Example 1: Nursing Care Plan for a Patient with Congestive Heart Failure (CHF)
Nursing Diagnosis
Fluid volume overload related to compromised cardiac function as evidenced by shortness of breath, bilateral crackles, and peripheral edema.
Goal
The patient will achieve optimal fluid balance within 72 hours.
Interventions
- Monitor vital signs, including blood pressure, heart rate, and oxygen saturation every 4 hours.
- Assess lung sounds and peripheral edema daily.
- Administer diuretics as prescribed and monitor intake and output.
- Educate the patient on a low-sodium diet and fluid restriction.
- Encourage the patient to perform deep breathing exercises and position changes to improve oxygenation.
Evaluation
Reassess the patient’s fluid status daily and adjust the care plan as needed. The goal will be met when the patient demonstrates stable vital signs, clear lung sounds, and reduced peripheral edema.
Example 2: Nursing Care Plan for a Patient with Diabetes Mellitus Type 2
Nursing Diagnosis
Imbalanced nutrition: more than body requirements related to insulin resistance as evidenced by a BMI of 32 and an HbA1c of 8.5%.
Goal
The patient will demonstrate improved blood glucose control, with an HbA1c of less than 7% within 3 months.
Interventions
- Monitor blood glucose levels before meals and at bedtime.
- Administer insulin and oral hypoglycemic agents as prescribed.
- Educate the patient on a diabetic diet, emphasizing portion control and carbohydrate counting.
- Encourage regular exercise, such as walking for 30 minutes per day, 5 times a week.
- Teach the patient about the signs and symptoms of hypoglycemia and hyperglycemia and how to manage them.
Evaluation
Reassess the patient’s blood glucose levels and HbA1c monthly. The goal will be met when the patient demonstrates consistent blood glucose levels within the target range and an HbA1c of less than 7%.
Example 3: Nursing Care Plan for a Patient with Chronic Pain
Nursing Diagnosis
Chronic pain related to degenerative joint disease as evidenced by a pain rating of 7/10, limited range of motion, and difficulty performing activities of daily living (ADLs).
Goal
The patient will report a pain rating of 4/10 or less and demonstrate improved functional ability within 2 weeks.
Interventions
- Assess the patient’s pain level, location, and characteristics every shift.
- Administer pain medications as prescribed and monitor their effectiveness.
- Teach the patient non-pharmacological pain management techniques, such as deep breathing, relaxation, and distraction.
- Encourage the patient to perform range of motion exercises and participate in physical therapy as ordered.
- Assist the patient with ADLs and provide assistive devices as needed.
Evaluation
Reassess the patient’s pain level and functional ability daily. The goal will be met when the patient reports a pain rating of 4/10 or less and demonstrates improved ability to perform ADLs.
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