Delaware Technical Community College

NUR 320 Health Assessment

RN to BSN program: Plan of Care Chart

STUDENT NAME: _Ashley Altman_____ DATE: ___8/3/22_____

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)
Risk for unstable blood Mr. A will achieve and Assess for signs and Monitor A1C frequently to Delaware Diabetes
glucose levels r/t lack of maintain glucose in symptoms of hypo and provide accurate Coalition-
adherence to diabetes satisfying range of blood hyperglycemia – results in information on how blood 107 Vollkorn Road
management medication glucose of 140 to 170 and an inadequate amount of glucose levels are being Magnolia, DE 19962
management, stress, A1C less than 7%. insulin to glucose. maintained. Delaware Diabetes
sedentary activity level Coalition - Your Source for
secondary to diabetes Mr. A will maintain proper Monitor blood glucose Continue monitoring and Diabetes Information
mellitus AEB poor diet self-care during working levels prior to meals and assessing abdominal pain (dediabetescoalition.org)
intake due to “eating what hours and obtain bedtime – Control of and provide follow up
I’m in the mood for at the medications on a timely blood glucose levels care as needed. Diabetes Wellness Center
time”, problems obtaining manner. within the nondiabetic at Bayhealth-
medications on time, range can significantly Monitor/ assess weight 640 S. State St.
physically active work in reduce the development management to ensure Dover, DE 19901
heat and abdominal pain. and progression of proper exercise and diet. 302-744-6307
complications. Diabetes Management |
Bayhealth
Assess/ monitor bowel
sounds and report any
 pain, N/V, and bloating –
hyperglycemia can disrupt
gastric motility

Importance of proper diet

and meal content/timing -
Pacing food intake
throughout the day places
more manageable
demands on the pancreas
and to help the
incorporate weight
management and learn
new dietary habits.

Risk of hypertension r/t Mr. A will identify possible Define safe limits of blood Mr. A will maintain a log American Heart
lack of knowledge and complications, such as, pressure (BP) under 120 of daily BP and will have Association of Delaware –
misinterpretation of poor perfusion (color of and explain effects on the follow up appointments to 131 Continental Drive,
information AEB type 2 skin, strength of pulses, body - Provides the basis check BP periodically. Suite 407 Newark, DE
diabetes and family and temperature) and for understanding New Castle: (302) 454-
history of high blood blood pressure above 140. elevations of BP and Monitor weight to ensure 0613
pressure. understanding that high proper diet and exercise. Kent and Sussex: (877)
BP can exist without 750-4276
symptoms is central to Delaware | American
enabling the patient to Heart Association
continue treatment, even
when feeling well.

Identify modifiable risk

factors (diet, sedentary
lifestyle, stress) - These
risk factors have been
shown to contribute to
hypertension and
cardiovascular disease.