Nursing Care Plan
Nursing DX/Clinical Problem
Client Goals/Desired Outcomes/Objectives
Knowledge deficient: disease
states, treatments, community resources, nutrition, and wellness activities r/t
information misinterpretation, unfamiliarity with information resources and lack
of exposure as evidenced by verbalized deficiency in knowledge, inaccurate perceptions
of health status and failure to correctly perform prescribed health behaviors.
Short term goals:
will demonstrate motivation to learn as measured by verbalization of desire and
asking questions related to health by 15:00 on [Month] 14, [Year].
will identify perceived learning needs as measured by verbalization of at least
2 topics by 15:00 on [Month] 14, [Year].
Long term goals:
will understand disease processes, causes and factors contributing to symptoms as
measured by verbalization of knowledge by 15:00 on [Month] 21st, [Year].
will identify medications used for symptom control of each medical condition as
measured by verbalization of accurate knowledge by 15:00 on [Month] 21, [Year].
will understand how to incorporate new health regimens into lifestyle measured by
verbalization of knowledge 15:00 on [Month] 28th, [Year].
will demonstrate knowledge of community resources via verbalization by [Month] 28th,
Asses the client’s ability, readiness to learn and previous knowledge r/t health
preservation, medication management, disease states and community resources. Learning best occurs when learners are
motivated and when instruction is tailored to the client’s cognitive ability (Olinzock, 2004).
Assess personal context and meaning of illness including perceived changes in lifestyle,
financial concerns and impact on culture.
Providing interventions that incorporate personal perspectives and meaning of illness
results in improved symptom management and client satisfaction
(Hornsten, Lundman, Stenlund, & Sandstrom, 2005).
Provide information to support self-efficacy, self-regulation and self-management
by focusing on problem solving and decision making.
Educational programs based on empowerment have demonstrated effectiveness
(Deakin, McShane, Cade, & Williams, 2005).
Tailor the delivery of instruction to the client’s cognitive level by using visual
aids (medication chart, brochures on Oak & Acorn and Elderserve’s Companion
Program) and accessible word choices.
Clients with lower literacy benefit from well-tailored materials
(DeWalt, et al., 2004).
Evaluate learning outcomes using patient verbalizations.
Evaluation serves as an assessment of the effectiveness of care and allows
opportunity for adjustments to the plan of care (Ackley
& Ladwig, [Year]).
Goal met. Client asked questions related to the purpose
of her medications, what they treated and expressed desire for reference materials. Client also expressed desire to learn
of community resources and ways to “not see the doctor.”
Goal met. Client identified learning needs as: medication information and management,
community resources, and nutrition suggestions.
met. The client has made no progress towards this goal. Evaluation of knowledge
r/t disease processes, causes and factors set for 15:00, [Month] 21, [Year].
met. Client identified Ativan as her
sleeping medication. Continued education
required. Evaluation set for 15:00
on [Month] 21, [Year].
met. The client has made no progress
towards this goal. Client has not described how to incorporate new health regimens
into her lifestyle. Evaluation set
for 15:00 on [Month] 21, [Year].
met. The client has made no progress
towards this goal. Client has not demonstrated knowledge of community resources. Continued identification of resources
required. Evaluation set for 15:00 on [Month] 28, [Year].
Assessment of client’s abilities, readiness to learn and previous knowledge performed. Client expressed desire to learn and
identified baseline knowledge. Client
is not interested in smoking or alcohol cessation information, but is motivated
to learn wellness behaviors, medication information and community resources. Client is unable to read and write,
but is able to retain verbal information and understands visual aids.
Assessment of personal context and meaning of illness performed.
Client expressed difficulty with incorporating “good” food choices for health
conditions due to finances, lack of knowledge and unfamiliarity with certain foods. She cited financial strain as a reason
for not refilling medications promptly. Client expressed fear of others in the community
and uncertainty of minimum exercise recommendations for her age and health.
Continuation of providing information to support self-efficacy, self-management
and self-regulation required. Client
identified a few ways she could maintain health (“walk more”) and solve specific
health problems (“use my breathing machine when it’s hot” as a solution to difficulty
breathing), more progress is achievable.
Continuation of tailoring of instruction required.
Provided medication information verbally and in writing, however reinforcement
is required. Procured brochure for
Elderserve Companion program, referral still required.
Procured information on Oak & Acorn, referral and disclosure of information
to client still required.
Continued evaluation of intervention efficacy still required.
Verbalizations indicating lack of knowledge
“I forget what all is wrong with me. I know I got hernia and I take stuff for
it.”on oas evidenced by I remember,""r medications
are used to treat, their side effects, and IADLS)friendships, fear of
know what all of these (medications) are for, I just take them when I have the money
for them. I take most of them for my
hernia and one for my sleeping.”
“There’s nothing to do and they don’t do
the craft anymore, I don’t know why.
I got no place to go to do anything.”
Client asks questions regarding health conditions.
Nonverbal behaviors indicate attentiveness
and concern for knowing.
