Care Plan Samples Updated: COMPILED BY: SAMMY (0247693186)
Care Plan Samples Updated: COMPILED BY: SAMMY (0247693186)
Care Plan Samples Updated: COMPILED BY: SAMMY (0247693186)
06/06/2019 Risk for Patient will maintain her i. Reassure i. patient/relatives reassured 06/03/19
imbalanced normal eating patient/relatives
10:00AM nutritional (less habits/appetite within ii. Mouth care encouraged 1:30pm
than body 1hour as evidenced by ii. Encourage on mouth
care iii. Best meal given to patient Goal fully met, evident by
requirement) patient eating more than
related to loss I. patient being able to iv. Soft nourishing diet
eat more than half of the iii. Give patient her best half of meal served and
of appetite meal provided to patient Nurse observing patient eat
food served.
half of the food served
II. Nurse observing iv. Provide soft nourishing v. Food served in bit and at
diet to patient regular intervals
patient eat half of the
food served v. Serve patient meal in vi. Fruits served to patient
bit and at regular interval vii. Patient’s food served warm
vi. Serve patient with viii. Patients’ served
fruits to increase the
appetite ix. Vitamins B complex
administered as ordered
vii. Serve food warm
5. Educate them on
personal and
environmental hygiene
06/03/19 Impaired 1.Patient will 1.Reassure patient of 1. Patient was reassured. 06/03/19
comfort experience comfort competent care to allay
12:30pm (chest pain) within the next 2 hour doubt 2. Quiet environment was 2:30pm
related to as evidenced by provided.
2. provide a quiet goal fully met, patient
inflammator 3. Patient was told to stop any verbalized absence of pain
y process of a. Patient verbalizing environment
absence of chest pain activities that cause pain.
the condition 3. Tell patient to stop any
b. Relaxed facial activities that cause pain. 4. Diversional therapy was
expression and ensured
cheerful looking 4. Ensure diversional
therapy 5. prescribed analgesics were
served
5. Serve prescribed
analgesics
06/03/19 Ineffective Patient will regain her 1.Reassure patient 1.Patient was reassured 06/03/19
breathing normal breathing
12:30pm 2. Remove all irritating 2. all irritating objects were 1:30pm
pattern pattern within 2 hours
(dyspnoea) as evidenced by; objects from the removed from the environment
related to environment
1.recording of normal 3. patient was encouraged to
decrease 3. encourage patient to take more copios fluid
oxygen breath rate and sound
take more copious fluid
perfusion 2. Patient breathing 4. prescribed cough mixture
normally. 4. administer prescribed was served
cough mixture
06/03/19 Anxiety Patient will regain her 1. Reasure patient that she 1.Patinet was reassured 06/03/19
related to mood within 1hour as will be better soon.
12:30pm unknown evidenced by cheerful 2. disease condition was 1:30pm
outcome of facial expression and 2. explain disease to her explained to her
disease. relating well with 3. encourage her to ask 3. patient was encouraged to
ward in-mates, and questions ask questions Goal fully met, patient
staff. looked cheerful and related
4. answer all questions in 4. Questions were answered in well with others
simple terms simple terms.
Date/ Nursing Objectives/ outcome Nursing orders Nursing intervention Evaluation
Time diagnosis criteria
06/03/19 Ineffective Patient will regain Remove tight cloths. Tight cloths were 06/03/19
06/03/19 Impaired Patient will regain his Reassure patient of Patient was reassured. 06/03/19
12:30pm comfort (pain) comfort within 24hrs competent health team. Comfortable bed was 1:30pm
related to as evidenced by Provide comfortable bed provided.
inflammation of patient verbalizing of of patient.
the scrotum. pain reduced. Apply cold compress to Cold compress was Goal fully met as
affected part. applied. patient verbalizing
Serve prescribed Prescribed medications that pain has been
medications. was served. reduced and being
comfortable in bed
06/03/19 Impaired skin Patient will regain Reassure patient Patient reassured 07/03/19
12:30pm integrity related skin integrity within Dress wound daily. Daily wound dressing 1:30pm
to break in the period of Provide good nutrition to done.
continuity. hospitalization as Goal fully met as
aid quick healing. Good nutrition was
evidenced by wound wound healed with
Serve prescribed provided.
healing without scar. no scar and patient is
medication Prescribed antibiotics
able to walk without
were served.
restrictions.
