Delaware Technical Community College

NUR 320 Health Assessment

RN to BSN program: Plan of Care Chart

Candice Hoffecker
STUDENT NAME: ______________________________________________ 2/18/2021
DATE: ____________________________________

Identified problem/need: Identified goal or Plan/ Interventions: Evaluation/ Outcomes Community resources/
(include supporting outcome: (Provide rationale/ Referrals
subjective and objective evidence to justify the
data) rationale)

LLQ abdominal pain related to Short term goal: Patient will Plan: Introduce alturnative Within 24 hours the patient Referred to a GI specialist.
uncomplicated diverticulitis: verbalize relief of pain from 7 methods to reduce pain. reported a pain level of 4 out Gave online resourse for
Patient rates pain 7 out of 10, to 4 within 24 hours. Interventions: of 10. American
describes the pain as - Apply a heating pad to the Gastroenterological
persistant achy or throbbing. LLQ abdomen for 15-20 min at Association
LLQ tenderness upon a time.
palpation. -Use guided meditation and
deep breathing excercises.
Patient reports an acceptable -Assess comfort status
pain level would be 4 out of frequently.
10. -Administer pain medications
as ordered
Dietary education to prevent Short term goal: After Intervention: Patient identifies 3 dietary Referred to a dietary
the reoccuance of diverticulitis teaching the patient will -Inform the patient about the ways to improve diverticulitis. specialist
verbalize 3 dietary ways to importance of increasing fiber
prevent the reoccurance of - Teach the patient that new
diverticulitis research indicates that its not
necessary to avoid nuts, seeds
and popcorn.
(https://effectivehealthcare.ahr
g.gov)
- Consume yogurt daily or a
probiotic supplement
Imbalanced Nutrition: Long term goal: There is -Collaborate with The patient lost 5 lbs but Referred to a dietary
Less than body no significant weight loss nutritionist to determine maintained a healthy specialist
requirements of 10 lbs or greater. the number of calories weight.
and nutrients needed for
the patient.
-Monitor the patients
caloric intake.
-Weigh the patient daily

Obstructive sleep apnea: Short term goal: The - Assess how the mask fits Patient maintained an Referred to a sleep
Ineffective breathing patient will wear CPAP on the patients face. effective breathing medicine specialist.
pattern device at night and -Monitor the patients pattern, as evidence by a
maintain a normal oxygen saturation. normal rate and depth of
breathing pattern - Assess respiratory rate breathing and absence of
and depth at least every 4 dyspnea.
hours.
Patient reports feeling
rested.

Lack of compliance with
CPAP device for OSA: The
patient reports using the
CPAP device 50% of the
time. Patient does not
like using the CPAP due
to skin reactions and dry
throat
Long term goal: Improve
CPAP use from 50% to a
minimum of 75% within
a month.
Plan: Collaborate with
sleep apnea specialist to
discuss options for
another type of mask
- encourage the patient to
keep a glass of water next
to the bed to help prevent
throat irritation.
Patient increase use to Referred
about 60%, will
re-educate patient on
importance of wearing
the CPAP device every
night.

Adapted from Florida International University: http://cnhs.fiu.edu/nursing/undergrad/_assets/common-assets/nursing-assesment-tools/NUR%20ASSESS_BSN%20Nursing%20Care%20Plan.pdf