Delaware Technical Community College

NUR 320 Health Assessment

RN to BSN program: Plan of Care Chart
STUDENT NAME: Kristina Funk______________________ DATE: April 27, 2017___________

Identified problem/need: Identified goal or Plan/Interventions: Evaluation/Outco Community

(include supporting subjective and outcome: (Provide mes resources/Refer
objective data) rationale/evidence rals
to justify the
rationale)
Acid reflux Client will follow Educate client on Client will Referral to
Client verbalized issues with acid mutually agreed anti-reflux discuss fear of or Registered
reflux/heart burn. on health care regimen, including obstacles that Dietician:
Interrupted sleep, frequent improvement proper diet and are impeding Daniel Munford,
waking up in middle of the night, program within positioning. him from RD
at least 3 to 4 nights per week. one week and Certain foods implementing 102 Sleepy
Client is at least 25 lbs. experience a trigger reflux. health regimen Hollow Dr Ste
overweight, with excessive reduction in acid Instruct to remain by end of office 200,
abdominal girth. reflux symptoms. in upright position visit. Middletown, DE
at least 2 hours Client will adhere 19709 (302)
after meals; to anti-reflux diet 378-9128
avoiding eating 3 and identify
hours before three foods or Dr. Frances
bedtime. Gravity drinks that Taccone
assists in keeping exacerbate his Griffith, PHD
acid from rising condition. 353 Greybull
into esophagus. Client will show a Dr, Bear, DE
Obtain complete decrease in 19701
nutritional history weight by next (302) 836-1798
and instruct to use office visit.
food log or app to Client will Samsung
track daily intake verbalize a Health app
and sleep. Allows decrease in allows tracking
him to identify episodes that of steps, active
foods that trigger interrupt sleep. minutes,
his reflux. caloric and
Assist the client in caffeine intake.
learning stress Weight
reduction Watchers app
techniques. Stress allows one to
increases acid track caloric
production. intake.
Refer to
nutritionist to
assist with meal
planning and
proper diet. Helps
educate on foods
to eat and foods to
avoid.
Explain how
reduction in weight
can decrease or
alleviate some of
the symptoms of
acid reflux. Weight
can increase
pressure on lower
esophageal
sphincter causing
it to open and
allow acid to rise.
Borderline Obesity Client will lose 5 Refer to Monthly weight Samsung
Client is at least 25 lbs. lbs. per month nutritionist to decrease, until Health app is
overweight, with excessive until reaches assist with meal target weight is available
abdominal girth. target weight. planning and reached. through clients
Client admits to poor diet (only proper diet. Evaluate food log Samsung
eats 2 meals a day, lacking Provides with diet or apps used to phone.
vegetables and fruits). appropriate for track progress,
Client reports walking as only weight loss. including Village Gym or
physical exercise; insufficient Educate client on exercise the Middletown
physical activity. importance of regimen. Y are gyms
No SOB noted during respiratory daily physical Evaluate SOB, located near
assessment, but client notes out activity and impact HR, and clients home.
of breath when running. to overall health. presence of
Physical activity increased Weight
can lower the risks endurance Watchers
of many chronic during moderate
diseases. physical activity. Family
Set target weight Client will involvement for
and exercise goals exercise at least success of
with client. Client 30 minutes a health
participation in day, five days a maintenance
goals makes it week, by the end plan.
more likely to be of the next Local parks
realistic and month. near clients
motivate the Monitor blood home:
client. pressure and Lums Pond
Educate client on evaluate State Park
use of technology patterns.
to track food Glasgow Park
intake, exercise,
and weight. Levels Park
Tracking progress
helps increase White Clay
motivation and Creek State
 provides insight. Park
Develop plan with
client to maximize
time to fit in
exercise; ex. pack
lunch and walk
during lunch hour.
Increases clients
chance of
participation if can
fit into daily
schedule.
Spiritual Distress Client will identify Observe client for Client will Connection
Evidenced by lack of a type of spiritual cues indicating verbalize one Community
concepts/beliefs that give experience that difficulties in other source of Church
meaning to his life other than my provides him with finding meaning, spiritual support 100 W Green
family. comfort by the purpose, or hope besides my St, Middletown,
Poor support, client lists only wife next office visit. in life. Provides an family. DE 19709
and 6 yr. old daughter as family understanding of
Guarded, nonspecific short clients support Pittman
answers and poor eye contact and belief system. Behavioral
during discussion of this topic. Create an Health
accepting, 102 Sleepy
nonjudgmental Hollow Drive
atmosphere. Suite 204
Establishes Middletown,
rapport and Delaware
promotes open 19709
communication.
Encourage the use
of spiritual
resources, if
desired. Spiritual
needs may
 sometimes be
overlooked or
ignored.
Observe and listen
empathetically to
his
communication,
using active
listening skills.
Increases
therapeutic
relationship and
allows nurse to
function as a
resource.
Adapted from Florida International University: http://cnhs.flu.edu/nursing/undergrad/assets/common-assets/nursing-assessment-tools/NUR%20_ASSESS BSN
%20Nursing%20Care%20Plan.pdf