Impaired Patient will be able to Reassure patient. patient was reassured 06/03/19
06/03/19 mobility related walk without any Ensure adequate bed rest. Adequate bed rest was 1:30pm
12:30pm to swelling of the restriction evidenced Remove tight cloths ensured.
scrotum. by observing patient Goal fully met as
around the affect area. Tight cloths were
walk normal patient could walk
Serve prescribed removed.
freely.
medication. Prescribed medications
were served.
DATE/ AGNOSES OBJECTIVES/ NURSING ORDERS NURSING EVALUATION
OUTCOME CRITERIA INTERVENTION
TIME
06/03/19 Anxiety related Patient will be relieved of 1.Reasure patient 1.Patinet was reassured 06/03/19
to unknown anxiety within 1 hour as
12:30pm outcome of evidenced by patient 2. educate patient about 2.Patinet was educated 1:30pm
disease verbalizing absence of disease process about disease process
Patient verbalized
anxiety and patient 3. Encourage to ask 3.paitnet was absence of
cheerful facial expression. question and express encouraged to ask anxiety and there
fears openly. question was cheerful
facial expression.
4. provide simple frank 4. Simple frank and Therefore goal
and clear answers and clear answers were fully met
questions and clam given to patient.
patient /family fears
5. Relatives were
5. allow relatives to allowed to visit.
visit
Impaired body Patient will be relieved of 1. Reasure 1. patient was reassured 06/03/19
comfort epigastric and abdominal patient/family that pain
06/03/19 (epigastric and pain within 2 hours as will be reduced. 2. patient advised to eat 1:30pm
abdominal pain) evidenced by ; in bit but in frequent
12:30pm 2. advise patient to eat interval Patient verbalized
related to minimal of
excessive gastric 1.Patient’s cheerful facial in bit but frequently
4. patient advised not to epigastric and
secretion expression 3. Advice patient not to take spicy foods abdominal pains.
eat spicy food e.g. Therefore goal
2. Verbalization of ginger peppers. 5. patient advised not to partially met
minimal or absence of take alcohol
epigastric and abdominal 4.advice patient not to
pain. take alcohol 6. patient encouraged to
take in adequate fluid no
5. Encourage fluid dilute hydrochloric acid
intake. (HCL)
06/03/19 Risk for Patient fluid and electrolyte 1.support patient when 1.patine was supported 06/03/19
deficient fluid balance would be vomiting during vomiting
12:30pm volume related maintained within 2hours 1:30pm
to vomiting as evidenced by patient 2. encourage sips of 2. intake of sips was
water encouraged Goal were fully
verbalization of absence of met as patient is
vomiting. 3. reassure patient 3. patient was reassured able to eat
6. administer or replace
fluid as ordered
06/03/19 Impaired Patient will maintain 1.Ensure complete rest 1.patient was made to 06/03/19
physical mobility normal body posture and 2.provide safety by rest
12:30pm (dizziness related orientation within the 2 using side rails of the 1:30pm
2. bed side rails were
to the disease hours as evidenced by bed to prevent patient provided Goals were fully
process. patient verbalizing absence from falling from bed met as patient
of dizziness and ability to 3. all harmful object moved about
walk around bed unaided 3. Instruct patient not to were removed unaided without
move or get up injuries
unaided. 4. floor was always dry
06/03/19 Hyperthermia- Patient’s fever will Assist patient to Tepid water was provided 06/03/19
12:30pm 37oc) related to be reduced to normal take tepid bath and patient took his bath 1:30pm
disease range of body Serve patient cold Cold drinks were served
condition temperature (36.5- drinks Windows were opened, Goal fully met as
37oc) within 2 hours Ventilate the room fans were also kept on for enough patient
as evidenced be: be opening the windows ventilation temperature
06/03/19 Impaired body Patient will be 1.Provide a 1.Comfortable bed provided 07/03/19
comfort related to relieved of pain and comfortable bed for
12:30pm pain and swelling swelling throughout patient to rest. 2. Patient reassured 1:30pm
of the left knee the period of 3. Cold compress applied Goal fully met.
hospitalization as 2. Explain disease
evidenced by; condition to patient 4.Disease condition explained Pain relieved.
3. reassure patient and swelling knee and
1.Patient verbalising 5. Affected leg measured and thigh subsided and
no more pain. family that pain will compared
be relieved. patient feel
2. Patient being able 6. Prescribed medications served. comfortable
to sleep soundly for 8 4. Apply cold
hours. compress on the
affected area
3. Verbalization of no
swelling at the 5. Elevate the affected
affected area. part to ensure blood
circulation.
