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Sample Care Plan NUR 210L
Sample Care Plan NUR 210L
Sample Care Plan NUR 210L
History of Present Illness Past Medical History Pertinent lab test (normal
(presenting signs & Past Surgical History ranges in parentheses) &
symptoms/diagnostic reports (Concurrent, onset, dates) diagnostic reports (with dates)
Patient was at home when he experienced Mr. MH has no prior illnesses except for Non- WBC- 1.4 (normal 4-10)
signs and symptoms of weakness. His Hodgkin’s lymphoma, which was diagnosed in RBC- 2.19 (normal 12-15)
wife brought him to the emergency room 2004. Platelets- 23
Nursing Care Plan 2
Identify Potential Health Deviations Signs & Symptoms Interventions (at least two each)
(include Collaborative Problems) (Independent Nursing Functions)
The patient has potential for electrolyte -Patient hasn’t been having adequate fluid -Assess patient for any electrolyte
imbalances. intake orally, and had 2 episodes of disturbances, such as skin turgor, any
diarrhea. muscle contraction, blurred vision, and
Nursing Care Plan 3
weakness.
-Monitor lab values as ordered, and notify
the physician if there are any electrolyte
imbalances.
- Hydrate the patient
The patient can have a potential infection -The patient has a WBC count of 1.4, RBC -Place the patient in reverse isolation
related to pancytopenia. count of 2.19, and Platelet count of 23. room.
-Instruct family that no outside fresh fruits
of flowers can be given to the patient
because it can cause infection.
-Monitor lab values as ordered
Nursing Care Plan 4
Implementations
Independent
Functional Health Planning Rationale
Nursing Diagnosis nursing functions, Evaluations
Pattern (outcome/goal) (use APA citations)
minimum two, &
prioritized)
Health Perception- Ineffective Patient will have a -Encourage -Lying flat causes -Goal was met due
Health Management Respiratory respiratory rate ambulation as soon the abdominal to the patient having
Pattern function related to within normal limits as consistent with organs to shift an oxygen
weakness as compared with medical plan of toward the chest, saturation of 97%.
manifested by baseline in 3 days. care. thereby crowding
patient exhibiting -Assist client to the lungs and
Shortness of breath reposition, turning making it more
on exertion. frequently from side difficult to breathe.
to side (hourly if -Exercises and
possible). movement promote
-Encourage deep- lung expansion and
breathing and mobilization of
controlled-coughing secretions.
exercises five times -Adequate hydration
every hour. and humidity
--Ensure optimal liquefy secretions,
hydration status and enabling easier
nutritional intake. expectoration and
preventing stasis of
secretion.
(Carpenito-Moyet
2006 p.528)
Nursing Care Plan 5
Health Perception- Risk for infection Patient will have -Place patient in -Prevents patient -Goat was met,
Health Management related to normal lab values reverse isolation from obtaining patients WBC count
Pattern pancytopenia as within 2 days. room infection coming was rechecked and
manifested by -Monitor vital signs. from an outside moved from 1.4 to
abnormal blood Note onset of fever, source. 3.9. Reverse
counts on lab draw. chills, diaphoresis, -Provides for early isolation was
and changes in detection of discontinued.
mentation. developing
-Assess lab values infectious process.
Doenges, 2006., p.
352).
- Suggestive of
presence of
infection/developing
sepsis, (Doenges,
2006)
Medications Mechanism of
Dose Common side Nursing
(with APA Class/Purpose Route Time action Onset of
(& range) effects considerations
citations action
Tylenol Nonnarcotic P.O. Every 4 hours 650mg – If Produces Anorexia, -Monitor s/s of
650mg Analgesic, As needed. temperature analgesia by vomiting, hepatotoxicity,
Antipyretic (Q4h PRN). >100.0 or for unknown dizziness, even with
If mild pain mechanism, but lethargy, moderate
temperature it is ventrally diaphoresis, acetaminophen
Nursing Care Plan 6
References
Planning, individualizing, and documenting client care. Philadelphia, PA: EA. Davis.
Wilson, B. A., Shannon, M. T., & Stang, C. L. (2008). Nurse’s Drug Guide 2007. Upper Saddle
Lifespan Feldman, R.,(2008) Human Development (11th ed.). Boston: McGraw Hill.
Miller-Keane. (2006), Encyclopedia & dictionary of medicine, nursing, and allied health – 7th
edition.Philadelphia, PA: Darlene Como
Nursing Care Plan 9
Stated correctly
Nursing Diagnosis Sufficient data to support 10
(20 points) diagnosis 10
Dated
5
Measurable
Goals 5
Realistic
(20 points) 5
Relates to ND
5
Relates to the etiology
Nursing Orders Individualized
8
Interventions Appropriate
8
(20 points) Includes assessment and
4
teaching interventions
Total