DELAWARE TECHNICAL COMMUNITY COLLEGE

NUR 320 HEALTH ASSESSMENT

RN TO BSN PROGRAM: PLAN OF CARE CHART

STUDENT CHRISTINA M. COLLINS, RN DATE: APRIL 15TH, 2017

NAME:

Identified problem/need: Identified goal Plan/Intervention Evaluation/Outco Community

(Including supporting subjective and for outcome: s: mes: Resources
objective data) (Provide /Referrals:
rationale/evidence to
justify the rationale)

1. Intermittent pain - left

side of abdomen 1. The patient will 1. The patient will 1. Patient states that 1. Surgical Referral
(Hernia) reduce amount of bend at the knees he has been lifting For evaluation of
flare up of pain when lifting, not objects by bending hernia repair
from hernia. from the back. at the knees, not by Christiana Hernia
Subjective: 2. The patient will - Bending over puts bending over at the Center
- Patient states when lifting maintain a healthy pressure on the back area. 302-225-7049
heavy objects, pain/bulging weight. hernia and can 2. Patient has been 2. Planet Fitness or
occurs on lower left side 3. The patient will create pain, going to the gym Gym at work
- Patient states pain started understand what a bending at the Monday through incorporate exercise
about 1 yr. ago hernia is, the knees does not Fridays walking on into daily regimen
- Patient states sometimes causes of hernias, increase the the treadmill for 30 PF Wilmington
hernia flares up in pain when the symptoms of a pressure in the minutes a day. 302-691-2844
exercising hernia, and abdominal area 3. The patient is able to 3. Follow up with
- Patient states when pain prevention of pain 2. The patient will explain what a primary care
occurs, it feels like waves of from a hernia splint area with hernia is, prevention physician in 6
muscle contractions, than the 4. Add fiber into diet hand when strategies, and months To evaluate
pain radiates upwards. 5. Educate patient of coughing to symptoms of status of hernia.
- Patient states flare up occurs 1- symptoms of decrease intra- hernias. Dr. Krasner
3 times a month, and pain lasts incarceration or abdominal pressure. 4. The patient states Broom Street
for 30 seconds to 1 minute strangulation of - Decreasing intra- that his flare ups of 302-656-5416
- Patient states pain can be hernia abdominal pressure pain related to the
triggered by lying down and will prevent a flare hernia have reduced
than trying to sit up to fast. up of hernia from 3 times a
3. The patient will month to 1 time a
 DELAWARE TECHNICAL COMMUNITY COLLEGE

NUR 320 HEALTH ASSESSMENT

RN TO BSN PROGRAM: PLAN OF CARE CHART

STUDENT CHRISTINA M. COLLINS, RN DATE: APRIL 15TH, 2017

NAME:

Identified problem/need: Identified goal Plan/Intervention Evaluation/Outco Community

(Including supporting subjective and for outcome: s: mes: Resources
objective data) (Provide /Referrals:
rationale/evidence to
justify the rationale)

Objective: maintain a healthy month.

- Palpate a bulge on lower left weight by 5. The patient states he
side when lying exercising. has lost 10 lbs. and
- Palpate a bulge on lower left - Increased weight has maintained his
side when patient coughs increases the intra- new weight for 3
- Weight: 215 lbs., Height: 59 abdominal pressure, months
- BP: 175/98 Pulse: 72 which push hernia 6. The patient states
- Temp: 98.6 through an opening that when he coughs
- States when pain occurs it is an creating pain he splints the
8/10 4. The patient will eat abdominal area with
- States at rest pain is a 0/10 foods such as, fruit, his hand to help the
vegetables, and hernia stay in place.
whole grains, which
will be a good
source of fiber into
the diet.
- Including healthy
food with fiber can
help prevent strain
when having a
bowel movement
5. Educate patient
about hernias
- Educating patient
about the hernia
will lead to adhering
 DELAWARE TECHNICAL COMMUNITY COLLEGE

NUR 320 HEALTH ASSESSMENT

RN TO BSN PROGRAM: PLAN OF CARE CHART

STUDENT CHRISTINA M. COLLINS, RN DATE: APRIL 15TH, 2017

NAME:

Identified problem/need: Identified goal Plan/Intervention Evaluation/Outco Community

