Nursing Care Plan Format
Nursing Care Plan Format
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
Date: November 12, 2050
Patient Information
|
Field |
Details |
|---|---|
|
Patient Name |
Clint Renner |
|
Age |
65 years |
|
Gender |
Male |
|
Diagnosis |
Hypertension, Diabetes Type 2 |
Assessment Data
|
Assessment Parameter |
Findings |
Date |
Notes |
|---|---|---|---|
|
Blood Pressure |
160/95 mmHg |
November 12, 2050 |
Elevated; requires monitoring |
|
Blood Glucose |
180 mg/dL |
November 12, 2050 |
Above target range |
|
Pain Level |
4/10 |
November 12, 2050 |
Mild discomfort |
Nursing Diagnosis
|
Nursing Diagnosis |
Rationale |
Date |
Priority Level |
|---|---|---|---|
|
Ineffective Health Maintenance |
Patient is unable to maintain blood pressure and blood glucose within target ranges. |
November 12, 2050 |
High |
Goals and Expected Outcomes
|
Goal |
Expected Outcome |
Target Date |
Evaluation |
|---|---|---|---|
|
Improve blood pressure control |
BP to be 140/90 mmHg or lower |
November 19, 2050 |
Monitor BP weekly |
|
Achieve optimal glucose levels |
Fasting blood glucose < 130 mg/dL |
November 19, 2050 |
Daily monitoring at home |
Nursing Interventions
|
Intervention |
Rationale |
Date |
Expected Outcome |
|---|---|---|---|
|
Administer antihypertensive medication as prescribed |
To lower blood pressure and prevent complications |
November 12, 2050 |
BP reduction |
|
Provide education on low-carb diet and exercise |
To help control blood glucose and manage weight |
November 12, 2050 |
Improvement in blood glucose |
Evaluation and Follow-Up
|
Evaluation |
Date |
Status |
Recommendations |
|---|---|---|---|
|
Blood pressure monitored weekly; goal not yet reached |
November 19, 2050 |
Ongoing |
Continue antihypertensive medication and lifestyle adjustments |
|
Blood glucose trending down but not at target |
November 19, 2050 |
Ongoing |
Adjust diet plan and review medication dosage |
