Sample Care Planning Document
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
This care plan is designed to outline the necessary interventions and goals to ensure optimal care for the patient. It is an essential tool for effective communication within the healthcare team.
Date | Patient Information | Nursing Diagnosis | Goals/Outcomes | Interventions |
|---|
January 5, 2050 | Nadette Ritchie | Risk for Falls | Goal: Prevent falls and promote safe mobility. | 1. Perform a fall risk assessment every shift. |
| Age: 78, Male, Hypertension, Diabetes | Secondary to dizziness and weakness | Outcome: Maintain patient’s current level of independence. | 2. Implement fall prevention measures (e.g., non-slip socks). |
| Patient Address: Salem, OR 97301 | | | 3. Educate patient on safe mobility techniques. |
| Emergency Contact: Zena Frami | | | 4. Ensure proper lighting and remove obstacles. |
Date | Assessment Data | Goals/Outcomes | Nursing Diagnosis | Interventions |
|---|
January 6, 2050 | Blood pressure: 150/90, Blood sugar: 180 mg/dL | Goal: Stabilize blood pressure and blood sugar. | Hypertension and Uncontrolled Diabetes | 1. Administer prescribed antihypertensive medication. |
| Weight: 80 kg, BMI: 27.1 | Outcome: Blood pressure < 140/90 mmHg and blood sugar < 130 mg/dL. | | 2. Monitor blood pressure and blood sugar levels every 4 hours. |
| Patient Concerns: Fatigue, Thirsty | | | 3. Encourage fluid intake and proper nutrition. |
| Patient Address: Salem, OR 97301 | | | 4. Educate patient on lifestyle changes (diet, exercise). |
This sample care planning document helps guide the management of the patient's health conditions, ensuring clear goals, systematic interventions, and effective communication. It is intended for use in collaborative, patient-centered care.
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