Delaware Technical Community College

NUR 320 Health Assessment

RN to BSN Program: Plan of Care Chart

STUDENT NAME: Tracey Wilson DATE: April 2017

Identified problem/need: Identified goal or Plan/Interventions: Evaluation/Outcomes: Community resources/

(include supporting outcome: (Provide Referrals
subjective and objective rationale/evidence to
data) justify the rationale)
Hypertension/Hyperch Nursing diagnosis: Discuss risk factors of The client will return to YMCA of Delaware
olesterolemia: Imbalanced nutrition: hypertension - the doctors office for a -https://www.ymcade.or
Client states family More than body Better understanding of follow-up in 1 month for g
history of both diseases requirements related to disease will increase evaluation of care plan. Bear-Glasgow Family
in his parents. Father excessive intake of high motivation to manage it Will show log of blood YMCA
had 3 strokes resulting fat and high sodium and lower readings. pressure readings, note 3451 George William
from hypertension and foods manifested by Have client take blood any changes below Way,. Newark, DE
high cholesterol. weight gain and elevated pressure readings weekly 146/90. Have blood 19702
Medications taken - blood pressure and and record. work drawn and check (302) 836-9622
Atenolol 100 mg a day cholesterol. Provide with dietary total cholesterol and Open 7 days a week
Atorvastatin 200 mg a materials (DASH diet) lipid levels. Look at
day Goals: The client will and review - dietary intake log. Herbalife Consultant
Blood pressure on have adequate nutritional Ensures client has Explain how diet has Carl Smith -
medications - 146/90 intake of low fat, information to plan changed and what food (302) 893-2275
Weight 275 lbs, gain of reduced sodium diet as healthy meals. choices are being made.
35 lb evidenced by lose of 1-3 Have client start a food Discuss exercise DASH Diet Eating Plan
lbs/wk. log: time, type and program started. Weigh http://dashdiet.org/defaul
amount - client. Starting weight t.asp
Engage in 20-30 minutes Helps client visualize in was 275 lbs., hope to see
of exercise 3 times a wk. writing what is being a loss of around 5 to 10 Blood Pressure Health
consumed and note lbs. Stations
healthy and unhealthy Walgreens, CVS, Rite
choices. Aid
Review with client age- Encourage client on the
appropriate exercises progress being made and Blood pressure
and start an exercise make any changes machines for upper
program - necessary if results are arm and wrist
Exercise will help burn not quite what is Walmart - price range
calories and increase expected. from 14.76 to 64.99.
energy level.
Back pain : Nursing diagnosis: Discuss changing The client will return to YMCA of Delaware
Client suffered a back Acute pain related to nutrition and need for the doctor's office for a -https://www.ymcade.or
injury in 2006 resulting musculoskeletal weight loss relating to follow-up in 1 month for g
in herniated/torn discs in problems manifested by back pain - evaluation of pain and Bear-Glasgow Family
L4-L5 occasional interrupted Better understanding of care plan. Will review YMCA
Receives epidural sleep patterns and loss of how extra weight can the pain log and the 3451 George William
injections about once a mobility. affect the back causing methods of pain relief Way,. Newark, DE
year for pain strain and loss of support used over the month 19702
management. Goals: The client will will increase motivation with the goal of reducing (302) 836-9622
Low activity level and have increased activity to loss weight, possibly Percocet use. The client Open 7 days a week
interrupted sleep patterns tolerance and mobility as alleviating pain. will demonstrate back Yoga Classes available.
due to pain. Work evidenced by knowledge Provide with stretch stretching exercises used
activity can cause pain and demonstration of exercise materials and to improve muscle Stretches for sciatica
as well. stretching exercises to review - strength and relieve pain relief - website
Takes Percocet relieve pain and pressure Stretching back impingement on nerves. material
prescribed by doctor for on nerves. exercises can help bring Will weigh the client https://breakingmuscle.c
severe pain (up to 30 back flexibility and hoping to see some om/learn/heal-your-
pills a month). Experience pain relief increase mobility, weight loss and discuss lower-back-pain-with-
without drug dependence decreasing back pain and the importance of this in these-5-yoga-poses
as evidenced by discomfort. relation to back pain and http://www.healthline.co
reduction in need for Discuss pain relief proper body alignment. m/health/back-
Perocet from 30 pills to methods - pain/sciatic-stretches?
20-15 pills. Exploring other options Encourage client on the m=0#overview1
for pain relief will give progress being made and
client choices other than make any changes Pain Management -
narcotics lessening risks necessary if results are Dr. Nancy Kim
for dependence. not quite what is 4735 Ogletown Stanton
Client will keep a log of expected. Rd #3302, Newark, DE
pain episodes, ratings 19713
and method of control. (302) 623-4144
Skin cancer: Nursing diagnosis: Discuss risk factors for The client will return to Protective clothing
Client diagnosed with Ineffective health skin cancer and sun the doctor's office for website
squamous cell skin maintenance related to damage to skin - follow-up in 6 months. http://www.sunprecautio
cancer on the right excessive sun exposure Better understanding of At that time will have ns.com
sideburn/pre-auricular as manifested by the disease and the his yearly skin
area of the face. Mohs removal of skin cancer behaviors contributing to examination discussing Ways to protect
procedure performed in and appearance of it will motivate the client any changes that may yourself from the sun
2016. Evidence of actinic keratoses. to better protect his body have been noticed, if not websites
further sun damage on from further damage. already detected and https://www.cancer.org/c
head and face in the Goals: The client will Provide with material what it is he should be ancer/skin-
form of actinic prevent further sun on sun protection and looking for each month. cancer/prevention-and-
keratoses. Client damage to skin/reduce ways to minimize Will explain the early-detection/uv-
suffered from severe incidence of further skin exposure - importance of sun protection.html
sunburns and had sun cancers as evidenced by Ensures client has protection and ABCs of sun protection -
poisoning as a child. knowledge of risk information on demonstrate the ways in http://www.sun-
Played outside with no factors and protection (ABC of sun which he is protecting protection-and-products-
sun protection. demonstrating proper protection) his body. Discuss the guide.com/Sun-
techniques for Discuss the importance use of Zyclara for Protection-
protection. of monthly skin exams, treatment of actinic Education.html
and what changes to keratoses.
look for - Best sunscreens -
Better understanding of Encourage client on the http://www.consumerrep
skin changes and progress being made and orts.org/cro/sunscreens/b
importance of prompt make any changes uying-guide
detection will motivate necessary if results are
client to be more aware not quite what is Dermatology - Dr.
and notify doctor of any expected. Hanson
differences. 537 Stanton Christiana
Rd #207, Newark, DE
19713
(302) 633-7550