(Including supporting subjective and for outcome: s: mes: Resources
objective data) (Provide /Referrals:
rationale/evidence to
justify the rationale)

to the treatment
plan.
6. Limit lifting weights
at gym to an
amount that is not
to heavy
- Lifting weights
that are too heavy
puts a strain on the
muscles
2. Increased Blood Pressure 1. Client will have BP 1. Administer 1. Patient has been 1. Pharmacy
(HTN) within acceptable medication as taking BP daily for 3 medications and
limits with ordered Losartan weeks. The BP has supplies, such as BP
Subjective: medication 100 mg, 1 tab, continued to be machine to take BP
- c/o of headaches and/or pressure management. daily. around 140/85 on a regular basis to
in his head a couple of times a 2. Increase days of - Angiotensin II consistently. stay on top of any
week. regular exercise receptor blockers 2. Patient has been fluctuations in BP.
- patient states stopped at store from 2 days a week (ARBs) block the going to the gym Walgreens Bear
and took BP and it was 170/100. to 5 days a week action of angiotensin II. Monday through 302-832-2300
- patient states he has been eating 3. Incorporate low As a result, blood Friday and walking 2. American Heart
fried french fries daily for a few sodium and low fat vessels dilate and BP is on the treadmill for Association. Can
weeks. food into diet reduced. 30 minutes a day. educate patient
- patient states he has gain 10- 4. Verbalize 2. Develop an exercise 3. Patient met with a about heart disease
15lbs in the last month or so. understanding of BP plan, such as dietitian to discuss www.heart.org
- patient states he has had job- medications, walking on a ways to improve 3. Hypertension
related stress in the last 2-3 dietary restrictions, treadmill or outside diet. Patient has Support Group
 DELAWARE TECHNICAL COMMUNITY COLLEGE

NUR 320 HEALTH ASSESSMENT

RN TO BSN PROGRAM: PLAN OF CARE CHART

STUDENT CHRISTINA M. COLLINS, RN DATE: APRIL 15TH, 2017

NAME:

Identified problem/need: Identified goal Plan/Intervention Evaluation/Outco Community

(Including supporting subjective and for outcome: s: mes: Resources
objective data) (Provide /Referrals:
rationale/evidence to
justify the rationale)

months. exercise, and the for a minimum of 30
- patient states he was exercising importance to minutes, 5 days a
5-7 days a week, now only 2 days attend follow-up week.
a week. appointments to - Aerobic exercise helps
- Patient denies shortness of help manage HTN. to lower BP and aids in
breath toning the
cardiovascular system.
Objective: 3. Implement dietary
Weight: 215 lbs. restrictions, such as
Height: 59 reducing calories 4. Patient verbalized
BP: 175/98 Pulse: 72 and avoiding
Temp: 98.6 sodium, fat, refined
Lungs are clear carbohydrates, and
Extremities no edema cholesterol.
- Limiting sodium can
Current Medications: help manage fluid
Fish Oil 1g, 1 softgel, daily retention and decrease
Red Rice Yeast Extract 600mg, 2 myocardial workload. A
capsules, daily diet rich in calcium,
potassium, and
Starting Medication: magnesium may help
Losartan 100 mg, 1 tab, daily lower BP.
4. Patient is able to
communicate
understanding by
repeating back
been avoiding 4. Stress management
sodium and has classes
been eating less 5. Weight loss groups
processed foods. Weightwatchers.com
Patient has also 6. Counseling services
incorporated eating
salmon, tuna, fruits,
vegetables, and low-
fat dairy foods.
understanding of his
medication and has
been taking it every
day first thing in the
morning. Patient has
made sure to follow-
up with a dietitian
and has been
attending regular
visits with his
primary care
physician.
 DELAWARE TECHNICAL COMMUNITY COLLEGE

NUR 320 HEALTH ASSESSMENT

RN TO BSN PROGRAM: PLAN OF CARE CHART

STUDENT CHRISTINA M. COLLINS, RN DATE: APRIL 15TH, 2017

NAME:

Identified problem/need: Identified goal Plan/Intervention Evaluation/Outco Community