06/03/19 Anxiety related to Patient will regain his 1.Rassure patient and 1. Patient and relatives reassured. 06/03/19
unknown outcome normal emotional relatives.
12:30pm and prognosis of state within 2 hours as 2. patient encouraged to express his 1:30pm Goal fully
the condition. evidenced by; 2. encourage patient to fears and doubts. met
express his fears and
1.Patient freely doubts. 3. Patient educated on disease Patient and
discussing with health condition. relatives anxiety
workers his disease 3. educate patient on relieved.
his condition 4. Patients who recovered from the
condition disease condition were introduced
2. Patient showing 4. Introduce other to him.
cheerful face. patients who have
recovered from the
same condition
06/03/19 Inadequate Patient will gain some 1. Educate patient 1.Patint educated 06/03/19
knowledge related knowledge about the
12:30pm to lack of health disease condition 2. Encourage him to 2.Patient encouraged to ask 1:30pm
education on the within 1 hour as ask questions during questions during health educations
health educations. Goal fully met.
disease condition evidenced by;
3. reassure patient. Patient understood
1.Patient recounting 3. provide simple answers to patient his condition
what his disease question
condition
4.Paient reassured.
2. patient asking
questions about his
disease condition.
06/03/19 Risk for Patient’s fluid and 1.Support patient when vomiting 1. Patient supported 16/09/14 at 10:30am.
diarrhea and absence of vomiting 4. Monitor intake and output maintained and monitored and improvements in
vomiting. and improvements in charting 5.mouth cleaned after vomiting skin turgor
skin turgor
5.Administer mouth care after 6. Medications served
ordered.
antidiarrheal as prescribed
06/03/19 Impaired Patient would maintain 1. Ensure complete bed rest. 1.Patient made to rest 06/03/19
06/03/19 impaired Patient would be 1.ensure quiet environment for 1. Environment made suitable 06/03/19
pains/weakness
(malaise
Date and Nursing diagnosis Objective/outcome Nursing orders Nursing interventions Evaluations
time criteria
14/10/2020 Ineffective Patient breathing pattern 1. Encourage patient to 1. Patient was 15/10/2020
14/10/2020 Hyperthermia Patient will regain 1.Tepid sponge patient 1.Patient was tepid 15/10/2020
(38°C) related to normal body 2.Open window to provide sponged
at 2:40pm disturbance in the 2:40pm.
temperature(36.2°C – adequate ventilation 2.Adequate ventilation
thermoregulation
center in the brain. 37.2°C) within 24hours 3.Serve was ensured Goal fully met as
patient with cold
as evidenced by drinks 3.Patient was served evidenced by rechecking
rechecking and recording 4.Check with cold drinks fanta and recording normal
and record
normal temperature and temperature every 30 minutes 4.Temperature was temperature and patient
patient body being checked and recorded body being normal to
5.Cover patient with light every 30 minutes
normal to touch clothing’s touch.
5.Patient was covered
6.Reassure patient and relatives with light clothing’s
7.Serve antipyretics as ordered 6.Patient and relatives
were reassured
7.Antipyretic was served
as ordered.
14/10/20 Deficient Knowledge Patient and family will 1. Establish rapport to gain 1. Rapport was established to 14/10/20
related to inadequate acquire knowledge on patient’s confidence and gain patients confidence and
2:50 pm 4:50 pm
information about heart failure within 2 cooperation. cooperation and also enhance
disease condition hours as evidenced by; an effective communication. Goal fully met as
2. Assess patient and
(predisposing factors 2. Patient’s level of evidenced by;
a. Patient and family family’s level of knowledge
management and knowledge about disease
repeating some lifestyle about condition. a. Patient and
complications) condition was assessed.
modification been family repeating
explained. 3. Definition, causes, signs some lifestyle
3. Educate patient/family on and symptoms, treatment modification been
b. Patient demonstrating
the predisposing factors, modalities and complication explained.
how to incorporate new
clinical manifestations, of heart failure were
health regimen into treatment and possible explained to patient in simple b. Patient
lifestyle. complications of his terms. demonstrating how
condition. to incorporate new
4. Patient was allowed to ask
health regimen into
4. Encourage patient to ask questions of which were
lifestyle.
questions which bothers him answered tactfully