Delaware Technical Community College

NUR 320 Health Assessment

RN to BSN program: Plan of Care Chart

STUDENT NAME: __Joel Pascual________________________________________ DATE: 12/1/19

Nursing plan of care

Identified Identified goal or Plan/ Interventions: Projected Evaluation/ Community Resources/
problem/need: outcome: (Provide rationale/ and Outcomes: (How will Referrals: (Must be
(include supporting cited evidence to justify you measure that it actual resources from
subjective and objective the rationale) worked?) the client’s community.
data) Include Name, address,
web address, and
phone number)
Hypertension: Client’s Maintain blood Schedule regular PCP Client has BP of 120/80 PCP: Delaware Primary
BP at rest 138/84, no pressure at or below visits: Helps PCP to or less at rest on 3 Care LLC Dover
subjective symptoms, 120/80 at rest. identify new issues, separate occasions. Dr. Sandeep Mann, MD
diagnosed. By primary recommend and treat (302) 730-0554
care provider ongoing issues like htn. https://mydeldoc.com
(Mayo Clinic, 2019) 810 New Burton Road
Suite-3 Dover, DE 19904
Take antihypertensives
per MD: If MD PCP: Delaware Primary
perscribes Care LLC Dover
antihypertensives, BP Dr. Sandeep Mann, MD
can be better (302) 730-0554
controlled. https://mydeldoc.com
(Mayo Clinic, 2019) 810 New Burton Road
Suite-3 Dover, DE 19904
 Eat less salt: high
sodium pulls water into
intravascular space
causing more resistance
and higher pressures.
(Mayo Clinic, 2019)

Limit alcohol: cause of

htn when drinking
unknown etiology,
possible SNS and RASS
activation.
(Ansari, Ferder &
Husain, 2014)

Get regular physical

activity: Allows the
conditioning of heart
for more efficient
pumping.
(Mayo Clinic, 2019)

Maintain healthy
weight: Increased fatty
tissue increases
vascular resistance and
increases work of heart.
(Jiang, Lu, Ruan, &
Zong, 2016)
Obesity: Pt is 240 lbs Reduce BMI to at or Get at least 150 Pt is able to reach PCP: Delaware Primary
and 5’5”. Body mass below 25, which would minutes per week of target weight of 150 in Care LLC Dover
index (BMI) is 39.9. BMI indicate a goal weight exercise – moderate one year, or 7.5 pounds Dr. Sandeep Mann, MD
30 or higher is of 150. intensity. per month. (302) 730-0554
considered obese. https://mydeldoc.com
Become less sedentary, 810 New Burton Road
keep moving Suite-3 Dover, DE 19904
throughout the day.

Visit PCP for treatment, PCP: Delaware Primary

intervention, advice, Care LLC Dover
and weight loss Dr. Sandeep Mann, MD
planning. (302) 730-0554
https://mydeldoc.com
See 810 New Burton Road
dietician/nutritionist for Suite-3 Dover, DE 19904
advice and planning.
Contemporary Nutrition
For all interventions Wendy Gibson, MS,
(Mayo clinic, 2019) RDN, CDE, CSSD, LDN
(302)285-9538
https://www.contempo
rarynutritioninc.com
301 Camden-wyoming
Ave
Camden, Delaware 199
34
References

Husain, K., Ansari, R. A., & Ferder, L. (2014, May 26). Alcohol-induced hypertension: Mechanism and prevention. Retrieved
December 2, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4038773/.

Jiang, S.-Z., Lu, W., Zong, X.-F., Ruan, H.-Y., & Liu, Y. (2016, October). Obesity and hypertension. Retrieved December 3, 2019, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5038894/.

Mayo Clinic. (2018, May 12). High blood pressure (hypertension). Retrieved December 30, 2019, from
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/diagnosis-treatment/drc-20373417.

Mayo Clinic. (2019, August 22). Obesity. Retrieved December 3, 2019, from https://www.mayoclinic.org/diseases-
conditions/obesity/diagnosis-treatment/drc-20375749.