NEW RIVER CTC SCHOOL OF PRACTICAL NURSING

NURSING PLAN OF CARE

STUDENT:_____________________________________________________________
DATE:____________________

PT. INITIAL/ADMITTING DIAGNOSIS:_______________________________________

FACILITY:__________________

ASSESSMENT NURSING PLANNING IMPLEMENTAT EVALUATION

DIAGNOSIS ION
DATA NANDA GOALS/ NURSING RATIONALE FOR CARRYING OUT GOAL MET
COLLECTION COLLABORATIVE OBJECTIVES INTERVENTIONS INTERVENTIONS NURSING GOAL NOT MET
PROBLEM INTERVENTION GOAL
S PARTIALLY MET
Pt will come 1. Discuss normal 1. Knowledge 1. Explaine
up with ways heart function. of disease d to the
SUBJECTIVE PRIORITY # 3 to get Include process and patient
DATA medications information expectations about A
Deficient filled before regarding can facilitate Fib which Goal met
knowledge R/T she runs out patients adherence to she has Pt made a list
lack of and variance from prescribed and the of interventions
understanding understand normal function. treatment importan on ways to fill
Pt. states she the importance the Explain regimen. ce of meds and she
went several of taking importance of difference 2. Promotes taking repeated why
days without prescribed taking between heart maintenance furosemi furosemide was
furosemide, medication prescribed attack and HF. of muscle de to so important to
didnt think it AEB pt went medications 2. Encourage pt. to tone and prevent her treatment
would cause several days daily by end developing a organ edema. by end of the
any harm>. without of the week. regular home function for Docume week.
Furosemide. exercise overall sense nted
program of well-being teaching.
3. Discuss 3. Excessive 2. Pt. listed
importance of physical ways she
being as active activity or would
as possible overexertion include
without can further daily
becoming weaken the exercise
OBJECTIVE exhausted and heart, to
 NEW RIVER CTC SCHOOL OF PRACTICAL NURSING
NURSING PLAN OF CARE
STUDENT:_____________________________________________________________
DATE:____________________

PT. INITIAL/ADMITTING DIAGNOSIS:_______________________________________

FACILITY:__________________

DATA of rest between exacerbating promote

activities. failure, and better
4. Assess ability to necessitates gait
remember and adjustment 3. Pt stated
perform daily of exercise she
medication program. knows
intake. 4. Cognitive when to
5. Assess impairments take a
motivation and needs to be break
willingness of identified so because
patient an she
6. Assess pts appropriate becomes
attitude and teaching dizzy.
feelings about careplan can 4. Pt
changes. be designed. appears
7. Provide 5. Adults must able to
information see a need rememb
about to or purpose er to
furosemide for learning. take
8. Document Learning also daily
progress of pts requires medicati
learning . energy, on. Pt
9. Give pt clear and which pts wasnt
simple may not be aware of
instruction on ready to use. the
taking 6. Assessments importan
medication and assists with ce of
why to not run understandin taking
out g how the furosemi
10.Assess why the learner may de daiy.
 NEW RIVER CTC SCHOOL OF PRACTICAL NURSING
NURSING PLAN OF CARE
STUDENT:_____________________________________________________________
DATE:____________________

PT. INITIAL/ADMITTING DIAGNOSIS:_______________________________________

FACILITY:__________________

pt went several respond to 5. Pt now

days without the understa
taking information. nd that
furosemide 7. To reinforce taking
what has medicati
already been on as
stated about prescribe
medication d
and also furosemi
allow pt to de with
have prevent
something to edema.
look back to 6. Pt was
after very
discharge excepted
8. Documentati of
on allows for informati
a baseline on
for what the regardin
pt already g
knows fluorsemi
9. To not dDocum
confuse the ent in
pt and to chart
make sure 7. Pamphlet
the pt given on
understands furosemi
what you are de
telling them 8. Docume
10.To help nted that
 NEW RIVER CTC SCHOOL OF PRACTICAL NURSING
NURSING PLAN OF CARE
STUDENT:_____________________________________________________________
DATE:____________________

PT. INITIAL/ADMITTING DIAGNOSIS:_______________________________________

FACILITY:__________________

unstand and pt know

make the
corrects so importan
pt doesnt go ce of not
without letting
medication furosemi
again. de run
out to
prevent
edema
9. Pt was
provide
simple
and clear
instructio
ns on
medicati
on
importan
ce
10.Pt stated
she was
taking so
many
different
meds
she
didnt
not
realize
 NEW RIVER CTC SCHOOL OF PRACTICAL NURSING
NURSING PLAN OF CARE
STUDENT:_____________________________________________________________
DATE:____________________

PT. INITIAL/ADMITTING DIAGNOSIS:_______________________________________

FACILITY:__________________

she had
been out
of her
furosemi
de. Pt
states
that
pharmac
y will
deliver
her
meds to
her.