Delaware Technical Community College
NUR 320 Health Assessment
RN to BSN program: Plan of Care Chart
Courtney Moore
STUDENT NAME: ______________________________________________ 11/26/2017
DATE: ____________________________________
Identified problem/need: Identified goal or Plan/ Interventions:
(include supporting outcome: (Provide rationale/
subjective and objective evidence to justify the
data) rationale)
Anxiety: To feel less anxious 1). Provide reassurance and
1. Patient states feeling comfort measures.(helps to
anxious. relieve anxiety)
2). Pt currently taking 2). Teach S/S of increasing
medications for anxiety. anxiety.
3). Administer SSRI's as
ordered. (PT on Prozac)
4). Encourage the PT to
participate in relaxation
exercise such as; deep
breathing, guided imagery, and
OCD mediation. (non
pharmacological interventions)
5). Have PT keep a journal. (can
help provide insight into
triggers and frequency of
anxiety.)
Evaluation/ Outcomes
Evaluate the effectiveness of
prescribed medicine. For side
effects is important as some
side effects might cause PT to
stop taking.
Evaluate level of anxiety and
what strategies work well.
See above
Community resources/
Referrals
Pt has therapist already at
A Center for Mental
Wellness (located at 121
Loockermen St, Dover, DE)
Therapy can provide a non
threatening environment
to talk, and who prescribes
medication.
Support groups are
available throught the
Mental health Association
of Delaware. They meet
the first and third Thursday
of the month from
7:00-8:30pm. This allows
PT to not feel alone about
their feelings.
Family therapy is offered at
A Center for Mental
Wellness, this can help
those who live with the PT
a place to voice concerns
 Obesity
1). BMI of 32
Peroneal Tendonitis
1) Diagnosed condition
2) PT was unable to run
Adapted from Florida International University: http://cnhs.fiu.edu/nursing/undergrad/_assets/common-assets/nursing-assesment-tools/NUR%20ASSESS_BSN%20Nursing%20Care%20Plan.pdf
To lose weight and
maintain health BMI
To be able to run again
1) maintain food diary
(allows PT to see what and
how much they eat)
2) formulate meal plan
3) make realistic goals (PT
will be more apt to follow
if they have realistic goals)
1) Ice/heat treatment
(helps sore muscles)
2) Easing back into
exercise (decreases risk of
further injury)
3) Stretching (decreases
risk of further injury)
Evaluate every 4 wks to
determine if treatment is
effective and also to
adjust caloric intake. We
do not want PT to lose
too much weight, the
desired weight is a
healthy weight (Which
would be BMI of 18.5-25)
Evaluate pain and level
of exercise to determine
if treatment is effective.
Desired outcome is to be
able to resume running.
Local gyms to refer PT
are: YMCA (dover),
Anytime Fitness
(Camden), Club Fitness
(Dover), Snap Fitness
(Dover), CNU Fit
(Dover).
A dietitian can help
with a meal plan:
Bayhealth has
outpatient Dietitian,
Robin Hayes (dover),
Wendy Flannery
(Camden), CNU Fit
(Dover).
There are apps that PT
can download on
phone: MyFitnessPal
Patient gets PT at Pivot
physical therapy which
is on 1015 S Governors
Ave, Dover.
MD prescribed NSAIDs
(Voltaran). If pain
persists MD may order
other medication for
pain.