Ivy Tech Community College - Northeast

Nursing Care Plan

Dates of Care:

Patients Age:

Pt. Diagnoses:

Gordons Functional Health Patterns

Assessment Data
I.

Health History/Health Perception

SUBJECTIVE

OBJECTIVE

Health perception:

General Appearance:
Race: Gender:
Age Group:
Body Build:
Stature:
Grooming:
Mental Status:
Signs of Distress:

Life style:
Health Maintenance:
Habits:
Use of alcohol:
Use of tobacco:
Other Recreational or OTC Drugs:

Breast or testicular self-examination:

Vital Signs
Body Temperature:
Blood Pressure:
Pulse:
Respirations:

Date of last dental examination:

Overall Health Status:

Preventive Health Behaviors:

Problems that could contribute to falls or

accidents:
Family history:
Problems that could contribute to falls or
accidents:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).

II.

Nutrition Metabolic
SUBJECTIVE

OBJECTIVE

Previous Dietary Intake

Height and Weight

Body Temperature:
Skin:
Color:
Color variations:
Lesions:
Turgor:
Temperature and moisture:
Edema:

Food Preferences:
Appetite:
Nutritional Impairment:
Inability to swallow?
Inability to chew?

Hair:
Inability to feed self?

Color:
Length:
Texture:
Distribution:

Weight Fluctuations Last 6 months:

Dentures:

Scalp:
Allergies:
Oral mucous membranes:
Color:
Consistency:
Gums:

Skin:
History of Skin/Healing Problems:
Usual Hygiene Practices:

Nails:
Skin Care Aides:

Color:
Shape:
Texture:
Nail Bed:
Capillary refill:
Teeth:
Condition:
Color:
Current dietary intake:
Vitamins or Supplements:
Amount eaten:
Fluid intake during the day:

Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
Diagnostic studies:
III.

Elimination
SUBJECTIVE

OBJECTIVE

Previous Urinary Pattern

Urinary:
Frequency of voiding:
Mode:
Characteristics:

Frequency of voiding:
Problems:

Bowel/stool
Bowel Sounds:

Previous Bowel Pattern: .

Bowel/stool:
Feces:
Amount:
Consistency:
Characteristics:

Abdominal appearance:
Contour:
Symmetry:
Surface motion:
Drainage:
Amount:
Color:
Odor:
Consistency:
Characteristics:
Presence of heavy perspiration/diaphoresis:

Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
Diagnostic studies:
IV.
Activity Exercise
SUBJECTIVE

OBJECTIVE

Previous pattern of activity:

Mobility aids:
Limitations in ability:
Use of diversional activities:

History of tolerance limitations:

Vital sign ranges:

Temperature:
Pulse:
Respirations:
Blood Pressure:
Oxygen Saturation:
Present pattern of activity:
Musculoskeletal:
Posture:
Muscle tone:
Muscle strength:
Gait:
Balance:
Range of motion
Weight bearing:
Cardiorespiratory:
Lungs:
Breath sounds:
Rate:
Rhythm:
Depth:
Cough:
Use of O2:
Heart:
Rate:
Rhythm:
Peripheral Vascular:
BP:
Peripheral Pulses:
Motor:
Present tolerance for activity:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).

Diagnostic studies:
V.

Sleep Rest
SUBJECTIVE

OBJECTIVE

Sleep patterns:

Observe appearance:

Routine:
Sleep aides used:

Observe behavior:

Problems:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
Diagnostic studies:

VI.

Cognitive - Perceptual
SUBJECTIVE

OBJECTIVE

Knowledge Level /Educational level achieved:

Ability to express self verbally:

Primary language spoken:

Ability to follow verbal/written instructions:

Past History of cognitive/perceptual illness:

Developmental Level:

Past History of sensory perception:

Insight:

Pain Assessment:

Memory:
Speech:
Paralanguage:
Articulation:
Sequencing:
Appropriateness of content:
Neurological:
Orientation:
Pupil reaction:
Grasp Strength:
Level of consciousness:
Perceptual Cognitive:
Hallucination:
Delusions:
Attention span:
Sensory:
Visual Impairment:
Auditory Impairment:
Auditory aide:
Other sensory impairments:

Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
Diagnostic studies:
VII.

Self-Perception Self-Concept
SUBJECTIVE

OBJECTIVE

Ability to accomplish age level tasks:

Developmental stage of life:

** Ericksons:
Are the goals and responses age related?

Ask the patient:

How would you describe yourself
What are your strengths?
What are your weaknesses?