(Including supporting subjective and for outcome: s: mes: Resources
objective data) (Provide /Referrals:
rationale/evidence to
justify the rationale)

information related
to medications,
dietary restrictions,
exercise, and follow
up appointments.
- Adequate information
and understanding of
the treatment plan can
enhance the patients
commitment to the
treatment plan. Lack of
engagement in the
treatment plan (IE.
Follow up appts.) is a
common reason of
failure of
antihypertensive
therapy.
3. Alcoholism Recovering
Alcoholic 1. Patient will attend 1. Implement using 1. Patient states that 1. Online Alcoholics
weekly AA meditation he attends AA Anonymous (AA)
Subjective: meetings relaxation meeting every Recovery Resources
- Patients states has been a 2. Patient will use technique. Thursday night at
recovering alcoholic for 28 relaxation - meditation helps relax 7:00 pm. www.recovery.org/aa
years techniques to the mind and focus on 2. Patient states that /
- Patient states that her attends minimize stress. the present he meditates twice a 2. National
 DELAWARE TECHNICAL COMMUNITY COLLEGE

NUR 320 HEALTH ASSESSMENT

RN TO BSN PROGRAM: PLAN OF CARE CHART

STUDENT CHRISTINA M. COLLINS, RN DATE: APRIL 15TH, 2017

NAME:

Identified problem/need: Identified goal Plan/Intervention Evaluation/Outco Community

(Including supporting subjective and for outcome: s: mes: Resources
objective data) (Provide /Referrals:
rationale/evidence to
justify the rationale)

Alcoholic Anonymous
meetings
- Patient states that in times of
stress, attends multiple
meetings a week
- Patient states prior to
becoming sober was an
alcoholic for 10 years
- Patient states that he is
Roman Catholic.
Objective:
- Patient is smiling, no signs of
distress
- Weight: 215 lbs.
- BP: 175/98 P: 72 R: 18
- Alert and Oriented to Person,
Place, and Time
3. Patient will maintain 2. Create a list of week. Clearinghouse for
spiritual well-being. support people 3. Patient states that Alcohol Abuse and
4. Patient will reach - Creating a list of when he feels Alcoholism
out to support support people will overwhelmed he www.health.org
system in times of allow the patient to uses breathing 3. Provide meditation
high stress. have a contact list techniques to calm information
readily available in down. 4. Barnes and Noble
times of high stress in 4. Patient states that Bookstore find
order to reach out to when he an books on relaxation
their support system. A extremely stressful techniques
strong support system week he attends 2-3 5. Referral to
is critical to prevention AA meetings. Therapists
relapse. 5. Patient states that 6. Address to Golf Clubs
3. Implement using when his stress level Participate in a
breathing is high, he reaches hobby that patient
techniques when out to his sponsor enjoys.
stress is high and/or family
- Breathing techniques members for
help calm a person, support.
reducing stress and 6. Patient states that
anxiety, clearing the he attends weekly
mind. Also a great tool mass on Sunday.
to cope with cravings. 7. Patient states that
4. Implement he plays golf once a
participating in a week with friends
sober free hobby. who are also
 DELAWARE TECHNICAL COMMUNITY COLLEGE

NUR 320 HEALTH ASSESSMENT

RN TO BSN PROGRAM: PLAN OF CARE CHART

STUDENT CHRISTINA M. COLLINS, RN DATE: APRIL 15TH, 2017

NAME:

Identified problem/need: Identified goal Plan/Intervention Evaluation/Outco Community

(Including supporting subjective and for outcome: s: mes: Resources
objective data) (Provide /Referrals:
rationale/evidence to
justify the rationale)

- Participating in a recovering
sober-free hobby allows alcoholics.
the patient to 8. Patient states that
participate in he has been seeing a
something joyful therapist at least
without the temptation. one time a month.
5. Create a list of AA
meetings in the
area to attend.
- Having a list makes it
easier to choice an AA
meeting in a moment
of high stress easier.
Attending regular
meeting is productive
in preventing relapse.
Talk with others who
relate. Others can help
identify coping
mechanisms.
6. Talk to a therapists.
- Talking about
problems with a
therapist reduces
stress. Therapist can
help identify coping
 DELAWARE TECHNICAL COMMUNITY COLLEGE

NUR 320 HEALTH ASSESSMENT

RN TO BSN PROGRAM: PLAN OF CARE CHART

STUDENT CHRISTINA M. COLLINS, RN DATE: APRIL 15TH, 2017

NAME:

Identified problem/need: Identified goal Plan/Intervention Evaluation/Outco Community

(Including supporting subjective and for outcome: s: mes: Resources
objective data) (Provide /Referrals:
rationale/evidence to
justify the rationale)

mechanism.