Delaware Technical Community College

NUR 320 Health Assessment

RN to BSN program: Plan of Care Chart

STUDENT NAME: Jessie Mbah________DATE: 06/17/2018

Nursing plan of care

Identified problem/need: Identified goal or Plan/ Interventions: Projected Evaluation/ Community Resources/
(include supporting outcome: (Provide rationale/ and Outcomes: (How will you Referrals: (Must be actual
subjective and objective cited evidence to justify measure that it worked?) resources from the
data) the rationale) client’s community.
Include Name, address,
web address, and phone
number)

1. Pain: Patient reports pain at a Assess pain intensity and Goal met. After Mr Armel is refered to
Chronic pain r/t potential level less than 4 on a 0 to aknowlege patient’s pain implementing the said Delaware Back Pain and
tissue damage AEB altered 10 pain scale level within experience: Acceptance nursing interventions, Sports; Address 29 N East
ability to continue 3 days. by the nurse allows for a patient reports pain level St, Smyrna De 19977.
previous activities. cooperative nurse patient of 2/10 on pain scale and Pnone # (302) 389-2225.
Patient engages in desired relationship and pain ability to perform desired www.delawarebackpain.c
Subjective data: activities without ratings are valid and activities without om
 Patient’s self experiencing an increase realiable as measures of experiencing increased Mr Armel is refered to a
report of pain in pain level within 3 days. pain intensity level pain. physical therapist for
 In patient’s own (McCaffery, Herr, & further assessment and
 words, the onset, Patient describes non Pasero, 2011). evaluation
duration and pharmacoligal methods ATI Physical Therapy
location of pain. that can be used to Educate patient on pain 1000 Smyrna-Clayton Blvd
 Patient’s supplement management approach Ste 4, Smyrna De 19977
description of pharmacological including medication www.ATIPT.com
quality of pain interventions to help administration, therapies, Phone # (302) 659-3102
(throbbing, achieve side effects and
burning, sharp, or comfort/functional goal in complications: A better
shooting). two weeks time. understanding of nature
 Numerical rating of pain, its treatment and
of pain at 7 on the patient’s role in the
pain scale of 0 to process leads to better
10 with 0 being pain control (Pasero et al,
the least pain and 2011).
10 the worst.
Objective data: Discuss patient’s fear of
 Vital signs (blood overdose or addiction to
pressure, pulse, pain medication:
respirations). Education is very vital for
 Patient behavior effective pain control due
(grimacing, crying to many misconceptions
or guarding). about pain management
 Patient’s medications. Opioid
expressions such tolerance and physical
as anger, dependence are expected
irritability and with long term opioid
fear. treatment and should not
be confused with
addiction (McCaffery,
Herr, & Pasero, 2011).
 Implement non
pharmacological
interventions such as
relaxation and heat and
cold application: Non
pharmacological methods
should be used to
reinforce and not to
replace pharmacological
interventions for more
effective pain control
management (Pasero et
al, 2011).

Educate patient to control Referred client to the

2. Risk for Patient will state stimuli that can cause Patient has lost 2 lbs. in Super Tracker website
imbalanced pertinent factors overeating such as one week. Patient agrees http://www.choosemyplat
nutrition: more contributing to weight watching frequent food to maintains a food diary e.gov/supertracker-
than body gain related commercials on and weight log. Patient tools/supertracker.html to
requirements r/t TV: A study by LeBlanc et agrees to walk 45 minutes help him plan his meals.
excessive intake in Patient will lose weight in al, (2011) found that 3 days a week and plans
relation to a reasonable period (1 to behavioral based to gradually increase it to Referred client to the U.S.
metabolic need 2 lbs a week ). treatments are safe and one hour 3 times a week . Dietary Guidelines found
Subjective data: effective for weight loss. He verbalizes at
 Patient reports he Patient will incorporate commitment to a lifelong http://www.cnpp.usda.go
has not engaged increased exercise Recommend that client plan of low fat, non sugary v/DietaryGuidelines.htm
in any physical requiring energy lose weight slowly, not diet and exercise. He to help him determine
activity since he expenditure into daily life more than 1 to 2 lbs a plans to attend and what kind of foods to eat.
 was 10 week: Slower weight loss participate in weekly
 Patient states he Patient will design dietary is generally more likely to nutrition classes and also Patient is given the
uses food as a modifications to meet be lasting weight loss weigh himself weekly at address to a walking trail
coping individual long term goal his local community clinic. in his community.
mechanism when of weight control Encourage client to Big Oak County Park
stressed out engage in both aerobic 417 Big Oak Rd, Smyrna,
 Patient states he exercise and strength DE 19977
eats a whole box training: Research shows co.kent.de.us/parks-
of large pizza and aerobic training is recreation.aspx
drinks 2 liters of associated with loss of Phone # (302) 744-2495
soda in one sitting visceral and subcutaneous
Objective data: fat where as strength
 Patient is 5’5 and training causes loss of
weighs 250 lb subcutaneous fat only (Li
 Patient pants et al, 2011).
when walking
short distances Encourage patient to
 Noticable tricep replace sugar- sweetened
skin folds greater beverages such as sodas,
than 15mm fruit juices and sports
drinks with plain water: A
study demonstrated that
sugary drinks increase
visceral fat and drives
insulin resistannce
predisposing to type 2
diabetes and heart
disease (Pan et al, 2012).
 Mr. Ahmed is a 24-year-old single, African American male admitted at the clinic with report of pain to his right ankle from an