Posture:
Eye contact:

Patients perception of ability to achieve goals:

Facial expression (affect):
Body Image:
Grooming:
Hair:
Hygiene:
Makeup:
Shaven:
Dress:

Mood:

Affect:
Describe Affect:
Attitude:
Expressed feelings about self:
Self affirmation comments:
Self derogatory comments:
Appropriateness of behavior:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).

VIII. Role Relationship

SUBJECTIVE

OBJECTIVE

Patterns of relating to others:

Patients interactions with others:

Identification of own role:

Does patient have visitors? .
Response to authority, peers, subordinates:
Age, marital status, occupation:
Perceptions of responsibilities:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).

IX.

Sexuality - Reproductive
SUBJECTIVE

OBJECTIVE

Number of living Children, abortions,

miscarriages, stillbirths:

Breasts: .
Areola:

Sexual self-feelings toward sex, role, self-concept:

Genitalia:
Effect of illness or impairment to sexuality:
Inappropriate sexual behavior:
Present sexual activity:
Use of birth control:
Age of onset of menses:
Onset of menopause:
Last pap smear:
Mammogram:
Nursing Diagnosis:
N/A
Diagnostic studies:
No diagnostic studies applicable to this patient.

X.

Coping Stress Tolerance

SUBJECTIVE

OBJECTIVE

Coping patterns:

Behavior patterns:

Support system:

Abusive to self or others:

Recent loss or change in life situation:

Mood:

Presence of stress-related disorders:

Appearance:
Affect:
Ability to reason and make sound decisions:

Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
XI.

Values Beliefs
SUBJECTIVE

OBJECTIVE

Health/illness beliefs:

Symbols of Faith:

Concern with meaning of life/death:

Current religious/cultural ties:

Concern with meaning of suffering:

Visits from clergy:

Anger towards God/religion:

Behavioral patterns of despair:

Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).

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DISCHARGE NEEDS
Treatments:
Special care or needs:
Special teaching:
Follow up care or appointments: .
Life expectancy:
Rehabilitation: specify type:
Return to:

MED-SURG TEXTBOOK PICTURE

Pathophysiology:

Signs & Symptoms:

Diagnostic Studies:

Medical-Surgical Treatment:

Nursing Care (Include Teaching):

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MED-SURG TEXTBOOK PICTURE

Pathophysiology:

Signs & Symptoms:

Diagnostic Studies:

Medical-Surgical Treatment:

Nursing Care (Include Teaching):

MED-SURG TEXTBOOK PICTURE

Pathophysiology:

Signs & Symptoms:

Diagnostic Studies:

Medical-Surgical Treatment:

Nursing Care (Include Teaching):

12

CLINICAL COURSE

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DIAGNOSTIC STUDIES
Lab studies and x-rays ordered:

Patient results (choose at least two of the above)

Name of test:

Normal values:
Patient values:
Significance (purpose of test, nursing preparation, explain abnormal values as they relate
to the patient):

Name of test:
Name of test:

Normal values:
Patient values:
Significance (purpose of test, nursing preparation, explain abnormal values as they relate
to the patient):

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Medication Information Form

Medication
Generic &
Brand Name

Dose Range

Client Dose

Medication Information Form

Classification
Indication and
Action

Side Effects/Drug
interactions

Nursing
Considerations and
Contraindications

NURSING CARE AND TREATMENTS

Examples of treatments: Dressings, irrigations, incentive spirometer, CPM application, AVI
or SCD boots, splints

Prioritization of nursing concerns

List all nursing concerns in order of priority.
Note: It is expected that if a problem is listed as numbers 1, 2, or 3 that these problems would
be addressed in the Care Plan. At least one problem should be related to the pathophysiology,
example: if the care plan is a heart patient, at least one nursing diagnosis should be related to the
heart disorder.

1.

(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis:
Validating Assessment Factors: (This is to PROVE that a Nursing Diagnosis is necessary to
resolve this problem.)

Goal:
Actions with rationale: (Minimum of three)
1. A 2. A3. A-

RRR-

Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it
appropriate to keep with the original plan?)

(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis:
Validating Assessment Factors: (This is to PROVE that a Nursing Diagnosis is necessary to
resolve this problem.)
Goal:
Actions with rationale: (Minimum of three)
1. A 2. A3. A-

RRR-

Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it
appropriate to keep with the original plan?)

(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis:
Validating Assessment Factors: (This is to PROVE that a Nursing Diagnosis is necessary to
resolve this problem.)
Goal:
Actions with rationale: (Minimum of three)
1. A 2. A3. A-

RRR-

Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it
appropriate to keep with the original plan?)