1

NORTHEASTERN OKLAHOMA A&M COLLEGE

DEPARTMENT OF NURSING
NURSING CARE PLAN
CINDY BROWN – MED SURG CLINICAL WEEK 1

ASSESSMENT DIAGNOSIS PLANNING PLANNING IMPLEMENTATION EVALUATION

ACTIONS RATIONALE

Data Organization Interpretation of Data Planning Nursing Documentation Validating Care Plan Evaluation of Goal
(Subjective Data) Determination of Actions for Why Nursing Documenting Care Plan Achievement
Nursing Dx. Priority *PROVIDE Actions Were Giving Nursing Care Reassement of Care
CLIENT STATEMENTS Setting INFORMATION Selected Continuing Data Plan
STATEMENTS “I DEALT DECISIONAL CONFLICT AA/ALANON PEOPLE WHO Collection
DRUGS, I NEW I WOULD RT RISKS VS BENEFITS COMMUNITY ABUSE CLIENT STATEMENTS
GET CAUGHT SOONER OF ILLEGAL RESOUCES TO SUBSTANCES OR Not Implemented REVEAL CONCERN FOR
OR LATER.” DANGEROUS DISCOURAGE DRUG USE ILLEGALLY *PROVIDE INFORMATION HEALTH AT LAST
SITUATIONS AEB ABUSE OBTAINED AA/ALANON CONVERSATION ON
PATIENTS DRUGS…ARE COMMUNITY RESOUCES 9.2.10
“I NEED TO WATCH MY STATEMENTS “I DEALT
DIABETES NOW, MY *DIABETES UNABLE TO TO DISCOURAGE DRUG
DRUGS, I NEW I WOULD MAKE HEALTHY ABUSE EXPECTED
MOTHER DIED FROM IT EDUCATION BY
GET CAUGHT SOONER DECISIONS AND OUTCOMES SHOULD
AFTER HER LEG WAS DIABETES
OR LATER.” TO SOLVE INLCUDE
AMPUTATED” EDUCATOR Implemented 9.1.10
Planning: Goal Setting PROBLEMS…. VERBALIZATION AND
PATIENT ENCOURAGED UNABLE TO *DIABETES EDUCATION DEMONSTRATION OF
(Objective Data) TO STOP *ENCOURAGE IDENTIFY AND BY DIABETES EDUCATOR DIABETES SURVIVAL
VS DEALING/DOING IMPROVED SKILLS
IMPLEMENT
T 98.1 DRUGS –IMPROVE NUTRITIONAL ADAPTIVE Not Implemented
DECISION MAKING INTAKE AND AND AT LEAST A
P 100 BEHAVIORS. *ENCOURAGE IMPROVED
REGARDING PERSONAL CONTROL OF VERBALIZED
R 16 BLOOD GLUCOSE (BRUNNER & NUTRITIONAL INTAKE INTEREST IN
SAFETY
LEVELS SUDDARTH P. AND CONTROL OF IMPROVED HEALTH
BP 161/95
120) BLOOD GLUCOSE LEVELS AND SAFETY.
SAO2 95 RA PATIENT WILL BECOME
COMPLIANT – MANAGE *TEACH DIET
DM BY PERFORMING MODIFICATIONS PATIENT Not Implemented
MEDICAL DIAGNOSIS: DIABETES SURVIVAL TEACHING IS THE *TEACH DIET
AND MODERATE
HT – DM – HYDRO SKILLS AND SELF- MAJOR MODIFICATIONS AND
EXERCISE TO
NEPHRITIS CARE ACTIVITIES STRATEGY USED MODERATE EXERCISE TO
PROMOTE WEIGHT
TO PREPARE PROMOTE WEIGHT LOSS
LOSS
CLIENT WILL ENGAGE PATIENTS FOR
BS 164-225 ON 9.2.10
IN ACTIVITIES TO SELF-CARE. Not Implemented
MORBIDLY OBESE PROMOTE WEIGHT *ARANGE FOR
(BRUNNER & *ARANGE FOR FOLLOW
UNCONTROLLED DM LOSS AND GENERAL FOLLOW UP HOME SUDDARTH P UP HOME CARE WITH
DEPRESSION HEALTH CARE WITH
1418) DIETICIAN, HOME CARE
IMPROVEMENT DIETICIAN, HOME
 2
CARE NURSE OR NURSE OR OUTPATIENT
OUTPATIENT CONTINUING DIABETES CENTER
DIABETES CENTER CARE IS
PARTICULARLY
IMPORTANT FOR
PATIENTS WHO
HAVE HAD
DIFFICULTY
COPING WITH
THE DIAGNOSIS,
PATIENTS WHO
HAVE
LIMITATIONS
THAT MAY
AFFECT THEIR
ABILITY TO
CARRY OUT THE
MANAGEMENT
PLAN.
(BRUNNER
&SUDDARTH
P.1419)