ASSESSMENT DIAGNOSIS

PLANNING
INTERVENTIONS RATIONALE
GOAL/OUTCOMES

EVALUATION REASSESSMENT

Subjective
Data:
-Clara Davis
-25 yr. old female
- 4/15/13
routine
Checkup
-Does not
exercise at
all
-I am so
busy with
school and
work, that it
is hard to
incorporate
exercise into
my daily
routine.
-I am also
stressed
because Im
always
busy.

GOAL: Become
physically active
by 4/25/13

1) Clara did
not exercise
at all
therefore
the goal was
not met.
5/02/13
2) As a result
of Claras
physical
inactiveness
she did not
lose any
weight, but
gained
more;
therefore
the goal was
not met.
5/09/13

Objective
Data:
-25 yr. old
female
-Temp. 97.8
- HR 97
- O2 93%
- BP 132/88
indicates
that she is
prehypertensive
- BMI of 25
which
indicates

SEDENTARY
LIFESTYLE
related to
lack of
interest,
motivation,
and
resources
evidenced
by daily
routine
lacking in
physical
exercise

OUTCOMES:
1) Exercise for 2
hours on two
days out of the
week by 5/02/13

2) Lose 5 lbs. by
5/09/13

1a) Determine
what type of
exercise Clara is
willing to do for
2 hours and
build a routine
based on her
needs.
1b) Come up
with a solution
to help Clara
better manage
her time
2a) Stress the
importance of
exercising and
the benefits
2b)Assess
Claras
confidence level
about losing
weight.

1a) Clara has to

be committed
to exercising in
order routine to
work (Doenges
pg.392).
1b) Lack of
resources
(Doenges
pg.392).
2a) Exercise
promotes
weight loss by
reducing
appetite,
increasing
energy, toning
muscles, and
enhancing
cardiac fitness
and a sense of
well-being and
accomplishment
(Doenges
pg.392).
2b) If Clara
believes in
herself she will
be more likely
to lose the
weight, but if
not she will
make excuses
for not being
able to lose the
weight
(Gulanick
pg.127).

The patient
continued to
focus on
school and
work,
without
adding her
health to the
list of
priorities.
She came up
with an
exercise
regime,
which would
fit her busy
lifestyle, but
never
implemented
the plan.
Clara needs
more help
initiating her
plan. She will
be referred
to a personal
trainer that
can help her
get, stay on
track, and
accomplish
her goals.

that she is
overweight.
-Clara states,
I have so
many other
things to do,
that I cannot
worry about
exercising

Works Cited

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing care plans, guidelines
for individualizing client care across the life span. (8th ed.). Philadelphia: F A Davis Co.
Gulanick, M. and Myers, J. I. (2010) Nursing care plans, diagnoses, interventions, and
outcomes. (7th ed.). St. Louis: Mosby Inc.