Ackley, B. J., & Ladwig, G. B. ([Year]). Nursing
Diagnosis Handbook: An Evidence-Based Guide to Planning Care (4th ed.).
St. Louis, MO: Mosby Elsevier.
Belza, B., Walwick, J., Shiu-Thornton, S., Schwartz,
S., Taylor, M., & LoGerfo, J. (2004). Older Adult Perspectives on Physical Activity
and Exercise: Voices From Multiple Cultures. Retrieved [Month] 18, [Year], from
Preventing Chronic Disease: Public Health Research, Practice and Policy: http://www.cdc.gov/pcd/issues/2004/oct/04_0028.htm
Boyd, M. A. ([Year]). Classification of Mental Illnesses
and Evidenced-Based Nursing Care. In M. A. Boyd, Psychiatric Nursing: Contemporary
Practice (pp. 16-17). Philadelphia, PA: Lippincott, Williams & Wilkins.
*Deakin, T. A., McShane, C. E., Cade, J. E., & Williams,
R. (2005). Group based training for self-management strategies in people with type
2 diabetes mellitus. The Cochrane Collaboration. Hoboken, NJ: John Wiley
and Sons, Ltd.
DeWalt, D. A., Pignone, M., Malone, R., Rawls, C., Kosnar,
M. C., George, G., et al. (2004). Development and pilot testing of a disease management
program for low literacy patients with heart failure. Patient Education Counseling
, 55 (1), 78-86.
Dudley-Brown, S. (2002). Prevention of psychological
distress in persons with inflammatory bowel disease. Issues in Mental Health Nursing
, 23, 403-422.
Farley, K. ([Year], January 1). Smoking's Impact on
Health Is Not Limited to Lung Cancer. Retrieved [Month] 18, [Year], from Discovery
Frances, A., & Ross, R. (2001). DSM-IV-TR(R)
Case Studies: A Clinical Guide to Differential Diagnosis. Arlington: American
Psychiatric Publishing, Inc.
Hauenstein, E. J., & Boyd, M. A. ([Year]). Suicide:
A Major Mental Health Problem. In M. A. Boyd, Psychiatric Nursing: Contemporary Practice
(p. 258). Philadelphia, PA: Lippincott, Williams & Wilkins.
Hilliker, N. A. ([Year]). Sleep Disorders. In M. A. Boyd,
Psychiatric Nursing: Contemporary Practice (pp. 577-578). Philadelphia, PA:
Lippincott, Williams & Wilkins.
Ho, A. P. ([Year]). A peer counseling program for the
elderly with depression living in the community. Aging Mental Health , 11
Hornsten, A., Lundman, B., Stenlund, H., & Sandstrom,
H. (2005). Metabolic improvement after intervention focusing on personal understanding
in type 2 diabetes. Diabetes Research and Clinical Practice , 68 (1),
Masiero, S., Boniolo, A., Wassermann, L., Machiedo,
H., Volante, D., & Punzi, L. ([Year]). Effects of an educational-behavioral joint
protection program on people with moderate to severe rheumatoid arthritis: a randomized
controlled trial. Clinical Rheumatology , 26, 2043-2050.
Morin, C. M., Mimeault, V., & Gagne, A. (1999).
Nonpharmacological treatment of late-life insomnia. Journal of Psychosomatic Research
, 46 (2), 103-116.
Olinzock, B. J. (2004). A model for assessing learning
readiness for self-direction of care in individuals with spinal cord injuries: A
qualitative study. Spinal Cord Injury Nursing , 21 (2), 69-74.
Puentes, W. J. (2002). Simple reminiscence: a stress-adaptation
model of the phenomenon. Issues in Mental Health Nursing , 23 (5),
Raak, R., Hurtig, I., & Wahren, L. K. (2003). Coping
strategies and life satisfaction in subgrouped fibromyalgia patients. Biological
Research Nursing , 4 (3), 193-202.
Resnick, B. (2001, January 1). Geriatric Health Promotion:
Alcohol, Smoking, and Diet. Retrieved [Month] 18, [Year], from Medscape Today: http://www.medscape.com/viewarticle/408406_8
Sateia, M. J., Doghramji, K., Hauri, P. J., & Morin,
C. M. (2000). Evaluation of chronic insomnia. An American Academy of Sleep Medicine
review. Sleep , 23 (2), 243.
Townsend, M. C. (2004). Nursing Diagnosis in Psychiatric
Nursing. Philadelphia: F.A. Davis Company.
Wallace, B. C. ([Year], February 27). Our World, Our
Community: Building Bridges for Health Equality. Retrieved [Month] 18, [Year], from
Minority Health Project to Eliminate Disparities: http://www.minority.unc.edu/sph/minconf/[Year]/materials/BarbaraWallaceKeynoteLectureAndCurriculumTool[Year]0227.pdf
Wassem, R., Beckham, N., & Dudley, W. (2001). Test
of a nursing intervention to promote adjustment to fibromyalgia. Orthopedic Nursing
, 20 (3), 33-45.