injury sustained from playing recreational basketball while in college. Patient rates pain at 7/10 based on a 0 to 10 pain scale. Vital

signs: BP 140/92, P 110, RR 18. Patient states he has been in pain for about five years now but has not sort effective pain management

until now. During assessment, patient was grimacing and guarding the affected ankle. Patient states he has been using over the counter

Motrin 400 mg three times a day when pain becomes unbearable. When asked why patient did not seek help earlier, patient states he

was worried the doctor was going to prescribe opioids for his pain and he did not want to become addicted to pain medications. Patient

was educated on the importance of effective pain management and the risk of physical dependence and tolerance with long term

opioid use and not necessarily addiction (McCaffery, Herr, & Pasero, 2011). Patient states the pain prevents him from effectively

carrying out his normal day to day activities thus forcing him to live a more sedentary lifestyle than he would have wanted to. Patient

states as a result of that, he has turned to eating as a coping mechanism and has noticed a drastic increase in weight and folds in his

mid-section and triceps that he never had before. Patient also complains of shortness of breath just from ambulating short distances. At

time of assessment, Mr. Ahmed also mentioned he has a family history of hypertension, diabetes, cardiovascular disease, and he

comes from a culture where men are perceived as being weak when they openly express pain. Nursing assessment is completed and a

treatment plan for Mr. Ahmed is initiated.

Patient states his goal for pain management is to get his pain below 4 on a 0 to 10 pain scale. According to McCaffery, Herr, &

Pasero (2011), pain rating is a valid and reliable measure of pain intensity. Patient is educated on the benefits of using non-
pharmacological methods such as heat and cold compresses for pain control and patient expresses his willingness to give it a try; a

study by Pasero et al, (2011) found that, the use of non-pharmacological methods to reinforce pharmacological interventions resulted

in more effective pain control management. Within three days of admission, patient’s pain was a 4/10. Since patient’s pain was being

controlled, patient was able to focus on weight loss strategies. Patient started walking the hallways 10 minutes a day and stopped

watching food related commercials on TV. As evidenced in a study by LeBlanc et al, (2011), it was found that behavioral based

treatments are safe and effective for weight loss. Mr. Ahmed was encouraged to reduce his intake of sugary drinks given he has a

family history of diabetes and cardiovascular disease. During meals, patient refrained from eating the junk food he normally eats and

drank more water instead of sodas and sports drinks. A study by Pan et al, (2012) demonstrates that sugary drinks increase visceral fat

and drives insulin resistance predisposing to Type 2 diabetes and heart disease.

Patient was evaluated by reassessment and feedback from patient. Within a week, patient’s pain level is a 2/10, patient is able

to ambulate short distances without panting, able to carry out ADLs without increased pain and has also lost 2 lbs within the same

time frame. Patient agrees to maintain a food dairy and weight log. Patient states he will engage in a more vigorous exercise regimen

such as incorporating aerobics with strength training exercises. Research shows that aerobic exercise is associated with loss of visceral

and subcutaneous fat whereas strength training causes loss of subcutaneous fat only (Li et al, 2011). Upon discharge, patient is

referred to a pain doctor and physical therapist in his community for follow up and long-term pain management. Patient is provided

with information on the Super Tracker and U.S. Dietary Guidelines to help with selecting food choices and meal planning. Patient is
also given information about parks and walking trails in his neighborhood. Patient is scheduled for a follow up appointment in a

months’ time to track his progress but is advised not to hesitate to call before the scheduled time in case of an emergency.