovery
|
Date |
Nursing Diagnosis |
Goal/ Expected Outcome |
Nursing Intervention |
Evaluation/ Outcome |
|---|---|---|---|---|
|
May 5, 2050 |
Risk for Infection related to surgical wound |
No signs of infection present |
Clean and dress surgical wound according to protocol |
Wound dressing applied correctly |
|
May 6, 2050 |
Risk for Infection related to surgical wound |
Surgical site remains free from infection |
Monitor surgical site for redness, swelling, or drainage |
No signs of infection noted |
|
May 7, 2050 |
Risk for Infection related to surgical wound |
Patient will verbalize understanding of wound care |
Educate patient on how to care for surgical wound at home |
Patient demonstrates correct wound care technique |
|
May 8, 2050 |
Risk for Infection related to surgical wound |
Patient will exhibit no signs of infection |
Continue monitoring wound and update care plan if necessary |
Wound remains clean and dry |
Case 3: Patient Education (Diabetes Management)
|
Date |
Nursing Diagnosis |
Goal/ Expected Outcome |
Nursing Intervention |
Evaluation/ Outcome |
|---|---|---|---|---|
|
May 5, 2050 |
Knowledge Deficit regarding diabetes management |
Patient will demonstrate understanding of diabetes care |
Provide patient with educational materials on diabetes management |
Patient can explain the importance of blood sugar control |
|
May 6, 2050 |
Knowledge Deficit regarding diabetes management |
Patient will correctly demonstrate blood glucose monitoring |
Teach patient how to check blood glucose levels |
Patient demonstrates correct blood glucose monitoring |
|
May 7, 2050 |
Knowledge Deficit regarding diabetes management |
Patient will show an understanding of medication administration |
Educate on the proper timing and dosage of prescribed medication |
Patient can correctly state when and how to take medication |
|
May 8, 2050 |
Knowledge Deficit regarding diabetes management |
Patient will report improved self-care behaviors |
Discuss healthy eating habits and importance of exercise |
Patient has improved blood glucose levels and dietary changes |
This plan is designed to provide a clear, structured approach to nursing interventions. It ensures effective patient care and ongoing evaluation to achieve optimal outcomes.
