Delaware Technical Community College

NUR 320 Health Assessment

RN to BSN program: Plan of Care Chart
STUDENT NAME: __Melissa Towe_____ DATE: __4/21/19_____
Nursing plan of care
Identified Identified goal or Plan/ Interventions: Projected Evaluation/ Community
problem/need: outcome: (Provide rationale/ and Outcomes: (How will you Resources/
(include supporting cited evidence to justify measure that it worked?) Referrals: (Must be
subjective and objective the rationale) actual resources from
data) the client’s
community. Include
Name, address, web
address, and phone
number)

Hypertension Patient’s blood pressure -Discuss heart healthy Patient will have a one, The Heart and
will be less than 130/80 dietary changes with three, and six month Vascular Hypertension
-Patient reports she at next office visit patient (esecially follow up appointment Clinic
“sometimes” has high reduction of sodium) where blood pressure
blood pressure diary will be evaluated 212 Carter Drive, Suite
-Develop moderate and patient’s blood D, Middletown, DE
-Patient reports HTN physical activity plan pressure will be 19709
may run in her family with patient recorded.
https://www.heartandv
-Provide patient with a ascularclinic.com/hype
take home blood rtension-clinic/
pressure cuff, educate
on proper use, and (302) 338-9444
encourage daily
recordings in a “Blood
 pressure diary” for at
least one month

Obesity Patient’s BMI will -Provide education on Patient will have weekly Christiana Care’s
decrease upon nutrition and physical weigh-ins during first 12- Fit4Life & Weight
-Patient reports desire completion of weight activity guidelinges. week program with the Smart Weight-Loss
to lose weight and “get management program. option to continue on Programs
healthy.” -Refer patient to weight with Christiana’s “Weight
management program. Smart” program for an 501 West 14th Street
-Patient reports additional 10-weeks. Wilmington Hospital
Gateway Building, 4th
nutritional concerns. -Refer patient to Patient will have weekly Floor Wilmington, DE
dietician/nutritionist weigh-ins during the 19801
-Patient’s BMI is course of the program
greater than 30. and then follow up with https://christianacare.or
an office visit upon g/services/weight/Fit4lif
e/
completion.
302-623-3475

Disturbed Sleep Patient will verbalize -Discuss Sleep is relatively Delaware Sleep
Pattern improved quality of nonpharmacological subjective, the patient Disorder Center
sleep by next office treatment options for will be evaluated in the
-Patient verbalized she visit. insomnia office after treatment 118 Sandhill Dr #201
was feeling “exhausted” options have been Middletown, DE 19709
during assessment. -Discuss medication implemented, regarding
options for insomnia quality of sleep and
 -Patient reports number of hours per http://www.delsleep.c
working night shift and -Refer to Sleep Disorder night. om
feeling as though she Center for further
doesn’t get enough evaluation if neither of (877)-335-7533
sleep the above are
successful