Running head: The Plan of Care 1

The Plan of Care

Misoon Kim

04/26/2019

NUR 320 5W1 Health Assessment

Delaware Technical Community College

The Plan of Care 2

The Plan of Care for My Patient

Through the holistic assessment of my patient, I was able to determine my patient’s

health history and the environmental/psychosocial factors that affect my patient’s health. I have

found out two current health problems of my patient. They are imbalanced nutrition (taking in

more than the body requires) and disturbed sleeping patterns. I identified them as problems

because both health issues the patient currently has can affect the patient’s health significantly

and can cause other future health issues. For example, according to the Centers for Disease

Control and Prevention [CDC], overweight and obese people are at an increased risk for many

serious diseases such hypertension, type 2 diabetes, coronary heart disease, and stroke (CDC,

2019). Disturbed sleep patterns can also provoke harmful health conditions such as heart

disease, hypertension, obesity, diabetes, and all-cause mortality (Healthy People 2020, 2019).

There are many resources available to provide help for losing weight and establishing a

healthy diet. Evidence-based interventions for losing weight include formulating a healthy eating

plan with the patient and keeping a daily food diary which records caloric intake, types and

amounts of food, and eating habits. Also, encouraging the patient to adopt an exercise routine

that involves at least 30 minutes of exercise 5 times per week can provide big benefits to one’s

health and aid in weight loss (CDC, 2019). To improve sleep disturbance patterns, educating the

patient on the proper food and fluid intake (such as avoiding heavy meals, alcohol, or caffeine

before bedtime) is important because this may interfere with the patient’s ability to relax and fall

asleep. Also, introducing relaxing activities such as a warm bath, calm music, reading a book,

and relaxation exercises before bedtime can be implemented. Lastly, recording her sleep patterns

in a sleep log or diary will help to assess the effectiveness of the program (Wayne, 2019).
The Plan of Care 3

The goals of the two health problems are losing weight at a reasonable rate (possibly one

to two pounds per week) and achieving optimal amounts of sleep as evidenced by a rested

appearance, verbalization of feeling rested, and improvement in sleep patterns within a month. I

will evaluate the interventions by meeting with the patient weekly to check on the progression of

the health plan and obstacles the patient might have. It might be necessary to change the care

plan according to the patient’s progress as time goes by. Along with interventions and

education, I can also offer outside referrals to my patient to provide additional information and

support. The Free Weight Management Seminar at Christiana Care Health System and the

Christiana Care Sleep Center (accredited by the American Academy of Sleep Medicine) referrals

are easy for my patient to access, since she works at the hospital.

For health promotion and disease prevention, I would recommend that my patient get an

allergy shot regularly. I have noticed many times that my patient has complained of an adverse

reaction to allergies, even though she took allergy medicine. These allergy reactions negatively

affect her daily life functioning and work performance. According to the research, allergy shots

can be a good treatment choice if allergy medication cannot control the symptoms well, and it

also reduces long-term use of allergy medication. Once the patient builds up a maintenance

phase from the allergy shot, the patient needs only one shot a month. The goals of the treatment

are to reduce the allergic reaction and improve daily life functioning. The evaluation of this

intervention is to observe if the allergic symptoms (such as headache, runny nose, and sneezing)

have subsided. Researchers state that after a successful treatment, some people do not have

significant allergy complications, even after allergy shots are stopped (Mayo Clinic, 2018).
The Plan of Care 4

References

Ackley, B., & Ladwig, G. (2018). Nursing Diagnosis Handbook-E-Book: An Evidence-Based

Guide to Planning Care. Elsevier Health Sciences.

Centers for Disease Control and Prevention. (2018, October). Healthy Weight. retrieved from

https://www.cdc.gov/healthyweight/index.html

Mayo Clinic. (2018, September). Allergy Shots. Retrieved from

https://www.mayoclinic.org/tests-procedures/allergy-shots/about/pac-20392876

Sleep Health. (2019, April). Retrieved from https://www.healthypeople.gov/2020/topics-

objectives/topic/sleep-health

Wayne, G. (2019, February). What are the nursing interventions for Insomnia? Retrieved from

https://nurseslabs.com/insomnia/