Sample Care Plan Template Page 49
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513) The nurse will complete the Braden scale
3) A risk assessment tool like the Braden
3) The nurse completed the Braden
assessment on the patient qshift.
scale can be used to assess immobility-
scale on the patient during the shift
related risk factors the patient has and rate
and the score was 9 placing the
the patient’s level of risk (Magnan &
4) Turn the patient q2hrs or elevate bony
patient in the high-risk category for
prominences with cushions/specialty devices to
Maklebust, 2009).
skin breakdown.
prevent skin breakdown (Ackley & Ladwig,
2011).
4) Turning the patient and using specialty
4) The patient was turned q2hrs and
devices like foam wedges are all pressure-
foam wedges were used under
reducing interventions that help to preserve
ankles during shift to prevent skin
skin integrity (Magnan & Maklebust, 2009).
breakdown. No skin breakdown
5) The nurse will administer the patient’s
was noted during the nursing shift.
prescribed nutritional supplements folic acid,
5) The patient is diagnosed with
thiamine, and multivitamin. Also the nurse, will
malnutrition and poor nutritional status,
5) The patient was administered his
minimize the time that the patient’s continuous
which can increase the risk for and impair
prescribed nutritional supplements
tube feed is put on hold.
the recovery of skin breakdown/pressure
and the nurse avoid excessive
pauses on the patient’s tube
ulcers (NPUAP, 2009).
feeding.
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan
12/17/2012
page 29
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